INR for mechanical AV

[MtBiker]

I'm due to have AVR and my ascending aorta replaced in a few weeks. I'm 52 and a very active biker, kayaker and skier. I've considered the Ross but ruled it out due to risk. I'm now deciding between a tissue valve and a mechanical valve. My surgeon says a St Jude's would be a good choice and that he routinely manages INR for active patients with mechanical valves between 1.8 and 2.2.

My questions are:

Does anyone out there have a mechanical valve being managed in that range?
How difficult is it to stay within a range that small?
What sort of bleeding issues do people experience at that INR?

Thanks in advance!

 

[Paul1401]

Hi,
I have a mechanical aortic valve (which one I don't know). My range is 2.9-3.9 by my doctor, although my surgeon said 2.0-3.0. Anyway, since the operation in 2001, I have gotten myself 4 black belts in jujitsu, had a crack at some mma and use a doubled edged razor, which I am thinking of upgrading to an open razor.
I have the odd bruise from some heavy hits in jujitsu, and the odd nick from the razor but that was because I let the blade go blunt !
Dental work is fun though !!!

 

[dick0236]

My questions are:

Does anyone out there have a mechanical valve being managed in that range?
How difficult is it to stay within a range that small?
What sort of bleeding issues do people experience at that INR?

Thanks in advance!

Welcome to the forum.
A range between 1.8-2.2 seems low based on what most posters report for the newer valves.....and does not leave much margin for error at the low end, since 1.0 is the norm for unanti-coatgulated people. The usual range is 2-3 or 2.5-3.5....mine is 2.5-3.5, and I am comfortable ANYWHERE in that range, but I am OK between 2-4, although those extremes occur very seldom and I adjust(slightly) whenever I approach the extremes.
It would be pretty difficult for me to stay in any range that is as narrow as you indicate....and unecessasary??
I have never been able to notice any unusual issues with bleeding in all the years I have been on warfarin(45+). During my working years I shaved with a safety razor...nicked myself fairly often. I have had the normal cuts and bruises to be expected during my years, including cuts that required stitches. I did teach myself "not to run with scissors". My only problem with warfarin came as a relult of letting my INR get too low(went on vacation without meds and suffered a stroke). That experience, about 39 years ago, is the only problem I have had with warfarin and I am much more concerned with low INR numbers, than high numbers. We have a saying on this forum...."It is easier to replace blood cells than brain cells".

 

[Protimenow]

I agree with the others -- 1.8-2.2 is a very tight range. Compounding the issue is the fact that INR testing is still not without error. (One of my goals is to find a testing method that is most accurate -- I regularly test with one or more of 4 different meters, and do occasional blood draws at a lab. I've had blood draws at two different labs - within hours of each other - and had VERY different lab results. There is usually a difference between two of my meters - and two other meters. It is sometimes troublesome or challenging to figure out WHICH result I want to believe.)

With a goal of 1.8 - and the possibility that a test - ANY test - may report a 1.8 and your actual INR is closer to 1.5 - scares me.

As Dick and others have noted, keeping within a range of 2.5 - 3.5 or so isn't that big a deal. If you cut yourself, you won't bleed to death. Dental extractions can be a bit of an issue - but can be dealt with. Don't do what I did years ago, and drop a 50 pound marble slab on your foot.

At your age, it seems to make the most sense to go with a mechanical valve (although there are supposedly tissue valves that can last 20 years or more - and by the time a tissue valve starts to fail, there may be non-invasive techniques to fix a failing tissue valve).

I don't worry about maintaining an INR of between 2.5 and 3.5 (allowing for a margin of error, this may be more like 2.2 - 3.8 or so). I don't think that you should, either. Personally, I WOULD be concerned with maintaining a target INR of 1.8-2.2. Even if this ultimately is demonstrated as the safe range for someone with your valve, you won't be hurting anything by staying within a slightly higher range that has been proven to be safe over decades of use. I'm not trying to contradict your doctor -- but you have to consider how much risk you're taking if you decide to maintain a slightly higher INR than what the doctors recommend. Millions of us already do, and we seem to be doing okay.

