INR range question, 2.0-3.0 vs 2.5-3.5 for mechanical AVR?

[jamie14512]

Hi I recently had open heart surgery 4 weeks ago for a mechanical AVR. I am now on warfarin, currently on with a target INR of 2.0-3.0.
Given that there is some risk of thromboembolism at lower INR ranges and the mindset of "I'd rather have a bleed than a stroke".

I understand the risk of stroke between 2.0-3.0 is very low, however from what i've read many people will still have minor TIAs at some point in their life. So my question is why not aim for 2.5-3.5 as although i may have more bleeding events, they are unlikely to leave permanent damage unlike a TIA or stroke.

 

[LondonAndy]

My surgeon agreed with your approach, and specified a range of 2.5 to 3.5 for my St Jude valve. He felt strongly about this level of INR, and wrote in my yellow Warfarin booklet "If under 2.5 administer Heparin", which was against the protocols of my anticoagulation clinic at that time.

 

[ATHENS1964]

Follow your doctor's instructions,also ask if aspirin can help
https://pubmed.ncbi.nlm.nih.gov/11157651/

 

[Amy]

I had the same question. My surgeon said 2.0-3.0 (and a daily baby aspirin); half of the other cardiologists I’ve seen since said 2.5-3.5... so in my mind it’s like 2.4-3.0;

& when doctors ask what my range is that’s what I say... They either accept it (usually) or demand to know why it’s so atypical. I’m not sure which is which, as far as which doctors know best....

The thing with using 2.5-3.5 is... it’s easy to get lazy and be okay having a 3.4 for weeks in a row; and from there it’s easier to jump up to something like a 4.2 where you might (I did) have some scary symptoms (short term memory issues all day).

But then with a smaller range like this, it’s harder to have an impressive ‘percent time in range’ ; ) I’d love to be able to brag ‘Yeah, I’m in range 95% of the time!’ but on top of the small range, I’m constantly changing my diet, amount of exercise, & supplements because of other health issues.

Good luck to you.

 

[dick0236]

Hi I recently had open heart surgery 4 weeks ago for a mechanical AVR. I am now on warfarin, currently on with a target INR of 2.0-3.0.
Given that there is some risk of thromboembolism at lower INR ranges and the mindset of "I'd rather have a bleed than a stroke".

I understand the risk of stroke between 2.0-3.0 is very low, however from what i've read many people will still have minor TIAs at some point in their life. So my question is why not aim for 2.5-3.5 as although i may have more bleeding events, they are unlikely to leave permanent damage unlike a TIA or stroke.

I believe that physicians and labs are most comfortable with 2-3 INR because the vast majority of their patients are older a-fib and other conditions requiring lower anti-coagulation. Even my doctors INR computer program only shows a 2-3 INR range and he and I know that my INR's are, almost always, at the top of his computer range, or above it.......my range is 2.5-3.5 and I try to stay a little above 3. I don't get excited with any INR above 2 or below 4 although I do make a dosing change if I hang around 2 or 4.

Whoope, gotta go, my wife just called me to dinner.

 

[pellicle]

Hi

So my question is why not aim for 2.5-3.5 as although i may have more bleeding events, they are unlikely to leave permanent damage unlike a TIA or stroke.

ok ... so let me again drag out "that graph"

which shows that the area of least incidents is indeed 2.5 ~ 3.0

Now as to why I may prefer to be 2.2 is down to less bruising when I do happen to bash myself (which I do from time to time)

On your point about stroke, its not as black and white as you make it out. Any throbmobembolic event counts as an event. So a TIA would in many studies result in a counted event. Strokes are not necessarily permanent especially if promptly dealt with. So what I'm saying its not only catastrophic situations.

My own surgeons advice was (with my ATS valve) to keep my range between 2.2 and 3 ... which I largely do. This is my data from last year

my counting of events is:

• an over event is a measurement of >3.2
• an under event is a measurement of < 2.0

whenever I meet my surgeon (rare these days, not for 4 years or so) I offer to show him my stats. But as he's seen them before and knows what I do and that I'm still doing it after 12 years he's not usually interested.

Build your data and keep it ... make it part of your new life. Its in total about 15 minutes per week of my time.

If you don't know how, reach out and I'll show you.

Best Wishes

 

[christopherj]

If you don't know how, reach out and I'll show you.

One of the best decisions I made post surgery was to take @pellicle up on this offer. His method makes me feel in control of my INR.

 

[pellicle]

One of the best decisions I made post surgery was to take @pellicle up on this offer. His method makes me feel in control of my INR.

thanks mate, I'm glad it helps

 

[Gail in Ca]

My INR was 2-3 after my 3rd surgery with a top hat Carbomedic valve. But, it was raised to 2.5-3.5 when I went into chronic a-fib in 2014 and that’s where I’ve stayed.

 

[carolinemc]

My surgeon agreed with your approach, and specified a range of 2.5 to 3.5 for my St Jude valve. He felt strongly about this level of INR, and wrote in my yellow Warfarin booklet "If under 2.5 administer Heparin", which was against the protocols of my anticoagulation clinic at that time.

