INR levels for aortic valve position

[Cozycat]

I'm 11 weeks out of surgery now and love my new mechanical aortic valve. But getting the INR to stabilize is challenging...the longest I have gone without a blood test so far is 8 days. My INR has been very close to 2-2.1 for the past couple of weeks but they (Coumadin clinic) is increasing the dosage slowly so hopefully Friday will show higher results.

My reason for starting this thread is that in the book "Your Heart: An Owner's Guide" by Drs. Elefteriades and Cohen from Yale, they talk about the aortic position for the mechanical valve being highly unlikely to form clots (least likely of all valve positions) and that they try to keep patients with only AVR at an INR of 1.8 to 2.2. My Coumadin clinic says the usual level of 2.5-3.5 is where I need to be. My dosages for the last three weeks have been 16.25 mg, 17.5 mg then 18.75 the third week and scheduled to take the same this week.

Any thoughts on this by you long time users?

And I feel the need to thank so many of you again...particularly those of you who have been at this for years and continue to do it so that the rest of us who have just gone thru it have a place to look for answers. Each of you convinces me daily that love is still alive and well on our beautiful planet.

Midge

 

[ALCapshaw2]

No wonder the Medical Community can't get their act together regarding AntiCoagulation... They're all reading from different "Bibles"!

MY understanding is that the 'standard' (if there is one) range of INR for Aortic Valve Recipients with NO other risk factors is 2.0 to 3.0 If there are additional Risk Factors (stroke, TIA's, etc.), then they bump it up to 2.5 to 3.5

For completeness, the 'standard' range of INR for Mitral Valve Recipients is 2.5 to 3.5. With additional Risk Factors, there seems to be a lot of divergence of opinion. Many are told 3.0 to 3.5. some are told 3.0 to 4.0

I predict it will be a LONG TIME before there are uniform standards agreed upon throughout the medical community in the USA, much less the world.

'AL Capshaw'

 

[Philip B]

Range

Range

My cardiologist subscribes to the preference of having AVR patients in the 2.5-3.5 range; however, he believes that a minimum of 2.0 provides an adaquate level of protection on those occasions when I drop below 2.5.

-Philip

 

[acr]

I got told my target range was 2.5 - 3.0

Then went to the anti-coagulation clinic and they said thats too narrow a range and you'll never stay within it, so my new range is 2.5 - 3.5.

 

[Ross]

I'm 11 weeks out of surgery now and love my new mechanical aortic valve. But getting the INR to stabilize is challenging...the longest I have gone without a blood test so far is 8 days. My INR has been very close to 2-2.1 for the past couple of weeks but they (Coumadin clinic) is increasing the dosage slowly so hopefully Friday will show higher results.

My reason for starting this thread is that in the book "Your Heart: An Owner's Guide" by Drs. Elefteriades and Cohen from Yale, they talk about the aortic position for the mechanical valve being highly unlikely to form clots (least likely of all valve positions) and that they try to keep patients with only AVR at an INR of 1.8 to 2.2. My Coumadin clinic says the usual level of 2.5-3.5 is where I need to be. My dosages for the last three weeks have been 16.25 mg, 17.5 mg then 18.75 the third week and scheduled to take the same this week.

Any thoughts on this by you long time users?

And I feel the need to thank so many of you again...particularly those of you who have been at this for years and continue to do it so that the rest of us who have just gone thru it have a place to look for answers. Each of you convinces me daily that love is still alive and well on our beautiful planet.

Midge

Midge the usual is 2.0 to 3.0 for aortic without other clotting issues. 2.5 to 3.5 for those of us who have stroked before.

Your clinic just isn't being aggressive enough in getting you where you need to be. I just figured you up to 19.25mg for the week, so they are only doing little 5% increases. Not a bad thing, just could be better.

Yale education must be very poor now a days. I'd love to see either of those guys keep someones INR in that tiny window. It's virtually impossible. Why do these people think INR is some kind of constant? Years and years of papers and studies and not one of them is on the same page yet.