(One more suggestion -- if you choose to go with a mechanical valve, get a meter, learn to use it, and test weekly once your INR is stable. It's empowering to have some control over your INR, and, to me at least, makes a lot more sense than the monthly testing that some doctors or labs are satisfied with. It also saves a trip to a lab or doctor's office)

 

[DavesMom]

HiYa,

I have to agree with Dick that 1.8 - 2.2 seems a bit low. My range is 2.5 - 3.5. My valve and I have been together fourteen years and (fingers crossed) I've had no bleeding issues. I think it helps that I am - sad to say - the most boring eater in the world. My diet doesn't change much so that has helped me stay in range for the most part.

At your age I would tend to go mechanical (got mine when I was 42) to hopefully avoid a second surgery. Best of luck with your decision!

 

[Superman]

That range goal is very tight. Doesn't give much wiggle room to find out how your metabolism reacts to different foods. Cranberry juice throws me through the roof, for example. TMI - but after pissing blood, I found out my INR was over 10 a few years ago after indulging a bit much (I like my juice, okay!). I've experimented since then with that being the only variable and realized it's best that I avoid it.

Not everyone responds this way to cranberry juice, and not everyone is as sensitive on the downside to leafy greens. Giving yourself a 0.4 range that's already below the low side of the typical mechanical valve patient target doesn't give much margin for error. My target range is 2.5 - 3.5 for the record. I understand 2.0 - 3.0 is also provided as an acceptable target range.

Seems like given industry recommendations your physician is opening himself up to unecessary liability by purposefully managing patients outside of those recommendations. Be a pretty easy lawsuit if one suffers a stroke and can provide a patient file showing that their doctor managed them to a target range that included numbers lower than 2.

 

[ski girl]

Hi MtBiker-

I can't tell you what bleeding issues you'd experience at an INR ~2.0 as mine is ~3.0 - but I can tell you about my bleeding non-issues! I'm also a keen mountain biker and paddler (mainly ocean surf skis). I have been cracked HARD on the head in the surf zone by my boat, had to paddle 1/2 hour upstream to get help, and it was two hours later before I made it to the hospital where they were not concerned about any internal bleeding. I crash off my MTB once a ride on average and have a nice collection of bruises to show for it, and frequently get cut, but I've never had any issues.

However if you prefer to race down rapids and get bashed on rocks a lot, or you're a much faster MTBer than me and have crashes where you break bones (or anything else that would land you in hospital anyway!), then I'd lean towards a tissue valve and just accept that you'll be having another OHS in 10-20 years. That was actually my choice with my first valve (at 39 years old) which had to be replaced 11 months later due to endocarditis.

I've definitely found that I'm not nearly as fragile on warfarin as I had been led to believe, but if I was riding hard and taking more risks I'd certainly prefer to be non-warfarinised.

And I agree with others, 1.8 is really low and leaves you open to strokes.

Good luck!

 

[MtBiker]

Thanks for all the responses. One factor in my decision is that there are several ongoing studies to look at reducing the inr range for mechanical valves or replacing warfarin with a new class of platelet inhibitors that are easier to dose and have fewer bleeding issues. I'd hate to get a tissue valve and a year later find that the protocols had changed. It's just that I don't eat a regular diet. I tend to binge after a workout and then often skip lunch. I'm not good at routines though i have been on a calcium channel blocker for years and find that no problem. I travel overseas once or twice a year so it's attractive to go without warfarin. Bleeding risk I'm getting more comfortable with. I don't flip much in my kayak and probably only have one or two bloody bike crashes a year where the blood is mostly from the shins and elbows. If only there were a perfect solution!

 

[pellicle]

Hi

I've got a mech and an ascending aorta. My INR range is 2.2 ~ 3

It's just that I don't eat a regular diet. I tend to binge after a workout and then often skip lunch.

that sounds like me, my INR tends to remain within range with just weekly checking and minor adjustment to dose.

