Can't stop bleeding will have to hold warfarin for awhile

[Gail in Ca]

When having repeat surgeries, I have been told to stop my coumadin, if I remember correctly, 5 days before the surgery. The surgeon wanted my INR to 1.6 maximum before the redos I've had. This last one was just 2 1/2 yrs ago. I also stopped it without bridging to have my sternal wires removed, and when I had my brain bleed.
I had confidence in my surgeon and cardio, that they knew the risks, and it must not be as high as we all tend to think, of short terrm low end INR.
However, when I had my 1st colonoscopy a few yrs ago, my cardio had me bridge with lovenox. So, why for that and not for surgeries?

 

[Protimenow]

Certain procedures probably expose a higher risk of clot formation than do others. I'm guessing that if polyps are found and removed during a colonoscopy, it's better to bleed a little and slowly have the base of the removed polyp slowly close up than it is for it to rapidly form a large clot. However, this is only a guess...there's probably something, somewhere, online that explains why this procedure requires bridging when others don't.

Then, too, I think the revised guidelines are fairly recent and what may have been thought to require bridging a few years ago may be considered to be safe without it. Medical research is ongoing, and some opinions, based on recent research, occasionally change. It would be good if more doctors (and perhaps even some of us) were more on top of these kinds of things.

 

[Lynlw]

I've posted a few times here about being below 2.0 NOT being an instant death sentence if you've got a bileaflet valve, and are more than 3 months post-op, and increase your dosage so that you're back in range within a few days. This is according to a protocol used by Duke Clinic (it could have been the medical school, but I think it's the clinic), and a recent paper on anticoagulation. The recommendations were to increase dosage, and that bridging wouldn't be necessary in most people, if the INR comes back up in a few days. The point is that the risk isn't as high as many here seem to believe - IF THE OTHER CONDITIONS ARE MET. Bridging is not ESSENTIAL in cases where the other conditions are met - as long as you follow protocol to increase your INR.

I spent more than a week below 2.0 - it was scary until I saw recent research, but I STILL made it a point to get back into range quickly. (I couldn't afford Lovenox, have no doctor to prescribe it, and was quite concerned until I read that in my situation (bileaflet aortic valve, more than 3 months post-op), it was safe to just increase dosage and not necessary to bridge).

It doesn't matter to me WHICH mechanical valve we're discussing (though I think I brought up the On-X in this thread) - I still think 2.0-3.0 is a safe choice. Many of us try to stay in that range, and we lead normal lives. Other than testing and taking our daily dose, it doesn't really change our lives much. Plus, for some of us who lead mostly sedentary lives, it may also help us reduce the risk of deep vein thrombosis.

I agree with Luana -- 2-2.5 is a very narrow range, and hard to maintain. 2-3 is more possible, and more manageable. (Currently, I'm working my way DOWN from 3.7 - a new medication makes warfarin work better -- I test more frequently than usual and expect to be back in range in a few days)

I have to just say that alot of this is just your opinion, or what you took from reading parts of papers and not necessarily what most of the guidelines suggest, either for low INRs or for many (NOT ALL) procedures Bridging IS recomended by many of the most recent guidelines.
Bileaf mechanical valves have been in use 30 years now, and the reasons so much research has gone into figuring out the risks of clots vs the risks of bleeds in many circumstances was to hopefully lower the rate of people having strokes caused by clots when they either had to go off Coumadin for procedures or for some other reason their INR dropped low, even with the "newer"(st jude) valves. I'm pretty sure even the results that have been released so far on ON-Xs trial with lower INRs showed people with the higher (normal) INR had more bleeds , but those with the lower had more strokes, or at least clots I cant remember specifically.

Alot of the general guidelines about coumadin are for ALL patients on Coumdin, patients with the lower odds of forming clots and the groups of patients at higher risk. The reason people with mechanical valves usually have a higher INR target than Afib ect, is because the risks of clots are higher, it is also why when testing new anticoagulants the trials are for Orthopedic surgeries and Afib patients and not mechanical valve patients first since they have a higher risk of forming clots.

Yes time of surgery, what valve and where it is all can make the risk of a clot/stroke higher or lower, but even the lowest risk, is still about a 1% chance of having a devestating stroke caused by clot. So yes out of 100 patients 99 will be fine but most people would want to lessen the odds of becoming the 1 person whose life is dramatically changed by having a stroke, that could have been prevented.
As Dick said so well
"Youse has your druthers....and youse takes your picks". Personally, I choose NOt to play "russian roulette".....

