INR Range of 1.8 to 2.4

[Taylor]

This is my first post. First the obligatory thank you! My wife founds this site after I was told in January that I needed my ascending aorta and bicuspid aortic valve replaced with a mechanical valve. The information and the positive attitudes of all of you that had gone before me was a big factor in both of us getting comfortable with the procedure and being on warfarin. Having a huge amount of trust in my cardiologist Dr. David Liang and surgeon Dr. Craig Miller, both at Stanford, obviously helped as well. They were both awesome and I'm doing great after my March 7 surgery. Now to my question - My doctors gave me an INR range of 1.8 to 2.4. I'm also taking a baby aspirin and their explanation of the lower end of the range being at 1.8 was that with the aspirin and my otherwise healthiness they are fine "running me a little lower" than the standard INR guidelines for valve replacement. I've obviously read many a post here that a range of less than one is a bit tight and perhaps unrealistic given the natural variances of warfarin therapy and the testing of it so we don't need to cover that. I'm wondering if anyone else out there has been given a range with a low end of 1.8 or so? Also generally wondering what your reaction to such a range is (other than it's a little tight). Just as an FYI - I was hovering about 2.1 or 2.2 until I went back to work and exchanged my 2 daily walks of 45 minutes for a 30-40 minute jog every other day. My last 2 tests (each 3 weeks apart) were 2.6 and 2.7 and I'll go another 4 weeks before my next test.

 

[ALCapshaw2]

Hmmm....

1.8 to 2.4 MAY be OK, BUT, ALL of your 'headroom' is to the bleeding side with NO Safety Net to the Low Side.

As I have posted several times (including just recently), the SAFE range for INR is from 2.0 to 5.0 with the Risk of STROKE rising for values below 2.0 and the Risk of Bleeding rising above 5.0. (Some of our members have reported INR's of 8.0 for brief excursions with NO Bleeding).

MOST of our members are more afraid of STROKE than of Bleeding. We even have a 'famous expression' that goes: "It's easier to replace Blood Cells than to replace Brain Cells".

That pretty much says it all.

'AL Capshaw'

 

[Karlynn]

Before I read your profile I was wondering if you had an On-X installed. I've seen a few INR ranges for the On-X go as low as 1.8, but not with a St. Jude.

If it were me, I'd want to keep the range at 2-3. Being healthy really has nothing to do with whether or not you risk a clot, so that made no sense to me. I'm glad you're healthy , but that really shouldn't factor into the dr's reasoning for your range. At least for most people. He should have gone with the recommended guidelines. Doctors are just so afraid of bleeding.

You are right 1.8 to 2.4 is tight and really makes no sense in that INR is not an exact science. There is a variance implicit in each test and can be +/- .3 or even a bit more. So if you are testing a 1.8, it could be a 1.5 or a 2.1

It sounds like you are starting to learn a lot and I applaud you for questioning your range. Have you been to Al Lodwick's site yet? www.warfarinfo.com

Most of us like to keep our INR's to the higher end of the range. It's much easier to lower a high INR than to raise a low INR. Anything up to 5.0 really isn't anything to sweat over for the vast majority of warfarin users. But some nurses and doctors will go and then give foolish instructions.

Welcome to the community!

 

[Blanche]

Taylor:
My husband had a serious stroke with an INR of 1.8. He had been on anticoagulation successfully for 10 years when this happened. Ill informed and mis informed doctors and coumadin clinic folks worry about bleeding but pay no attention to strokes. Taking aspirin and good health are not sound medical reasons for reducing the recommended INR range. When they do this, they flirt with disaster.
Blanche

 

[Ross]

Ask them to show you evidence or a study of why they want to run you low like that. I would not be comfortable at all. That tiny window is nearly impossible to maintain and they should know better too.

 

[catwoman]

Taylor:

Many cardiologists/surgeons Rx a baby aspirin in addition to warfarin for mechanical valvers. However, I haven't heard of many who have lowered the INR range just because of that.
Aspirin keeps platelets from clumping.
Warfarin counteracts several of the clotting factors produced in your body or by vitamin K. (About 40-50% of the vitamin K in your body is naturally produced in your intestinal tract.)
Granted, it will take longer to stop a bleed with either aspirin or warfarin, but these are 2 different factors.

Like others have said, a range of 1.8-2.4 is extremely narrow. (I've likewise questioned the range of 2.0-2.5 my husband's surgeon advised after his MV repair.)

My guess is that many anticoagulation "managers" (i.e., someone who runs the test machine and then consults someone else, or someone who is not a certified manager -- seee www.acforum.org) have a majority of their caseload comprised of short-term warfarin patients. Rather than managing people like us, who will be on warfarin for the rest of their lives, unless a mechanical is replaced with a tissue.

Therefore, managers tend to think of the risks of bleeding, rather than stroke.
I'd venture to say that many -- if not most -- of these people have never taken warfarin themselves. They have no personal experience with the drug and external/internal factors that affect it. Only experience from dealing with patients.

Would they themselves prefer to deal with the effects of a stroke -- mental, physical, occupational -- rather than having to apply pressure a little longer to stop a bleeding cut?

I don't think so.