I'm not good at routines though i have been on a calcium channel blocker for years and find that no problem.

what if you learned to change? I mean after all ... the surgery is a life changing experience right?

I travel overseas once or twice a year so it's attractive to go without warfarin.

I go overseas a fair bit too ... why not just take some with you? I mean really its not like you go weekly.

If only there were a perfect solution!

there was ... and you were born with it and you had it for some years. Now the choices are different. If you got sick and developed acquired diabetes and required insulin would you stop your plans? That monitoring is far more onerous than Warfarin is.

I genuinely think this is just a case of 'coping with change' ... that and assessing the actual risks rather than the imagined ones.

I also monitor my INR with a Coaguchek.

 

[pellicle]

Sorry to answer this out of order

My questions are:

Does anyone out there have a mechanical valve being managed in that range?

someone for sure, but its in the minority. Most will have a slightly wider range. I don't really understand why not go over 2.2 ... perhaps the particular medioc is not well educated on the issues?

How difficult is it to stay within a range that small?

Perhaps a bit tight no matter who manages you, if you can accept going a bit higher, then piece of cake if you monitor yourself. I don't think that's particularly a small or narrow range but then I'd also tolerate going higher by up to 3 without any panic. I'd go higher without issue than go lower. Ask around, but some people will say higher (like mine) is more reasonable.

Below is a segment of my personal log of INR data

You can see that I trend around an area ... I try to keep my INR around 2.6 ... although some would say "sit higher and have less risk of falling lower" ... lower is where you risk a clot. There were a few "whoops, I missed a dose" events there too.

What sort of bleeding issues do people experience at that INR?

I think you need to go to INR of more like 4 or higher before bleeding is an issue.

unless you're elderly and frail with fragile skin. Hemorrhoids?

 

[Gail in Ca]

I got a mechanical AV inside a hemashield graft and like you, I was told a range of 2-2.5 was fine, even if it went down to 1.8, that was okay, too. Something about the stitching on the outside makes for less clotting risk, hence the lower range. (most normal mech AV range is 2-3.0 and mitral mech range is higher 2.5-3.5). I tried for awhile to keep that tight range, and it worked pretty well, but when it went down to 1.6, my cardio said to increase the range to 2-3.0. So, that's where I'm at and it stays in that range very well. As far as bleeding, I don't notice that I bleed more at 2.2 or 3.0. I am at 2.2 today and my dog scratched me on the foot last night. It bled quite a bit, I had to put a bandaid on it overnight. When your INR is double normal and up, you bleed more. That's how it affects me anyway.

 

[RobThatsMe]

Hi,

OK, here is my response to your concerns. I have had 2 mechanical valves within the last 12 years. My first was a St Judes, my second is an On-X. My first didn't fail, but my body rejected it by building panus tissue under the valve, and blocking the blood flow.
The On-X has a newer design that helps against panus issues.

During my 12 years I traveled extensively with my job, I traveled overseas and back every 2 weeks. Coumadin was a non-issue.
As far as your INR range, per your doctor, I totally agree with the others, it's tolerance range is way too low. Seriously, an INR between 2 and 4 is OK. below 2, you risk stroke, above 4 you risk hemorrhage. Of course both risks increase the further out of tolerance you go. So you have to ask yourself, do you really want to gamble with such a low tolerance when others are perfectly fine living for years with a higher tolerance range. I personally aim for a 2.5 to 3.5 range. This gives me peace of mind. I try to target 3.0 and mostly stay within my range. I home test every two weeks, and make adjustments to my Coumadin dose as needed.

My advice, no valve is guaranteed for life. Yes, my mechanical was according to all the doctors and mfgrs. But, it was not the valve that failed, my body rejected it. Some folks are prone to pannus development. Tissue valves also have their issues with longevity.
Re-surgeries are not fun, and they don't get any easier with each time you have one, either from age, or from they fact that the surgeons have to deal with scar tissue from the prior surgery.