Then of course part of the problem, is Coumadin/bridging is one of the things many doctors have different opinions on and there isnt a large consensis. Once of the main concerns about bridging before or after procedures, is the chances of increased bleeding during surgery or in the post op period if it is started soon, this usually isn't a concern in the cases of bridging because your INR is low, since there isn't an open wound trying to heal.
Also part of the reason many centers or organizations don't reccomend Lovenox or even heparin as a Bridge in the written guidelines, (which usually claim they are just general guideines and each patient has different risks factors and pretty much for the doctor there own judgement) is mainly because it is "off label" there is a pretty good, if long thread discussing alot of the issues if anyone cares to read it from a couple years ago, http://www.valvereplacement.org/forums/showthread.php?6933-Virtual-Colonoscopy-Anyone&highlight=
But commen sense would tell me, if they give instructions for bridging for procedures that need you to stop Coumadin to decrease the risk of strokes when you're below range, is saying there IS a risk big enough to be concerned about..even if it is 1%/

Am I saying everyone needs to bridge? NO but that general blanket statements like Bridging is NOT reccomended in most cases were valves are older than 3 months old etc. OR "Also, more recent guidelines, with more recent valves, don't stress the importance of forming a clot on the valve"' does not go along with most guidelines since there IS still a risk. Its a known fact the risks of having a stroke are 1-2% (depending which articles and studies you read) EVERY year you have a mechanical valve,not just the first and Most people would agree many of the people who DO have a stroke had it when their INR was below range at the time or shortly before.

IF anyone rather take that risk thats fine, but to write over and over how bridging isn't needed or is outdated or whatever is not true and IMO can even be dangerous advice.
I am very glad you didn't have any problems when your INR was about the same as a person who doesn't take Coumadin for a week. but it doesn't mean anyone else would be as lucky.
And FWIW NO ONE here ever said below 2.0 (or even any low INR) "is an instant death sentence if you've got a bileaflet valve", like you try to pretend that is what anyone, let alone many people says, but I noticed many of your arguments or posts are pretty much strawmen where you say or act like people are saying something ridiculous that they are not, which also can take the reason of the thread off track. but again, thats just MY opinion.

 

[Protimenow]

What I was saying was based on recent materials. And, yes, if you look at other posts, you'll see many instances where some (many?) members of this forum say, with knee-jerk frequency, that you 'must' bridge to anyone reporting an INR below about 2.0. In fact, when my INR was low, briefly, and I said that I couldn't afford to bridge, complaints were made about me to the person who runs Valvereplacement.org because I wasn't bridging. There seems to be a strong, pervasive feeling among many here that it is essential in ANY and ALL cases when an INR is below 2.0 that you MUST bridge -- even if the guidelines I already posted links to say the contrary.

In another thread, there's an unfortunate member who had some pretty disastrous bleeding following knee surgery possibly because the Lovenox contributed to the hemorrhaging in the knee.

I'm not against following medical guidelines -- but these should probably be based on recent research and, if possible, with the advice from a physician whose knowledge is up to date.

I wasn't talking about patients with A-Fib not needing to keep their INRs in range, or suggesting that they shouldn't need to bridge. I wasn't talking about others who don't fit into the 'bileaflet valve, aortic valve, more than 3 months post-op' group.

Certainly, all of what I write -- or what ANYONE writes - or even what physicians write - is based on 'opinion.' Any of us (even those hallowed doctors) can prefer to selectively agree with whichever sources they choose to agree with and to discount the rest. Hell, in Pakistan, people are refusing to take Polio vaccine because it's an American plot to sterilize children. We can believe what we want to believe. Personally, I choose to give some validity to the materials I've frequently quoted from Duke and other papers that discount the risk of a low INR, temporarily, in people meeting certain conditions. These guidelines don't give odds of having a stroke in these individuals - clearly a 1 in 100 chance is unacceptable - the risks were apparently so low for this group that it was deemed safe just to increase the daily dose until the patient was in range. (1 in 1 million seems low, unless you're that unlucky one -- but seems much more acceptable than the 1 in 100 that you seem to be quoting as clinical fact).

You said that it's 'a known fact the risks of having a stroke are 1-2% every year you have a mechanical valve.' Then, according to your known 'fact', since I'm in year 21, I'm at somewhere between a 21% and a 42% risk of having a stroke? In 10 years - if I don't have a stroke by then -- my risks would be between 31% and 62%? And, if I should somehow last another 30 years with this old valve, then my risks would be between 51% and dead. Right?