We have some in the USA who do not go by the standards. Good you have a great doctor watching out for you.

 

[perrybucsdad]

Hi

ok ... so let me again drag out "that graph"

View attachment 890209
which shows that the area of least incidents is indeed 2.5 ~ 3.0

Now as to why I may prefer to be 2.2 is down to less bruising when I do happen to bash myself (which I do from time to time)

On your point about stroke, its not as black and white as you make it out. Any throbmobembolic event counts as an event. So a TIA would in many studies result in a counted event. Strokes are not necessarily permanent especially if promptly dealt with. So what I'm saying its not only catastrophic situations.

My own surgeons advice was (with my ATS valve) to keep my range between 2.2 and 3 ... which I largely do. This is my data from last year

View attachment 890210
my counting of events is:

• an over event is a measurement of >3.2
• an under event is a measurement of < 2.0

whenever I meet my surgeon (rare these days, not for 4 years or so) I offer to show him my stats. But as he's seen them before and knows what I do and that I'm still doing it after 12 years he's not usually interested.

Build your data and keep it ... make it part of your new life. Its in total about 15 minutes per week of my time.

If you don't know how, reach out and I'll show you.

Best Wishes

Thank you for sharing! I just returned to this site after some time away to see why my doctor changed my INR range, which had been 2.0 - 3.0, but now is 2.5 - 3.0. I think this gives me the answer.

The problem I am having though is how do I adjust for 2.5 - 3.0? All the dosing guides I have seen are 2ither for 2.0 - 3.0 or 2.5 - 3.5.

One of the best decisions I made post surgery was to take @pellicle up on this offer. His method makes me feel in control of my INR.

@christopherj What is the @pellicle method?

 

[pellicle]

Good morning

What is the @pellicle method?

its basically a set of spreadsheets (in a Google Docs workbook) where you

• document your INR and dose weekly (assisting you in keeping regular just in itself)
• takes that data and uses that in a simple data model to inform you on your own INR response to warfarin
• summarises this in a table which enables you to make data driven decisions on what dose you need to achieve your goals (say, a target of 2.5 or in your case a target of 3
• produces graphs which (if you understand how to read and interpret them) inform you more
• produces yearly summary data

PM me if you want to do that, most people find it pretty helpful and the stats are good to know. A sample; the graph showing my INR and dose (with a trend line) produced from just entering your data

You can see exactly when I changed my dose and by how much and why (INR range is the only why).

I developed this ins 2013 when I was going through "difficult times" and it enabled me to make decisions on how to manage my (driven by daily antibiotics for 10 years) troubled INR and maintain my INR range pretty darn well.

This is my data from last year

Basically its an evolution of 12 years of doing this for me and providing the basics of what's needed in one place.

My goal is always to teach a person how to fish, so they can then fish for themselves. It usually takes a few lessons to get the hang of what's going on (depending on the student).

PM me if you're interested

Best Wishes

 

[Habana58]

I did the OnX 1.5 -2 for 18 months, but dropped it because anything goes +/- 2.0 and if you are resting on 1.5 that is dangerous "for me", therefore, after reading many medical papers and consulting with the abnormal quantity of doctors in my direct family (12); i settled for 2.0 -3.0 , on ONE condition, i must test Weekly; and also dropped the OnX daily 81 mg ASA daily, do take 1 aspirin 81mg Once a week, my own doing, nobody told me to do so.

Best thing here is read the extensive amount of documented work done by Pellicle for the benefit of all; and with that and consulting with your doctors you will be fine; See attached medical paper as an example, which means that any modern bileaflet valve will work fine with that 1.8-2.8 If you test weekly no matter what; so, 2 - 3 with weekly test is a safer position, i would say. I always remember a lady i know, she had a baby at 17, and soon after a Cage-IN-Ball AVR, 47 years later, the ball still in the cage, and the lady going and going;

 

[dick0236]

I always remember a lady i know, she had a baby at 17, and soon after a Cage-IN-Ball AVR, 47 years later, the ball still in the cage, and the lady going and going;

Say hi to your friend for me. I also have one of those old "ball-in-cage" valves (57 years old). Those old valves last a long, long time.....but they had a history of throwing clots and that is the reason they are no longer on the market. Like me, I think her INR range is 2.5-3.5 because of the "clotting issue" with that valve.....and also like me she probably has no problems with that INR range. I see no benefit, and a lot of potential trouble, with INR ranges under 2 and with todays technology and home testing there is no need to ever strive for an INR under 2. Remember the old saying...."blood cells can be replaced but brain cells can't".

 

[perrybucsdad]

Good morning


its basically a set of spreadsheets (in a Google Docs workbook) where you

• document your INR and dose weekly (assisting you in keeping regular just in itself)
• takes that data and uses that in a simple data model to inform you on your own INR response to warfarin
• summarises this in a table which enables you to make data driven decisions on what dose you need to achieve your goals (say, a target of 2.5 or in your case a target of 3
• produces graphs which (if you understand how to read and interpret them) inform you more
• produces yearly summary data

PM me if you want to do that, most people find it pretty helpful and the stats are good to know. A sample; the graph showing my INR and dose (with a trend line) produced from just entering your data

View attachment 890362

You can see exactly when I changed my dose and by how much and why (INR range is the only why).

