INR - How low should you go?

[pellicle]

... General i will be changing to a lower target of 1.5 in accordance with ON-X apparently

well firstly the target is 2.0 (and 1.5 is the lower bound of the range), then I'd go print out the documentation from On-X that provides those guidelines (hint, they don't recommend, they suggest its possible).

I would ask for evidence based guidelines to move away from target = 2.5 (and seek solid clarification that they grasp the difference between a range 2 ~ 3 and a target 2.5

so glad I side step all this

 

[pellicle]

@Nick Drew , did a bit of searching.

https://www.onxlti.com/fda-approval-onx-aortic-less-warfarin/

• He adds that, because the FDA’s reduced INR guidance applies only to individuals with an On-X aortic mechanical valve, all patients should check with their doctor to determine whether changes to any medical regimen are appropriate.
• Data published in 2014 in the Journal of Thoracic and Cardiovascular Surgery on On-X’s PROACT (Prospective Randomized On-X Anticoagulation Clinical Trial) study affirmed that high-risk trial patients with On-X Aortic Heart Valves who reduced their regular blood-thinning medication dosage to maintain a lower INR of 1.5 to 2.0 and took a low-dose aspirin experienced a 65% overall reduction in bleeding events with no increase in stroke rate

except of course they did have an increase (see this recent post)
They say:

with no differences in the rates of TE and thrombosis events (2.96%/pt-yr in the test group versus 1.85%/pt-yr in the standard group, p = 0.178)

https://www.acc.org/Latest-in-Cardi...0/12/16/22/01/2020-ACC-AHA-VHD-GL-Pt-3-GL-VHD

For mechanical On-X AVR and no thromboembolic risk factors: A lower INR of 1.5-2.0, starting 3 months after surgery with addition of aspirin (ASA) 75-100 mg daily (Class 2b)​

don't forget the points I've underlined.

Also, read this letter and read the fine print too
https://www.valvereplacement.org/threads/on-x-lower-your-inr-target-mailer.888652/

 

[Nick Drew]

thank you very much mate this will be a discussion when i visit Leeds in a month or so

 

[dick0236]

In my opinion, letting your INR stay at 1.5 is like "whistling while walking thru a cemetery".......just hoping you don't have a stroke! Been there, done that, and lost the bet!!!

 

[Consuela]

Last week I had a stupid accident whilst out hiking - one boot's laces caught in the lace hooks on the other boot - result was spectacular thump onto tarmac with bump to head, painful shoulder, and grazing. A visit to the Emergency Department for a CT scan (potential brain bleed) and shoulder X-Ray followed. Thankfully, both were negative.

The next morning, I checked my INR and it was 2.4. This is below my UK therapeutic range for mechanical mitral valves which is 3.0 to 4. That may well have been beneficial in avoiding a brain bleed.

It got me thinking about how low I should aim to keep my INR. Had my tumble been with an INR of 4 or even above, a brain bleed would be significantly more likely. I gather the US therapeutic range is more like 2.5 to 3.5. I am considering aiming for 2.5 - what do people think?

My range is 2.5 to 3.5. I was told by my doctor who gave me a mechanical mitral heart valve 17 years ago. I try to keep it on the lower end.

 

[pellicle]

a mechanical mitral heart valve 17 years ago. I try to keep it on the lower end.

17 years and still tikking ... glad to hear it

lower end of that range is a reasonable place to be (based on the research). Are you taking any aspirin? If you aren't (and that's fine) and ever get any indication of a TIA then my first move would be (actually was) to move to something like 75mg (of aspirin) every other day.

Best Wishes

 

[slipkid]

so here in the UK my target is 2.5. (ON-X) but recently i have been told at my next visit to Leeds General i will be changing to a lower target of 1.5 in accordance with ON-X apparently so waiting to see what happens with that.

An illustration of how the medical "experts" that control our care are usually clueless.

When ON-X first got approval here in the US to go down to 1.5-2.0 range from 2.0-2.5 range they sent a letter to me about that & said to pass it on to my Dr.