As one member posted earlier, you are going through a life changing event. Some things do have to change as a result of that. The percent of change is up to you, but it can be managed.

Good luck, and good health,

Rob

 

[Heart Of The Sunrise]

My INR and Coumadin dosage seem to be stabilizing. When I left the hospital I was told to aim for 2.5 to 3.0. My last test was on May 6th. My INR was 3.2. My next test is not until May 24th. My last couple tests have been 3.2. I have had a couple minor cuts. The pressure of a band-aid wrap stopped the bleeding fairly quickly. So I feel good with my INR at 3.2. I would not feel safe nor is it advised to have an INR of 1.8 to 2.2 with my ON-X valve. MTbIker I just turned 57. I had my entire ascending aorta replaced. I love my new ON-X valve. I am doing fantastic! Good luck with your surgery. I went with the ON-X over the St. Jude for many reasons. But,as RobThatsMe mentioned the ON-X is designed to reject pannus growth which can adversely affect valve function as it did with his St Jude valve. Longevity runs in my family. My mother will turn 90 on her next birthday. I could not imagine knowing that I would need several replacements of a tissue valve, this was another reason for my choice of the ON-X.

 

[sood]

I just got an on-x valve. My target INR is 2 - 3. Still haven't stabilized, I've hit 2.0 once and have been around 1.7.

 

[tom in MO]

I am like Gail. I had a St. Jude put in last year. I take low dose asprin and warfarin. Like Gail "I was told a range of 2-2.5 was fine, even if it went down to 1.8, that was okay, too." My doctor said that some go well with just asprin, but the statistics say warfarin is indicated. Once I stabalize, within the last year, I found it easy to maintain 2-2.5 with two caveats. First I do biweekly testing at home. Second, when I travel, get sick, or take drugs that may interfere, I call my coumadin clinic and test and adjust more often when needed.

My only real hicupp was being bit by my brain tumored, blind, arthritic and allergy suffering dog 3 weeks ago. It was also my first real negative experience with a dog bite. I have been bitten often, but not as hard and I never got infected. My hand and half my forearm swelled up. I became a one-armed man. They had me on massive oral doses of penecillin and Cipro with routine injections of penecillin every three days. This threw my digestive system in a loop. I went down to 1.8, then 2.5 and up to 3.3. Right now, I am working on going back down. To me, not a big deal compared to OHS ; but I am very happy to be home testing and discussing things with my clinic.

 

[hannahsmom]

My daughter has a Carbomedics AV and her cardiologist likes her to be between 2.5-3.0 (She averages between 2.6-2.8 usually). Her "safe" range according to her cardio is 2.5-3.5. She had a two month period where she was around 2.2 which they contributed so some lifestyle changes, growth, etc and they up'd her dose to get her back into range. I am not sure how much it varies between each type of valve, but most of the literature I have read states 2.5-3.5. Her doctor has a anticoagulant nurse on staff, so may be your cardio may have someone on staff that can give you an informed answer. I will say that Hannah being at the range she is we do not notice a significant change in bleeding, so please do not fear the slightly higher range if the 1.8-2.2 is not sufficient.

 

[Protimenow]

Personally, regardless of the valve, I would still feel safer with an INR of 2.5-3.5. I have had my INR below 2.5 on occasion, and it's rather scary considering that there's an increased possibility of a clot forming on the valve. Being at 2.5 - 3.5 - or even somewhat higher - hasn't been an issue for me, and I don't think that many others on the forum had any really significant issues with that slightly higher INR.

I dropped a heavy hunk of marble on my foot many years ago, and got a big bruise that would probably not have been as large or as persistent as it would have been if I wasn't taking warfarin. I got a concussion a couple years ago when a dishwasher was dropped on my head (don't ask) -- an MRI revealed that there was no bleeding in my head, and my INR at the time was 2.9. I don't know that a 3.5 or a 4.0 would have increased my risk of a brain bleed.