 

[EVELYN]

2.5 to 3.5 is the range our surgeon and cardio both gave us. That's what we go by.

Evelyn

 

[catwoman]

My reason for starting this thread is that in the book "Your Heart: An Owner's Guide" by Drs. Elefteriades and Cohen from Yale, they talk about the aortic position for the mechanical valve being highly unlikely to form clots (least likely of all valve positions) and that they try to keep patients with only AVR at an INR of 1.8 to 2.2. My Coumadin clinic says the usual level of 2.5-3.5 is where I need to be. My dosages for the last three weeks have been 16.25 mg, 17.5 mg then 18.75 the third week and scheduled to take the same this week.

Midge:
I have that same book and it's pretty good. I found Dr. Elefteriades' e-mail address and sent him my thanks for publishing the book.

However -- 1.8 to 2.2 is toooooooooooo narrow of a range. Someone would yo-yo around trying to hit that range.
Your INR and dosages will bounce around for awhile. Don't get discouraged; we've been there, done that.

 

[Bina]

Midge, with my AVR (and no other issues), my surgeon gave me a range of 2.5--3.5
I have also been told not to freak out if it should temporarily drop a bit lower than 2.5,
but anything below 2.0 would warrant a Lovenox shot.
This INR stuff becomes second nature soon enough.

 

[dick0236]

Midge:

However -- 1.8 to 2.2 is toooooooooooo narrow of a range. Someone would yo-yo around trying to hit that range.
Your INR and dosages will bounce around for awhile. Don't get discouraged; we've been there, done that.

I agree with Catwoman that your 1.8-2.2 will be very difficult, if not impossible, to maintain. Personaly, I would be uncomfortable with any INR range at 2.0 or below. Mine is 2.5-3.5 and I am most comfortable at the higher end of my range. However, I have an "early generation AV and the INR range seems to be different for many of the newer valves.

As Ross said, your ACT manager is being very conservative in adjusting your dosage, but that is better than the large "yo-yoing" dosage changes. You will get there. Once you have established your dosage you should have few problems....so long as you take Warfarin as prescribed and test regularly.

 

[tex]

My range is 2.5-3.5, when i first started on it my INR levels were up and down like a dont no what but now the passed 4 weeks my level has stayed at 2.8 but thats thanks to these guys on here, I dont have a lot of faith in the Anticoagulant here i knew when i went 6 weeks ago they were dosing me to high, and i came on here and asked if other guys thought so too, so they did agree and told me what dosage they thought and do you know since i took their advice my levels have been great and for the first time ever i dont have to go back to the clinic for a month, sometimes i was there twice a week.I was honest with the clinic and told them what i had been taking didnt want them getting the praise for sorting me out LOL. I am sure if anything changes with my INR i will be asking the guys on here for advice they sorted me out LOL

 

[sheridan07]

2.5 - 3.5 is what my docs say too

 

[olefin]

The surgeon and cardiologist I've had and have recommended a control range of 2.5 to 3.5.

I once went to a GP doctor and he wanted to lower the control, I fired him.

It's worked for almost 18 years and I'm sticking to that story.

 

[Ross]

*Sigh* Long and boring, like most medical papers, but here it is:

http://circ.ahajournals.org/cgi/content/full/107/12/1692

If you don't want to read the whole thing, here is the relevant part:

The American College of Chest Physicians guidelines234 of 2001 recommended an INR of 2.5 to 3.5 for most patients with mechanical prosthetic valves and of 2.0 to 3.0 for those with bioprosthetic valves and low-risk patients with bileaflet mechanical valves (such as the St Jude Medical device) in the aortic position.

 

[Megan]

so can someone tell me since im new to the idea of anticoag..what are the risks of a stroke if it falls below a 2.o in the av position with no other rish factors?