His response was " GREAT!!! I LIKE THAT!!". He didn't think about it, the consequences, the possible issues, the unbalance of risk vs reward in increasing stroke possibilities for really little if any benefit, none of that. And neither did I. Thank Dog for this forum. Because it made ME think about it then go back to him and say "y'know, I'd rather not risk dipping too low under 1.5 & significantly increase my risk of a stroke, let me try to stay at least above 2.0 as a target but be thankful if I dip below 2.0 I should still be OK". So he agreed with that & I've tried to stay around 2.0-3.0 with no worries if I even go over 3 once in a while (like what happened to me on antibiotics). I'd rather have a bleed event than an outright clot/stroke event. Just had a bleed event btw after a bad attack of ulcerative colitis. Not fun. But I survived and the bleeding stopped on its own....

 

[pellicle]

His response was " GREAT!!! I LIKE THAT!!". He didn't think about it, the consequences, the possible issues, the unbalance of risk vs reward in increasing stroke possibilities for really little if any benefit, none of that.

Yep

But always trust your doctor right?

 

[tom in MO]

Old Russian proverb доверяй, но проверяй "Trust by verify" However, when one gets a second opinion, the second person should be as competent as the first.

 

[LondonAndy]

Old Russian proverb доверяй, но проверяй "Trust by verify" However, when one gets a second opinion, the second person should be as competent as the first.

Good advice, but the trouble with medical things is that most of us don't know enough to judge the competence of either of them!

 

[V__]

Good advice, but the trouble with medical things is that most of us don't know enough to judge the competence of either of them!

It's a good point. I'd think that, as in most things, "knowing" is a matter of degree though. Sometimes patient reviews are available. And there can be signs during the visit. As an extreme examples:

• My cardiac annual surveyance started with a former PCP saying "Your heart murmur sounds worse than last time. Let's get checked out by a cardiologist." This was during an annual physical. That blew my socks off. She clearly remembered what it was "last time" -- a year before. Since then I understood that the murmur was indeed loud, and may be unusual enough to remember. Still, retaining the memory a year later was very impressive, and the pro-active followup strategy was great.
• The first visit with the cardiologist was "interesting" in a different way. They guy asked my age, symptoms, then basically said "Then why are you here?" That was the end of the visit. I requested to never see him again.

 

[Protimenow]

The company that made your valves should have sent you a card describing the valve, giving a serial number and date implanted, probably a contact number for the manufacturer, and maybe information about MRIs. You keep this information in a wallet or purse.

I'm not aware of any valves with metallic parts - although there MIGHT be some - and I'm not sure about stents having components that are sensitive to MRI magnetism.

As for me, personally, I can't get an MRI for the rest of my miserable life -- when I got a different pacemaker, the surgeon left a lead that, of course, couldn't be removed, and couldn't be attached to the new pacemaker inside my body. For some reason, the pacemaker can be reset to allow MRIs to be done, but this solo lead will cause problems with MRIs. I don't particularly want this lead to be pulled through my chest, ripping any tissue in the way.

 

[pellicle]

The company that made your valves should have sent you a card describing the valve, giving a serial number and date implanted, probably a contact number for the manufacturer, and maybe information about MRIs. You keep this information in a wallet or purse.

I think this varies from location to location.

 

[ClickerTicker]

The company that made your valves should have sent you a card describing the valve, giving a serial number and date implanted, probably a contact number for the manufacturer, and maybe information about MRIs. You keep this information in a wallet or purse.

I'm not aware of any valves with metallic parts - although there MIGHT be some - and I'm not sure about stents having components that are sensitive to MRI magnetism.

As for me, personally, I can't get an MRI for the rest of my miserable life -- when I got a different pacemaker, the surgeon left a lead that, of course, couldn't be removed, and couldn't be attached to the new pacemaker inside my body. For some reason, the pacemaker can be reset to allow MRIs to be done, but this solo lead will cause problems with MRIs. I don't particularly want this lead to be pulled through my chest, ripping any tissue in the way.

Yes, my MRI has been held up for some days whilst I battled through the "privacy team" at the private hospital group that did the op 20-odd years ago. I did eventually manage to set up a medical team to medical team communication so the MRI team at the public hospital could get the info directly from the private medical records team. I also finally got the info needed sent to me personally as well (after a further sign-off) - basically, although I had the make (Carbomedics) and the size and serial, I didn't have the exact model. I now do have that and have added the info to my Medicalert profile and personal records. So, if you have a card - make sure you copy it and try not to lose it!