I'm glad to see that the bleeding issue of the person who started this thread has been resolved.

Lets hope that our doctors -- if we can afford them -- are up to date, but conservative and careful enough (but not unduly conservative) to provide good advice for ongoing anticoagulation and for any procedures -- no matter how minor -- so that we neither have strokes or awful consequences from over anticoagulating.

 

[Jkm7]

Just my opinion but the difference is that the MD"s have many years of schooling, internships, residencies and experience along with a license that usually would make their opinion of a higher value..... at least for me it would. And yes, I know there are some doctors that are better than others but for most of us, we choose the doctors we see and if we don't respect their opinions and skills, we look elsewhere.

We all should take the advice of our personal physicians before an internet message board but these boards are fabulous for learning. We learn what it is we need to know in order to ask the right questions and get the professional opinions.

Again, Just my opinion........

 

[ElectLive]

I do not want to enter into the bridging vs no bridging discussion, but would like to point out that stroke risk is affected by many things, not just valve type and INR level. There are hereditary risk factors, there are lifestyle risk factors. There are generalized medical risk factors and individual patient medical risk factors, heart related and non-heart related. More primarily, maybe the neck and brain arteries are narrowed, maybe they are not.

So, the problem is, any given person here who is faced with bridging issues, could be at a high risk for stroke, or at a low risk, and no one here will have either the expertise or necessary patient information to determine. Now, I won't go so far as to say that a given patient's cardio team will have a definitive evaluation either, there are many shades of grade in evaluating stroke risk and corresponding decisions. But certainly the medical professionals should be in the best position to make the proper call since they at the very least should have all the pertinent patient information and some degree of medical know how. Will they? And are they sufficiently up to date? That's where it gets tough...

It is important to note that stroke risk is always there, though, it never disappears. I may have a tissue valve, but I'm at risk too. Medical consensus determined in my situation, at my risk profile, that an Aspirin 81 should put me at lower risk than I would otherwise be on Warfarin, even in the first 3 months post surgery. Is the medical consensus right? I sure hope so. But who knows. I've often wondered when and how that protocol was reached. I assume that was not always the case, but actually don't know for sure any of the specifics. I wonder what degree of evidence was documented to make both doctors and patients fully comfortable that discontinuing Warfarin would be acceptable? I wonder if some of these bridging circumstances might one day go through a similar process, or perhaps that's what Protimenow is referring to, and it's already starting?

 

[chaconne]

The risk of developing a clot on an MHV is difficult to apply to ourselves. We don't really know what our individual chances of forming a clot are. What I'm hearing is: each year, 1-2% percent of the population who do have MHVs, have a stroke (correct me if this is not accurate). Are these the same people having a stroke each year, or are new ones having a stroke each year? If the latter were true, this would add more weight to the "cumulative risk" camp.

On the other hand, where do I stand in risk among this population? I don't know, because I don't have a MHV yet. It would seem that Protimenow is not in the 1-2% camp, given the time he's had the valve, and his experiences with low INR. We just do not have enough data, and there are to many variables to know how these numbers apply to us. The "average" may be 1-2%, but what is the "variance" of that data. Am I an outlier point with either better or worse risk? One way to find out might be to have a clinical trial with 5000 41 year-olds with health condition, ethnicity and life habits similar to me. But these might not even be the right parameters to study. Doctors must make decisions based on what statistics they do have.

Being engineer by trade, I wish the medical data provided answers as exact as calculating the radial range of a Mars orbiting spacecraft, but alas, it doesn't work like that. Personally, the 1-2% risk seems low to me. I'm at far greater risk for dying of Melanoma. Two years ago I was in the 70% chance of 5 year survival camp. I've survived so far, and thank God, I now qualify for OHS.

-Steve

 

[Protimenow]

It's nice - and often comforting - to think that YOUR doctor is the best in your city/state/community/planet, and I think many of us foster those beliefs. Personally, I've known some doctors who probably just squeaked through a second rate medical school, somehow passed their licensing exams, and didn't choose to crack open a book once they got their licenses. The were able to get continuing medical education credits by cramming some of the specialized training - did their requisite hours (which may have been as simple as sitting down to a free dinner at which some respected physician lauded the medications offered by their sponsoring pharmaceutical company), and somehow managed to retain their licenses. One doctor I knew did so poorly on his pre-test for a particular topic (17% out of 100) that it's amazing that he knew what he was doing -- after studying special materials for a couple hours, he was able to pass the test -- but this doesn't mean that whatever he 'learned' stayed in his brain.

