Anticougulation Therapy in Europe

[Buzz Lanning]

All,

During a recent ProTime test at our Coumadin Clinic (in Colorado), the medical assistance that was measuring my INR had just returned from a training class. I ask her about the class, and she indicated the class dealt with anticougulation therapy in Europe, etc.. Anyway, she indicated that "in Europe, Coumadin is not usually prescribed for mechanical valves in the aortic position; aspirin only". I couldn't believe it, so during my next visit, I ask her again. Yes, apparently the Europeans have a different approach to mechanical valves in the aortic position than doctors in the United States.

How can this be? Obviously, the Europeans can't be having a significant increase in clotting problems as compared to the U.S., or the doctors would prescribe Coumadin. Yes, I know we're more conservative in the U.S., but . . .

Just curious.

 

[catwoman]

I'm willing to bet that she's wrong and that, yes, warfarin is Rxed in Europe for mechanical aortic valves.

I'm sure Al Lodwick will correct me if I'm wrong.

 

[Dustin]

All,

During a recent ProTime test at our Coumadin Clinic (in Colorado), the medical assistance that was measuring my INR had just returned from a training class. I ask her about the class, and she indicated the class dealt with anticougulation therapy in Europe, etc.. Anyway, she indicated that "in Europe, Coumadin is not usually prescribed for mechanical valves in the aortic position; aspirin only". I couldn't believe it, so during my next visit, I ask her again. Yes, apparently the Europeans have a different approach to mechanical valves in the aortic position than doctors in the United States.

How can this be? Obviously, the Europeans can't be having a significant increase in clotting problems as compared to the U.S., or the doctors would prescribe Coumadin. Yes, I know we're more conservative in the U.S., but . . .

Just curious.

To my knowledge the only difference between the US and Europe is the drug used. In some EU countries, for example, you'll find that warfarin is not registered so that Acenocoumarol (= Sintrom) or Phenprocoumon (= Marcoumar) is prescribed. The mere difference between these drugs and warfarin is the half-life. Acenocoumarol is a very fast anti-coagulant and easily metabolized, so what you take today will change your INR tomorrow. The half-life of this drug is often said to be approx. 12 hours. Phenprocoumon on the onther hand has a half-life of approx. 140 hours, so it is a much slower drug than warfarin, yielding a very stable INR but it becomes rather problematic when the INR is too low or too high. It's like choosing between a small yacht or an oil tanker: some people like fast control though others like steering an oil tanker for its stability. In any case, I have not heared of aspirin-only therapy for mechanical valve patient anywhere in Europe.

I'd guess Allodwick can clarify this in much more detail.

Best wishes,

 

[RCB]

I'm betting on Catwoman

I'm betting on Catwoman

I'm willing to bet that she's wrong and that, yes, warfarin is Rxed in Europe for mechanical aortic valves.

I'm sure Al Lodwick will correct me if I'm wrong.

and against your MA. Aspirin therapy only is not SMC anywhere!

I would start taking name and kicking ............! Report this to her supervisor!
She may have learned this or have an opinion, but she is not qualified to make that statement in the context of a doctor's office and I'm sure he would
like to know what she is saying CAUSE IT IS HIS LICENSE ON THE LINE!

You know since I could use the money, maybe someone here would like to place a bet?
Oh never mind- Check out table 3, page 6:
http://www.sign.ac.uk/pdf/sign36.pdf
For a shorter article:
http://www.pubmedcentral.gov/articlerender.fcgi?artid=1124694

 

[Buzz Lanning]

To RCB

To RCB

RCB,
Don't worry, the medical assistant was on the same page as the rest of us, she couldn't believe it either (SHOCKED is a better word). She was just sharing some information from a a recent training class on different approaches to anticoagulation therapy around the world. It's possible the material was geared to the new generation of mechanical valves. This class could also be providing 'brand-new' information based on a clinical study? Regardless, our Coumadin clinic, nor the medical assistant, was NOT recommending no anticoagulation therapy (nor will they). They feel the same way you do . . .

During my next visit, I'll see if I can get the information that was presented in the class. The class may have addressed lots of other issues too. NOTE: My ProTime clinic is managed by my cardiologist group.

Anyway, I don't feel the medical assistant was out-of-line with sharing this information with me . . .

 

[Ross]

Buzz I think that would be cool if you could get some notes out of her. I'm betting your right that it's on some newer generation trials, but not an actual in use idea.

 

[RCB]

RCB,
Don't worry, the medical assistant was on the same page as the rest of us, she couldn't believe it either (SHOCKED is a better word). She was just sharing some information from a a recent training class on different approaches to anticoagulation therapy around the world. It's possible the material was geared to the new generation of mechanical valves. This class could also be providing 'brand-new' information based on a clinical study? Regardless, our Coumadin clinic, nor the medical assistant, was NOT recommending no anticoagulation therapy (nor will they). They feel the same way you do . . .

During my next visit, I'll see if I can get the information that was presented in the class. The class may have addressed lots of other issues too. NOTE: My ProTime clinic is managed by my cardiologist group.

Anyway, I don't feel the medical assistant was out-of-line with sharing this information with me . . .

If you are uncertain about the information she was giving you, that in and of itself is reason enough for her not to have made the statement(s). It is clearly not in the scope of her practice. It is up to you whether or not you want to report this, however I think her supervisor would be interested in your perceptions. I would guess that most of the pts. who go to this clinic,
are unaware of a website like this to check out her ideas. They also might take her ideas as suggestions.

I would be real curious about what Al thinks of MAs sharing these "thoughts" with ACT pts?