The likelihood of "bleeding to death" is probably 0.05% (my conjecture) while on warfarin. If you're going to bleed to death, it's going to happen regardless if you're on warfarin or not. It's going to be because of a major catastrophic event -- a limb being severed due to a car accident, a flying sheet of metal that comes sailing at your neck during a hurricane, etc.

Like others have said, it's easier to lower a high INR than to raise a low one.

Take a look at Al Lodwick's www.warfarinfo.com. Purchase one of his warfarin dosing charts. (I think these are must for anyone with a mechanical heart valve!) You'll understand the increases/decreases needed in your Rx to achieve an optimal INR.

Good luck! When I left the hospital, I felt slightly overwhelmed. There was sooooooooo much to absorb. Four years later, warfarin is a no-brainer -- except I have all my brain cells intact!

 

[Bina]

Hi Taylor,
Welcome to this fabulous group!
You have already received excellent advice to your question.
My INR is steady at 3.2---3.4
This level gives me a little room in case I should ever forget to take a pill or decide to have a "spinach binge"....Just joking.

 

[Cooker]

As I have posted several times (including just recently), the SAFE range for INR is from 2.0 to 5.0 with the Risk of STROKE rising for values below 2.0 and the Risk of Bleeding rising above 5.0. (Some of our members have reported INR's of 8.0 for brief excursions with NO Bleeding).
'AL Capshaw'

Thanks Al, I must have missed this but it is good to know. 2-5 makes it a bit easier for me to feel in the safe zone.

Tom

 

[Taylor]

Thanks. Very helpful stuff. I will give my doctors a call and follow up on the range and the reasoning/studies that led to it. I like all of you am very content being at the top of (or even a bit above) the range given and so I'm been keeping around the 2.6/2.7 area. And I'm becoming more comfortable adding a little more greens into my diet. I think like a lot of newcomers I felt most comfortable first limiting my leafy greens a bit, getting my INR to a stable zone at the high end of the range and then slowly eating a bit more greens. And a clarification on the "being healthy" thing ( I may have put words in their mouths)- what I believe they said was that there were no other risk factors that would lead them to the higher ranges that are seen with aortic valve replacements (2.5 to 3.5). I did pick up Al's dosing chart as well - he actually encouraged me to join Valvereplacement.com instead of just viewing it as a guest. Thanks again everyone. I', becoming fascinated by this whole warfarin thing and look forward to the years of learning to come.

 

[Ross]

Taylor your going to find that greens and diet in general play a very small roll in INR management. You'd have to really binge eat on something in particular to phase your INR. I'm talking like instead of a salad with spinich, eating a whole bag of spinich alone. That sort of stuff. You'll get real comfortable soon if your not already.

 

[njean]

Being that I have both a mitral & aortic mechanical valves, the doctors want me to keep my INR levels between 3.0 - 4.0 due to the possibility of clotting. And believe me, you don't want that to happen to you! In fact, on two or three different occasions it fell below 2.0 & I had to start giving myself "lovonox" injections on the stomach! That is not fun!

I also bought me my own home monitor from QAS & I just love it! It is so easy to use & you can test yourself at any time in the comfort of your own home. In order to get one, just have your doctor write you a prescription for one & then submit the information to the company. My insurance company also paid for everything!

I have been on coumadin for 34 years and it's still baffling to the doctors, but I can sense when my level is either too high or too low. I start feeling sluggish & my blood pressure even goes up a bit! Weird, I know but after being on coumadin for so many years, you get to know your body better than anyone!

Good luck to you & stay well!

 

[Taylor]

I thought I would update everyone on what I found out from my doctors over the past couple of weeks. My cardiologist and his nurse practitioner initially gave me a range of 2-2.5 but are fine with me following the standard range of 2-3. My surgeon's assistant said they routinely run patients with a composite valve graft (CVG) in the 1.8-2.4 range with a baby aspirin and coumadin. The reason they run a little lower with CVG is that it comes preassembled from the factory and has no internal suture line and that the risk of an embolus is lower than normal aortic valve replacements b/c there are suture internally. It's nice to know that they feel confident that I can be so low but I am still content with my pretty consistent 2.6.

Thanks all.

 

[Natanni]

Hi

My husband's cardio at the Mayo has him in a narrow range; They want him 2.5-3.0, which is very odd to have such a narrow window, but with the Aspirin coverage, they do not feel he needs to be any highter than 3 with a mechanical in the aortic position. We were told at his appt on August 6 that
they have been watching a group of poorly/non-anticoagulated aortic
mechanicals valves for several years, and they are very encouraged. Not really sure what it all means, but we were told things could change with INR protocols in the future. Having this narrow range makes controling INR a little trickier, but he is managing.

As Ross said, food has had very little to do with Nathan's INR. Medication and activity would cause slight changes. I swear Toprol dosage change did but I hear that is rare.

 

[ALCapshaw2]

Some time ago, my Cardiologist recommended staying in the high end of my range, i.e. 3.0 to 3.5.

Over the past 2 years I believe my lowest INR was 2.5 and highest (real) INR was 4.0 which is just fine with me. My CRNP's use very small (1 mg/wk) changes to ease me back towards my goal with NO wild swings.

'AL Capshaw'