Having worked with a lot of doctors, I've learned that many are marginally competent, and I kind of have to wonder how they ever became doctors in the first place. I've seen doctors who are so focused on their area of specialization that EVERY ailment you've got only fits into their area or specialty. For example -- you've got an infected toe. An allergist would conclude that this infection is an allergy to something that your toe came into contact with. A psychiatrist would conclude that your toe isn't really infected - it's a response to some emotional trigger. A cardiologist may almost accurately conclude that he doesn't care what the hell it is - you've got an infection and need to be treated with an antibiotic because it could cause endocarditis. I'm scared to think what a proctologist would conclude.

I've been fortunate enough to have found a few competent, caring physicians. The incompetent family practitioner I was seeing was, at least, able to help me find a very good cardiologist, and an excellent surgeon -- but this guy who made the referrals didn't care if I EVER had an INR test.

In short (after a long diatribe), it's good to trust our doctors. As Jkm7 said, we can look elsewere if we don't respect a doctor's opinions and skils. However, it may also be worthwhile to realize that, to the doctors, we're usually just patients, and they try to care for ALL their patients. For us--many of us having gone through OHS or on anticoagulant therapy for a-fib or other reasons - it's OUR LIVES we're dealing with. Although many of us probably don't really understand the technical stuff in the way that MDs usually do (and we shouldn't have to), there are some of us who can probably grasp the key concepts and may, in fact, be better sources than some doctors who don't have the same kind of life or death stake in getting the right information or doing the right things.

No -- don't trust anything here, except, perhaps, for the dosing charts -- but also feel free to be a bit critical of your health care providers, too. They can't - and often don't - know it all.

 

[Lynlw]

What I was saying was based on recent materials. And, yes, if you look at other posts, you'll see many instances where some (many?) members of this forum say, with knee-jerk frequency, that you 'must' bridge to anyone reporting an INR below about 2.0. In fact, when my INR was low, briefly, and I said that I couldn't afford to bridge, complaints were made about me to the person who runs Valvereplacement.org because I wasn't bridging. There seems to be a strong, pervasive feeling among many here that it is essential in ANY and ALL cases when an INR is below 2.0 that you MUST bridge -- even if the guidelines I already posted links to say the contrary.

In another thread, there's an unfortunate member who had some pretty disastrous bleeding following knee surgery possibly because the Lovenox contributed to the hemorrhaging in the knee.

I'm not against following medical guidelines -- but these should probably be based on recent research and, if possible, with the advice from a physician whose knowledge is up to date.

I wasn't talking about patients with A-Fib not needing to keep their INRs in range, or suggesting that they shouldn't need to bridge. I wasn't talking about others who don't fit into the 'bileaflet valve, aortic valve, more than 3 months post-op' group.

Certainly, all of what I write -- or what ANYONE writes - or even what physicians write - is based on 'opinion.' Any of us (even those hallowed doctors) can prefer to selectively agree with whichever sources they choose to agree with and to discount the rest. Hell, in Pakistan, people are refusing to take Polio vaccine because it's an American plot to sterilize children. We can believe what we want to believe. Personally, I choose to give some validity to the materials I've frequently quoted from Duke and other papers that discount the risk of a low INR, temporarily, in people meeting certain conditions. These guidelines don't give odds of having a stroke in these individuals - clearly a 1 in 100 chance is unacceptable - the risks were apparently so low for this group that it was deemed safe just to increase the daily dose until the patient was in range. (1 in 1 million seems low, unless you're that unlucky one -- but seems much more acceptable than the 1 in 100 that you seem to be quoting as clinical fact).

You said that it's 'a known fact the risks of having a stroke are 1-2% every year you have a mechanical valve.' Then, according to your known 'fact', since I'm in year 21, I'm at somewhere between a 21% and a 42% risk of having a stroke? In 10 years - if I don't have a stroke by then -- my risks would be between 31% and 62%? And, if I should somehow last another 30 years with this old valve, then my risks would be between 51% and dead. Right?


I'm glad to see that the bleeding issue of the person who started this thread has been resolved.

Lets hope that our doctors -- if we can afford them -- are up to date, but conservative and careful enough (but not unduly conservative) to provide good advice for ongoing anticoagulation and for any procedures -- no matter how minor -- so that we neither have strokes or awful consequences from over anticoagulating.