 

[Cozycat]

Thanks everyone for your help and input. I'm a much more secure doser now. I know it takes time to get adjusted and I'm sure that coming up slowly and steadily is better than bouncing up and then messing around with getting back down. My cardio is on vacation this month and he told me to ask him, not the Coumadin clinic, because he thinks he can do a better job and really seems to want to be involved. So will ask when he gets back...have an appointment for a follow up visit anyway.

Ross, thanks for the link. I browsed it for a few minutes and will go back to it....can only take little bits of that type of info at a time. But it sure looks to be very comprehensive and will garner what I can from it to use when I start pleading my case for home monitoring in the future (after I feel well stabilized.) Hope you feel appreciated!

 

[dick0236]

so can someone tell me since im new to the idea of anticoag..what are the risks of a stroke if it falls below a 2.o in the av position with no other rish factors?

Megan, hard to say. An INR of 1.0 is what a person not on anticoagulant would have. A 2.0 for a valve patient is not critically low, but it is low enough to get my attention and I would not let my INR stay at that level. I wouldn't freak out, but I would increase my warfarin to increase my INR to above 2.5 and I would test every 4-7 days until I got back in range. If my INR was much below 2.0(maybe 1.5 or so), I would consider a Lovenox shot and work closely with my doctor.

I have been on warfarin over 40 years and have seldom had INRs below 2.0 and I have always been able to get back in range with increased medication.

I have also had a CVA (stroke) that was almost certainly due to my mismanagement. My counsel to new people is "take the warfarin as prescribed and test regularly" and you should have few problems. Warfarin is not to be feared but it must be respected. I've heard stories of people who go for years without ACT and with poor management with no problems. I ain't one of them. It took me four(4) days without warfarin to cause a CVA and a lifelong visual disability. Since my stroke, I have been certain to take my warfarin daily and to test regularly and I have had NO further problems...that's been 35 years with no problem.

 

[catwoman]

so can someone tell me since im new to the idea of anticoag..what are the risks of a stroke if it falls below a 2.o in the av position with no other rish factors?

Megan:

A friend's husband has a St. Jude AV. Wasn't really punctual about going to his cardio for INR tests, I was told. Had a clot due to his INR being too low (I wasn't told how low it was or how long ago the previous test was). Had a stroke while playing golf at a country club in Fort Worth Texas. He's now pretty regular with his INR tests. I suggested that he get his own INR tester, but he enjoys going to the cardiologist's office; it's an outing for him.

When you look at stats, they're just stats. But those stats represent people's lives and those of their families. Do what you can to avoid drawing the black bean.

 

[Ross]

Thanks everyone for your help and input. I'm a much more secure doser now. I know it takes time to get adjusted and I'm sure that coming up slowly and steadily is better than bouncing up and then messing around with getting back down. My cardio is on vacation this month and he told me to ask him, not the Coumadin clinic, because he thinks he can do a better job and really seems to want to be involved. So will ask when he gets back...have an appointment for a follow up visit anyway.

Ross, thanks for the link. I browsed it for a few minutes and will go back to it....can only take little bits of that type of info at a time. But it sure looks to be very comprehensive and will garner what I can from it to use when I start pleading my case for home monitoring in the future (after I feel well stabilized.) Hope you feel appreciated!

I've got better, more to the point material on home testing. I just posted that so that anyone wanting to know where the numbers came from, could bore themselves reading the whole thing or simply take the relevant point posted.

 

[Ross]

so can someone tell me since im new to the idea of anticoag..what are the risks of a stroke if it falls below a 2.o in the av position with no other rish factors?

Megan that's a "Look into the Crystal Ball" question. For some people, being below 2.0 can mean stroke in a matter of hours or minutes, for others, it may never happen. With that being said, there has been a couple times that I had to unprotected for extended periods. My Cardio didn't give me the numbers, but said the risk is low, but it's a risk nonetheless and shouldn't be taken unless absolutely necessary.