I don't know that it's been demonstrated in a large enough population of people with some of the newer valves that aspirin alone provides adequate protection from clot formation. I don't know if it's been demonstrated in a large enough population of people with some of the newer valves that lower INRs are really safe. Sure, a 1.8 means that it takes 1.8 times as long to form a clot as it does with those who are completely uncoagulated - and this may be safe - but with a margin of error for the INR testing, a 1.8 could be more like a 1.6, and I don't know that I'd feel all that safe with the possibility of an INR that low.

Having an INR above 2.0 isn't a terrible, life altering thing. I personally feel safer with a somewhat higher INR (since it's really not a problem to have the higher INR) than if I was near the bottom of my range. I suspect that others--even those with newer valves that are reportedly less prone to clot formation - also feel a bit safer at the higher end of their ranges.

(If you don't have a meter--other than the costs involved -- I believe that it's a good idea to self-test weekly, no matter what some doctors may suggest)

 

[tom in MO]

My valve design is not new and it has the lower range of 2-2.5. I want my INR within range, and if the range is low, all the more better...it makes me more "normal".

I have seen many accidents and fights in my life that involved external and internal bleeding and I don't want to bleed out due to an INR higher than it needs to be.

Your blood clots for a good reason. Nobody wants to be a hemapheliac.

 

[yotphix]

This has been covered pretty well from top to bottom, but I'd just like to throw my own thoughts on the pile.
First, based on my own experience, you'd go nuts trying to maintain an INR in any specific range that narrow, unless you were willing to accept results outside the range, in which case you'd really be fooling yourself, wouldn't you? That is, whichever values outside the range were considered acceptable, would really define the range, not the stated numbers.
Second, 1.8, while it is well above the 1 value of the un-anticoagulated, is, from my reading, the very minimum value which confers a legitimate, measurable level of protection. Since the test equipment and processes, whether at home or in lab, have margins of error, I'd try to steer clear of that by a least a few 10ths.
Finally, I've kept in my range of 2.0 - 3.0 without trouble for coming up on 4 years now, since my AVR with a Carbomedics mechanical. I also take 81mg aspirin. While anti-coagulated I've been knocked on the head, hit in the face with a 2x4, fallen off a bicycle, and had my hand slammed in a car door. I've worked at two different very physical jobs, with hard knocks dealt to me every day, I've cycled, motorcycled, inline skated, jet-skied, sat for four tattoos, travelled several thousand miles at sea, flown 2 dozen plus flight segments across 22 time zones (10 forward and 12 back), got married 3 times in 3 countries (same woman, different friends and family!) and had a new baby(well, my wife did all the work, but I get half the credit!). None of it has killed me, and only the thumb in the car door and the baby forced me to cross the threshold of the hospital.
Believe me, a little anti-coagulation doesn't need to hold you back, even if it stays in the upper 2's as mine generally does.
P

 

[Protimenow]

Tom:

An INR that is even as high as 4 is certainly nothing like 'hemophilia.' An INR that is maintained between 2.5 and 3.5 shouldn't change your life.

HOWEVER -- given the possibility of error in measuring your INR, if you are comfortable with your INR being 'around 2.0', it may actually be somewhat lower. An INR below 2.0 - possibly as low as 1.6 or 1.7 - can definitely put you at risk of stroke. I know. And I know that my meter, at the time, reported that I was above 2.0. If you shoot for 2.5-3.0 (still a tight range), even if your meter reports .4 higher than your actual value, you'll still have an INR above 2.0, and will probably be less likely to form clots on your valve than if you aimed at 2.0.

Although I don't know if there's anything magical about being at or above 2.0, I personally don't want to risk having my INR at that level. A 2.5 - or even a 4.0 - would make you far from being a 'hemophiliac', and as far as feeling 'normal', this really shouldn't make much difference in daily activities. Just don't have disagreements with a chain saw or pair of brass knuckles, and you should be okay.