I'm surprised that your stray wire is causing such problems, my first assumption would have been that it would have a non-magnetic copper core. Maybe I'm wrong and implanted wires must be stainless steel or titanium or something else that doesn't react or potentially break down in some way.

 

[Chuck C]

The first visit with the cardiologist was "interesting" in a different way. They guy asked my age, symptoms, then basically said "Then why are you here?" That was the end of the visit. I requested to never see him again.

Good for your doctor to refer you to cardiology. Also, good for you to requrest to never see him again after his dismissive attitude. Always self advocate. Sometimes that means firing an "expert" who acts obtuse.

 

[Protimenow]

Yes, my MRI has been held up for some days whilst I battled through the "privacy team" at the private hospital group that did the op 20-odd years ago. I did eventually manage to set up a medical team to medical team communication so the MRI team at the public hospital could get the info directly from the private medical records team. I also finally got the info needed sent to me personally as well (after a further sign-off) - basically, although I had the make (Carbomedics) and the size and serial, I didn't have the exact model. I now do have that and have added the info to my Medicalert profile and personal records. So, if you have a card - make sure you copy it and try not to lose it!

I'm surprised that your stray wire is causing such problems, my first assumption would have been that it would have a non-magnetic copper core. Maybe I'm wrong and implanted wires must be stainless steel or titanium or something else that doesn't react or potentially break down in some way.

It was a bit surprising to me, too -- the new leads on my pacemaker are probably also made of the same material as the old lead. Maybe (just maybe), the pacemaker will keep the lead from flying out of my chest by restricting their movement. Without an anchor like a pacemaker to attach it to will not offer any resistance to a flying lead.

 

[ClickerTicker]

It was a bit surprising to me, too -- the new leads on my pacemaker are probably also made of the same material as the old lead. Maybe (just maybe), the pacemaker will keep the lead from flying out of my chest by restricting their movement. Without an anchor like a pacemaker to attach it to will not offer any resistance to a flying lead.

I just had my MRI, seemed to be in the thing for a long, long time - at least 30 minutes. The radiologist said it was because the pituitary gland they had to scan was so small they needed it in great detail. Apparently, it takes longer to do just the pituitary gland than it does the whole brain - hmmm. Canula site from the dye infusion looks to be still bleeding a bit. Anyway, I digress.

Back to wires... as my MVR was over 20 years ago and surgically very challenging (endocarditis had munched things up) - it was open heart. The MRI team weren't worried about the wire that was used to hold my sternum together afterwards, which is still in place. They said it was long enough ago that it didn't matter. I'd guess the bone has by now grown around it and it isn't going anywhere no matter how much field it is subjected to.

 

[pellicle]

They said it was long enough ago that it didn't matter. I'd guess the bone has by now grown around it and it isn't going anywhere no matter how much field it is subjected to.

Weird, the actual aspect is that surgical wires are not ferromagnetic AFAIK

 

[SatoriFound]

The table I was quoting from is from the UK's "NICE" - National Institute for Health and Care Excellence" document on warfarin anticoagulation. It's pretty much the same as yours but doesn't specifically mention valve types - so thanks! Nice to know my Carbomedics valve is low risk (no pun intended).
CKS is only available in the UK

Slightly off topic, but on reviewing the CT scan done for my fall they also discovered I've an enlarged pituitary gland. I now need an MRI scan. Now that's a whole new can of worms as each valve has its own limit on how powerful an MRI scan should be. The MRI booking folks wanted exact details of my valve - luckily, I do have them recorded. Not everyone may have this info to hand, and you never know when you're going to need an MRI. Maybe they should tattoo implant details somewhere inconspicuous but standard, like under the armpit (that was meant as a joke, but doesn't sound such a bad idea on reflection).

You could put the details on a medical alert bracelet. Far less permanent in case you end up with a different valve for some reason later in life. HAHA

 

[Protimenow]

Behind the knee. Or, perhaps, inside one of the glutes (if the tattoo artist can separate them enough -- and OUCH -- maybe not the best place for a tattoo -- but it seems that, because just about EVERYTHING gets pierced these days, maybe a tattoo in an unexpected place MIGHT not seem so strange).