 

[ALCapshaw2]

There ARE studies being performed in Europe for Aspirin Therapy for THIRD GENERATION Mechanical Valves such as those from On-X, Sorin, ATS. Maybe that's what she was hearing about and generalized her impression to ALL valves???

'AL Capshaw'

 

[Buzz Lanning]

To RCB again . . .

To RCB again . . .

I probably shouldn't have mentioned the NO coumadin thing overseas, but I was curious if there was something new (and this site would know). I never inquired about the specifics.

The subject originally was brought-up by me. I had made a comment during my ProTime test about the possibility that some valve patients (i.e., a small number, but greater than zero) probably don't need anticoagulation therapy. That's when the medical assistant responded about a recent class. I didn't ask for more information. It was obvious she didn't concur with the study results.

Anyway, I definitely don't think the medical assistant was out-of-line; It was more wishful thinking on my part. I'll be more careful in the future about posting information that is not substantiated in more detail.

 

[RCB]

It was more wishful thinking on my part.

Your not alone Buzz- we all wish those thoughts!

 

[Guest]

I suspect that Dustin's mention of phenprocoumon etc led to a misunderstanding. Several European countries use different derivatives of products similar to warfarin. There may have even been some mention of aspirin as an alternative. I'm not aware of any recommendation to not use something similar to warfarin for these valves.

 

[Dustin]

I suspect that Dustin's mention of phenprocoumon etc led to a misunderstanding. Several European countries use different derivatives of products similar to warfarin. There may have even been some mention of aspirin as an alternative. I'm not aware of any recommendation to not use something similar to warfarin for these valves.

You're right, Allodwick, I forgot to say that both Sintrom and Marcoumar are similar to Coumadin chemically speaking. Anyway, other than trials, there is no established aspirin/plavix prescription for mechanical valves that I'm aware off.

I'll undergo AVR next tuesday to receive the On-X, but my cardiologist is putting me on Sintrom the first few months after which Marcoumar is likely to take over, depending on INR stability. So there you go, no unnecessary risks are taken, even with the On-X.

 

[OldManEmu]

Act

Act

On-X are doing Aspirin only ACT trials on volunteers in Germany at preset this is obviously because of less medico, legal problems than in the US. ATS has lower than standard AVR mechanical ACT levels recommended by at least one European heart centre. http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=12918853

 

[RCB]

I don't think they are going that far

I don't think they are going that far

On-X are doing Aspirin only ACT trials on volunteers in Germany at preset this is obviously because of less medico, legal problems than in the US. ATS has lower than standard AVR mechanical ACT levels recommended by at least one European heart centre. http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=12918853

Althrough the result of the research were "encouraging", I am not sure they are recommending "lower than standard AVR mechanical ACT levels". At least I interpret the last sentence that way. People should be very care to consult
a cardiologist to make sure they don't make reductions in the target INR, without understanding their own specific risks, even with an ATS valve.

 

[Emma]

Nope, not true to my knowledge and I live in Europe!

All the people - adults and childen I know with mechanical aortic valves take warfarin - and I know of quite a few.

I can only think this person either got their facts completely wrong, or confused their statement with trials which are happening for on-x and aspirin??

Emma
xxx

 

[Valve-Viking]

Not true in Sweden/Scandinavia either - it must be misunderstood.
We´re all flesh & bone here too!

/
Martin

 

[Guest]

I think that the reference was to the fact that many European ohysicians use an INR up to 4.0 as a standard for mechanical valves.

So from some Europeans standpoint the US INR level is too low. But the Americans say that many Europeans use a level that is too high.

This only backs up my contention that there are very few problems that result from INRs that are above 3.5 but less than 5.0.

 

[temp69]

Buzz:

The studies are so far very promising. In 3rd world countries where follow up on coumadin dosage is difficult -- they're finding that avr recipients of the On-X are doing just fine without coumadin. Of course, this is just a trial. But my surgeon, Dr. Laks at UCLA, is very optimistic about the probability of low or no dose of coumadin fairly soon -- within a few years.

He's the head of the department at UCLA. So I hope this helps you. I just had an On-X valve put in and of course I'm hoping that the thing doesn't need coumadin, too.

Another UCLA cardiologist, Dr. Michelle Hamilton, has indicated that it might be that sometime inthe future, us On-X valvers will learn that we don't have to take coumadin.

But...that's still just a hope at this point.

Temp69

 

[Guest]

It is probably the best hope. As far as I know, nobody is testing a drug to replace warfarin for valvers.

 

[RCB]

Keep in mind one thing

Keep in mind one thing

Buzz:

The studies are so far very promising. In 3rd world countries where follow up on coumadin dosage is difficult -- they're finding that avr recipients of the On-X are doing just fine without coumadin. Of course, this is just a trial. But my surgeon, Dr. Laks at UCLA, is very optimistic about the probability of low or no dose of coumadin fairly soon -- within a few years.

He's the head of the department at UCLA. So I hope this helps you. I just had an On-X valve put in and of course I'm hoping that the thing doesn't need coumadin, too.

Another UCLA cardiologist, Dr. Michelle Hamilton, has indicated that it might be that sometime inthe future, us On-X valvers will learn that we don't have to take coumadin.

But...that's still just a hope at this point.

Temp69

In the early years, it was normal for people to go off warfarin after a few month. It wasn't till my second valve and a TIA that my cardiologist "suggested" I go on ACT. That was seven years after my first AVR. Al can tell you stories of much longer than that with no ACT. Of course, even today people on ACT get strokes. You never know- I would have to see ironclad evidence that ACT made no difference before I would consider going off warfarin- No make that GOLDPLATED!