INR Level & Coumadin Clinic

[INRtest]

I'm confused (& a bit worried) about my INR. Before I found this forum and all the info on the correct INR for an artificial MV, my cardio wanted my INR in the range of 2.0 to 2.5, because I had a subdural hematoma when I was in the hosp and she was (is) worried about bleeding.

Last Mon. I tested at 1.8 so we upped my dosage from
5mg x 3.5 days & 7.5 x 3.5 days (every other day) up to
5mg x 5 days & 7.5 x 2 days

I was told to re-test in 2 wks. on 06/20. For these 2 wks. I won't have ANY alcohol (I usually drink 0 to 2 drinks/week) and I'm watching my Vit k intake.

I live in L.A., yet I can't find a Coumadin Clinic. I contacted several clinics and either they are no longer in business, or they're connected to the VA or an HMO. There is one clinic, not as close as the lab where I get my monthly blood testing, but I'd have to see a dr. in that group and I want to continue with my own Cardio. What to do?

 

[Guest]

Old dose

5 X 3.5 = 17.5
7.5 X 3.5 = 26.25

17.5 + 26.25 = 43.75 av mg per week for a 2 week period
_________________________

New Dose

5 X 5 = 25
7.5 X 2 = 15

25 + 15 = 40 mg/wk
__________________________

In an effort to raise you INR you warfarin manager lowered your dose ???

And convinced you that it was increased???

You do need a new warfarin manager.

Have you looked at www.acforum.org and clicked on "clinic locations" ?

If you were my patient and your INR was only 0.2 units below your desired range and had a history of subdural hematoma, I would not have "increased" your dose.

 

[INRtest]

Old dose
5 X 3.5 = 17.5
7.5 X 3.5 = 26.25
17.5 + 26.25 = 43.75 av mg per week for a 2 week period
_________________________
New Dose
5 X 5 = 25
7.5 X 2 = 15
25 + 15 = 40 mg/wk
__________________________

In an effort to raise you INR you warfarin manager lowered your dose ???
And convinced you that it was increased???
You do need a new warfarin manager.
Have you looked at www.acforum.org and clicked on "clinic locations" ?
If you were my patient and your INR was only 0.2 units below your desired range and had a history of subdural hematoma, I would not have "increased" your dose.

Correction: It was increased to 5.0 x 2 & 7.5 x 5 (10 + 37.5 = 47.5)
I thought that it should be between 2.5 & 3.0 with an MVR?

I looked at www.acforum.org for a clinic and as I said, either they were out of business, didn't respond to my e-mails, were connected to an HMO & then I think I found one attached to Cedar's Sinai Hosp., but then I need to be under the care of a dr. there. I may do just that and then continue to see my cardio as needed.

 

[geebee]

INRtest,

I used to see a great internist at Cedars-Sinai. If you would like his name, just send me a PM & I will provide the info.

 

[Gemma]

I was told to re-test in 2 wks. on 06/20. For these 2 wks. I won't have ANY alcohol (I usually drink 0 to 2 drinks/week) and I'm watching my Vit k intake.

To quote Ross - "dose the diet, don't diet the dose". If you're intending to give up alcohol forever and continue to "watch" your vitamin K intake, fine, but if you're only doing it for a fortnight to try and get your INR in range, don't do it! You'll get your INR stable much quicker by just doing what you normally do and having the dose adjusted accordingly. Moderation and consistency are the key factors.

BTW, I was under the impression the usual INR range for a mechanical mitral is 3.0-4.0, and for mechanical aortic 2.0-3.0. Unless the guidelines have changed again? With your subdural hematoma it presumably needs to be a bit lower - Al will be able to tell you.

Gemma.

 

[ALCapshaw2]

One of our members, Gisele, had to have her mechanical valve replaced (after many years) with a tissue valve because of her subdural hematoma and brain bleed risks. You may want to read through some of her posts.

'AL Capshaw'

 

[Ross]

The thing that gets me is the narrow window of 2.0 to 2.5. It's nearly impossible to manage a window that small.

 

[Guest]

The UK uses an upper limit of 4.0, but the US lowered it to 3.5 about 10 years ago.

 

[Gemma]

The UK uses an upper limit of 4.0, but the US lowered it to 3.5 about 10 years ago.

We had to convince Jim's local hospital that his INR range should be 2-3 with his aortic mechanical (well, the ER doc he saw a month post-op wanted it at 3-4 "as they do for all patients on warfarin" (I assume they meant those with mechanical valves, but who knows!) and didn't believe we knew what we were talking about). We ended up having to get written confirmation from Jim's surgeon and forwarded it to his anti-coag cinic. They were fine with it though so maybe just the doc in the ER was having a bad day...

 

[Gemma]

I also recall reading something which had a table of US and UK INR ranges - the UK is 1 higher in general, so aortic would be 2-3 US (and Jim's surgeon and hospital where he had the surgery followed these guidelines) but in the UK it's 3-4. I have a feeling mitral in the UK is 3.5-4.5. They were based on a study a few years older than the US recommendations were though. Maybe by now we're more in line with the US.

 

[ClickerTicker]

UK INR Levels for MVR

UK INR Levels for MVR

My cardiologist (Southampton General) has set mine at 3.0 to 4.0 for my MVR. I normally tend to keep it to the upper end of that limit - maybe I'll make an effort to keep it in the 3.0 to 3.5 in future after reading some of the bleed risk issues here.
It's hard though, even with a Coaguchek, to keep an INR like mine in that tight a band... it has made lurches from values like 3.7 to 7.1 in a week - with no obvious change in anything and on a dose that has been stable for several weeks.
I self-test and self-dose weekly at a minimum.

 

[Gemma]

Hello Ron,

From what I understand, INRTest has a susceptibility to subdural hematoma and this is the reason he's been told to keep his INR lower - if it was in the normal range for a mitral valve and he had another hematoma the bleeding could be dangerous.

For you though, I'd suggest you speak to your cardio/GP before lowering your INR range. It does need to be a bit higher with a mechanical mitral valve as the clotting risk is slightly more than with a mechanical aortic valve. Also, as Ross pointed out keeping in a narrow 0.5 range is pretty difficult, so 3.0 - 4.0 is probably fine. Al has said before that in his clinic he doesn't worry unless a person's INR is above 5.0. And to quote someone else (maybe Al again), "It's easier to replace blood cells than brain cells".

If you're worried, check out this story from Al Lodwick a few months ago. Kind of puts an INR of even 7.1 into perspective! http://www.valvereplacement.com/forums/showthread.php?t=9684

Gemma.

 

[ClickerTicker]

Gemma - thanks for the pointer to Al's thread - wow, that guy must have been a rat in a previous incarnation!
With my 7.1 - I did have an initial panic attempt to see if I could get my Coaguchek reading verified with a venous sample - but I was on a small island off the mainland and it would have involved a boat to the main island, clinic sample, sample being helicoptered to the mainland for testing etc. etc. etc. So I just stopped warfarin for 1 day and it was down to 4.8 and carried on with a slightly lower dose until it dropped below 4 after about a week.
BTW, I keep all my INR readings in a database on my Palm Pilot which syncs with my PC - very useful for historical info.
An an aside, I starting talking to a cardiologist in Australia about my "Palm Pilot" records and he told me it was not a wise description to use in Oz - apparently it is local slang for a particularly male sort of self-abuse...
Ron

 

[Guest]

If I were a rat, the stuff would have killed me by now.

 

[ClickerTicker]

Al - I certainly didn't aim the rat comment at you...
It was for the guy with the INR at 398.5 - really amazing!

 

[Guest]

Even when I thought it was about me, I laughed.