I developed this ins 2013 when I was going through "difficult times" and it enabled me to make decisions on how to manage my (driven by daily antibiotics for 10 years) troubled INR and maintain my INR range pretty darn well.

This is my data from last year
View attachment 890361
Basically its an evolution of 12 years of doing this for me and providing the basics of what's needed in one place.

My goal is always to teach a person how to fish, so they can then fish for themselves. It usually takes a few lessons to get the hang of what's going on (depending on the student).

PM me if you're interested

Best Wishes

Thanks, pellicle, this is very similar to what I had done too. Mine just would flag me if I was out of range. I always wanted to write some code to have it recommend the adjusted dose, but I just never did.

Have you or anyone else here ever seen a dosing adjustment guide though for 2.5 - 3.0? I've only ever seen 2.0 - 3.0 and 2.5 - 3.5. Since my doc switched me, looking at my stats, I will be out of compliance more often, and I don't like that, so I am trying to convince him otherwise.

I thought it might be possible to look at both dose adjusting guides and look at what to do below 2.5 (looking at the 2.5 - 3.5 guide) and then look at what to do if above 3.0 (by looking at the high side of the 2.0. - 3.0) but it is a narrower band for compliance, so those suggestions for adjustment may not be right as it assumes you have more wiggle room.

 

[pellicle]

I always wanted to write some code to have it recommend the adjusted dose, but I just never did.

reach out if you ever want to add this, I have an existing data model for that

Have you or anyone else here ever seen a dosing adjustment guide though for 2.5 - 3.0?

no, and when you see real world INR responses of enough people you know that its just not possible for most people because of the width of the standard deviation of their natural metabolic variance.

a narrower band for compliance,

is simply meaningless (given the data)

and impractical given how few people (as a %age) are even remotely organised enough in administration compliance

 

[YogiSue]

I’ve had a St. Jude’s prosthetic aortic valve for the last 35 years and I’m 53. My therapeutic range has changed to 2.5-3.5. My advice having a lifetime on Coumadin is to monitor your INR regularly, keep a diary of your diet; especially vitamin k intake, limit alcohol, and always check of interactions with other meds. Other than that, live your life and be grateful for technology & advancement in cardiac care.

 

[perrybucsdad]

reach out if you ever want to add this, I have an existing data model for that



no, and when you see real world INR responses of enough people you know that its just not possible for most people because of the width of the standard deviation of their natural metabolic variance.



is simply meaningless (given the data)
View attachment 890368
and impractical given how few people (as a %age) are even remotely organised enough in administration compliance

What is the source of this data? Possibly I can share this with my doc to help convince him.

 

[tom in MO]

Thanks, pellicle, this is very similar to what I had done too. Mine just would flag me if I was out of range. I always wanted to write some code to have it recommend the adjusted dose, but I just never did.

Have you or anyone else here ever seen a dosing adjustment guide though for 2.5 - 3.0? I've only ever seen 2.0 - 3.0 and 2.5 - 3.5. Since my doc switched me, looking at my stats, I will be out of compliance more often, and I don't like that, so I am trying to convince him otherwise.

I thought it might be possible to look at both dose adjusting guides and look at what to do below 2.5 (looking at the 2.5 - 3.5 guide) and then look at what to do if above 3.0 (by looking at the high side of the 2.0. - 3.0) but it is a narrower band for compliance, so those suggestions for adjustment may not be right as it assumes you have more wiggle room.

My range is 2-2.5 and I have no trouble staying within by myself w/o a doctor, dosing guide or spreadsheet. I did use my cardio's coumadin clinic at the beginning and that gave me a good feel as to how to adjust, but now I'm on my own. My only aid is the book that comes with the meter to write your results in.

If I go out of range, I do a bump (20-50% of daily dose). If I consistently go out of range in the same direction several times, I change the dose. My current dose is 3.5mg Mon, Wed, Fri and 4 mg the other 4 days. If I go less than 2, I add a 1 or 2 mg and test in 4 days. If I go more than 2.5, I don't adjust unless >2.7 and then I drop 1 or 2 mg and test in a week. If I forget a daily dose, I take 150% the next day. If I need to go to INR of ~1 for a procedure, per my cardio's direction, I stop taking it 5 days before and start-up when the doctor doing the procedure says I should, usually the same day or a day later.

 

[pellicle]

Good Morning

What is the source of this data?

Source here.
July 13, 2009

Optimal Level of Oral Anticoagulant Therapy for the Prevention of Arterial Thrombosis in Patients With Mechanical Heart Valve Prostheses, Atrial Fibrillation, or Myocardial Infarction A Prospective Study of 4202 Patients​

Best Wishes