Again, the only reason I even respond to post that I think are dangerous or go against what most doctors or guidelines , and even most patients who HAVE been on Coumadin for years will say is so new people looking for information will know the majority of people probably disagree with your "facts"
First of course many, most people WILL suggest if you drop below 2, you should talk to your doctor about bridging to hopefully avoid a stroke. Since many /most studies show clots increase with INRs below range. That is hardy the same as saying being below 2.0 being "an instant death sentence if you've got a bileaflet valve", like your statement would make it seem that many people or even someone says around here..

As for your sarcastic argument against my pointing out that the risk of having a stroke is between 1-2 percent every year, wether you choose to believe it or not NO I'm not saying anything close to

"You said that it's 'a known fact the risks of having a stroke are 1-2% every year you have a mechanical valve.' Then, according to your known 'fact', since I'm in year 21, I'm at somewhere between a 21% and a 42% risk of having a stroke? In 10 years - if I don't have a stroke by then -- my risks would be between 31% and 62%? And, if I should somehow last another 30 years with this old valve, then my risks would be between 51% and dead. Right?"

NO Each year starts fresh and that year your chances of having a clot are 1-2%. If you want to make it cumulative, it doesn't mean in your 20th year you have a 20-40% of having a clot THAT year, that simply means by the time someone has a mechanical valve say 20 years at the 1% risk, odds are 20% they will have had an "event" since they got the valve, or even for the 2%-- 40% of the people who've had their mechanical valve will have had an event. Even then, that means 60% of the people who've had their mechanical valve 20 years will not have had a problem at all. So yes the risks are low, BUt there are things you can choose to do or not do that make your odds better.

Are you saying that the majority of people who DO have strokes past their 1st 3 months didn't have INR either too low in cases of clot strokes or too high incases of brain bleed (that weren't caused by traums or falls) strokes? IF that is the case and to quote you "more recent guidelines, with more recent valves, don't stress the importance of forming a clot on the valve" Well IF that was the case why would they even reccomend people with mechanical valves take coumadin and the risks that CAN (not will) go along with that such as brain or internal bleeds?


IF you or anyone else chooses not to believe the risk of a clot is 1-2 % every year you have a mech valve oh well, and that is the average, it is also well known and accepted that there are times when your risk of a clot go up, like low INR either because of stopping and starting for procedures or just because things happen and it went low.

There ARE hundreds of studies showing that to the point it has become a known accepted fact that having a mechanical valve is a risk of forming clots AND so you need to take Coumadin or another anticoagulant and that increases your chances of a bleed. Its why many people choose to have tissue valves, with the increase risks of "events' during REDOs. Every valve study since the beginning shows the rates of Clots and rates for bleeds for a reason. Every article about valve choice discusses the fact mechanical valves increase your odds of having a clot and so you need to take coumadin, The average is about 1-2 percent each year for the valves in use today.

Even the ON-X one of the newest, with supposedly the best chances of avoiding clots, beside the midterm results of the PROACT trials that showed patients with the lower INR had more strokes and the higher (normal INR plus aspirin) had more bleeds "The low-anticoagulant group had 2.5 bleeding events per patient-year, vs 4.4 per patient year in the control group, but the stroke rate was 1.3% per patient-year in the low-anticoagulant group vs 0.4% per patient-year in the control group. For the combined end point of stroke and thrombotic and bleeding events, the rates were 3.8% per patient-year in the low-anticoagulant group and 4.9% per patient-year in the control group".
and in the trial these were followd by the best centers and all home test.

Also the midterm, 5 year results showed the risk of clots were about 1% a year
Between 2003 and 2008, 737 patients underwent either aortic valve replacement (n = 400), mitral valve replacement (n = 282), or double-valve replacement (n = 55). Longitudinal performance, freedom evaluation, and risk analysis were assessed with regard to major thromboembolism and hemorrhage. Risk modeling was performed with 16 variables inclusive of age, atrial fibrillation, concomitant coronary artery bypass grafting, New York Heart Association class, and ventricular dysfunction.
RESULTS:
Early mortality was 2.5% (n = 10) for aortic valve replacement and 3.2% (n = 9) for mitral valve replacement. Late mortality for aortic valve replacement was 4.8% per patient-year and 6.0% per patient-year for mitral valve replacement. Five-year freedom from major thromboembolism was 96.5% ± 1.2% for aortic valve replacement and 97.7% ± 0.9% for mitral valve replacement. Five-year freedom from hemorrhage was 93.6% ± 1.8% for aortic valve replacement and 95.7% ± 1.5% for mitral valve replacement. Concomitant coronary artery bypass grafting was predictive of major thromboembolism after aortic valve replacement (hazard ratio, 5.3; P = .02) and antithrombotic hemorrhage after mitral valve replacement (hazard ratio, 4.7; P = .03). No other independent predictors of major thromboembolism or hemorrhage were identified. One thrombosed mitral prosthesis was observed after deliberate discontinuation of anticoagulation. The major thromboembolic events occurred with variation of international normalized ratio levels inclusive of subtherapeutic levels. The majority of hemorrhagic events occurred with high international normalized ratio levels.

http://www.ncbi.nlm.nih.gov/pubmed/20546795

 

[Jkm7]

Again, the only reason I even respond to post that I think are dangerous or go against what most doctors or guidelines , and even most patients who HAVE been on Coumadin for yearswill say is so new people looking for information will know the majority of people probably disagree with your "facts"



<snip>

I agree.
That is the only reason I responded to this thread.
I find some posts to potentially be dangerous to a 'brand new valver' who is starting to learn what they can about these issues.

Our doctors are always our best resources and if we aren't comfortable with the advise we get from our personal physicians, we need to look for another.

IMO

 

[Protimenow]

It would be nice if you carefully read what I wrote. I TRIED to understand Lynn's last post, but much of it made little sense to me.

I did NOT say that a person with a prosthetic valve should NOT be anticoagulated. The ideal state is to retain an INR within 'range.' This 'range' is based on the type of valve and its location. For Dick, who unfortunately suffered a stroke when he forgot to take his warfarin for a few days, the risk of stroke for that early valve was quite high and he suffered the unfortunate consequence of letting his INR drop too low. Today, the INR for someone with his type of valve should be maintained above 3.0 (the British Society of Hematology, in 1998, suggests an INR of 3.5), according to the ABCs of Antithrombotic Therapy.

I didn't report anything as FACT. In fact, as a person who was formerly involved in research and who has studied biostatistics and other sciences, I don't know exactly what a FACT is. I certainly wouldn't have labeled anything that I wrote as a fact.

The point I was trying to make was that in certain cases some researchers and clinicians don't see the need for bridging in people who meet certain conditions -- but who also have taken positive steps to bring their INRs back INTO range. I did not say that ANYONE is safe to maintain an INR that is below range. I certainly did not suggest that people with mechanical valves should NOT anticoagulate.

In many cases, if the INR is lowered for surgery or other procedures, the guidelines DO call for bridging. I didn't state that they didn't. This may come down to the surgeon or dentist or cardiologist making recommendations based on the best, most trusted, recent information. (And many of you have questioned the correctness of a particular professional's recommendations)

I didn't write anything that would make a new 'valver' not take warfarin or properly anticoagulate. SO - IF THERE ARE ANY VALVERS OUT THERE WHO COULDN'T UNDERSTAND WHAT I WROTE PREVIOUSLY - IF YOU HAVE A MECHANICAL VALVE DO NOT STOP YOUR ANTICOAGULATION THERAPY. EVEN WITH A NEW VALVE TECHNOLOGY, YOU MUST STILL CONTINUE TO MAINTAIN AN INR WITHIN RANGE.


This thread has gotten so much off target that I don't plan to post to it again....even in response to any further misunderstandings of what I've written.

 

[chaconne]

In defense of Protimenow. I don't think it's dangerous to respond with new information about research that suggests differently than the medical community currently believes as a whole. That is what research is all about. That's why several of us have selected On-X valves. We're not putting our complete trust in these new things, but we're looking for improvements that may be on the horizon to give us a better life. I think we all know to take the opinions on this site with a grain of salt. As a relative newbe, I have found all the varying opinions on this site helpful, even those who may seem far off, and I'm glad that people aren't afraid to speak them out for fear they are dangerous.

 

[lance]

I for one will not: 1. go off warfarin. 2. go off warfarin and not bridge. 3. skip a full dose of warfarin when INR is high.
Others do what is best for them.
Personal experience with warfarin is a great teacher. This is not a simple drug and is certainly not what I was told to expect from anti-coagulation therapy. My finding is it's a life-long complication to anything else medical that complicates your life requiring expert management to maintain stability. This being said it is still the best anti-coagulation treatment available to-day.