INR

[Protimenow]

Hey, Tom. I see that you're an expert in deciding what dose (and, I guess, what INR) is necessary. You seem to believe that testing 'every 2-3 weeks' is adequate. And it appears, from this, and earlier posts, that you see some danger in having an INR with a midpoint of 3.0.

You appear to have absolute faith in your doctors.

I won't reopen the earlier discussions about weekly testing or the benefits of a higher INR than you've chosen.

It's YOUR life.

 

[vitdoc]

vitdoc said:
I personally have had around three or four fortunately transient retinal artery occlusions even on Warfarin.

are you also taking any aspirin?


I take aspirin intermittently. When I go bike riding. I have only experienced the branch retinal artery blockages while riding. Have not had one for at least 5 years. Fortunately they were all transient lasting several minutes. I get a partial scotoma in one eye only. Either superior or inferior with a horizontal cut in vision. Not migraine which I also get rarely. Very scary. I plan to ride today so I will take my 81 mg. I tend to have bleeding from hemorrhoids so I don’t like chronic ASA use. Incidentally one easy treatment for hemorrhoids is rubber banding which causes them to undergo necrosis in about a week. The treatment is contraindicated however while on anticoagulation. There may be significant bleeding. So I have soldiered on with them. Not bad enough for regular surgical intervention.

 

[tom in MO]

Hey, Tom. I see that you're an expert in deciding what dose (and, I guess, what INR) is necessary. You seem to believe that testing 'every 2-3 weeks' is adequate. And it appears, from this, and earlier posts, that you see some danger in having an INR with a midpoint of 3.0.

You appear to have absolute faith in your doctors.

I won't reopen the earlier discussions about weekly testing or the benefits of a higher INR than you've chosen.

It's YOUR life.

Never said I was an expert, just that I follow a team of expert's conclusions that I vet using this forum and mostly on-line literature...Thank You ValveReplacement.org!

If my valve required an INR in the range of 2-4, I'd shoot for 3, but it doesn't. For my valve that is 2-2.5. That range is too narrow to shoot for a target, I just shoot for the range.

"Danger" is your word not mine. I believe in using the amount of drug to get the desired therapeutic effect. There are non-therapuetic effects of an elevated INR. You prefer to ignore them. I however have put my head into a windshield as a passenger and the head of a friend into a windshield when I was a driver. You prefer to ignore this possibility...It's YOUR brain.

I place absolute faith in no human. You must have missed some of my posts. I've related personal stories of physician errors that have effected me and killed two family members. Doctors are humans and when doctors make mistakes the consequences can be tragic, however the consequences of valve disease w/o doctors is always tragic.

 

[Protimenow]

Danger is, I think, a word that many others on this forum would agree with.

I don't believe that a handful of doctors know everything there is to know about anticoagulation, and that you're treading on shaky ground, in my op0inion.

So - you've had TWO 'head in the windshield' events - one as a driver, one as a passenger? What are the odds for that? I'd rather have a higher INR and avoid having a stroke than worry about a one in many million event, such as slamming my head into a windshield. (Airbags, anyone?)

I may have avoided a few of your posts - I'm not sure.

The consequences of valve disease without medical intervention is NOT always tragic. People live with undiscovered valve disease for full lifetimes; some have valve disease that doesn't reveal 'always tragic' results. When diagnosed and overly aggressively treated, simple valve issues may yield tragic results, if pre-op, intra-op, and post-op problems are factored in.

 

[tom in MO]

Danger is, I think, a word that many others on this forum would agree with.

I don't believe that a handful of doctors know everything there is to know about anticoagulation, and that you're treading on shaky ground, in my op0inion.

So - you've had TWO 'head in the windshield' events - one as a driver, one as a passenger? What are the odds for that? I'd rather have a higher INR and avoid having a stroke than worry about a one in many million event, such as slamming my head into a windshield. (Airbags, anyone?)

I may have avoided a few of your posts - I'm not sure.

The consequences of valve disease without medical intervention is NOT always tragic. People live with undiscovered valve disease for full lifetimes; some have valve disease that doesn't reveal 'always tragic' results. When diagnosed and overly aggressively treated, simple valve issues may yield tragic results, if pre-op, intra-op, and post-op problems are factored in.

The point of that example is accidents happen including accidents with severe brain trauma. My dentist had a garage door fall on him and he died of a brain clot. A friend had a walnut headboard he was putting up into an attic fall and it gave him a brain clot that lasted for months until it was shrunk by drugs. If their INR was 3, their clots would have been 3X larger. Brain trauma is real. Airbags don't protect you if you are hit in the street by a car. I walk and ride a bus to work. Airbags don't protect you if you ride a bicycle. Brain trauma is why they told one forum member with a mechanical valve and thus an elevated INR that he shouldn't do headers in soccer anymore.

We can disagree, I am sure I won't change your mind. But I don't think you are correct, so I am free to offer the opinions and advice of the US medical community. Some recent discussions have shown the British NHS have a higher INR range than the US medical community. Which is right? The answer is there is no definitive answer...

 

[Protimenow]

Sure, accidents happen. If you're as worried about accidents as it seems, you should be wearing body armor and a motorcycle helmet everywhere you go (of course, with your low INR, perhaps your fear of a chandelier dropping on your head, or a tree crashing through your roof, or other possible, though pretty unlikely head injury may be slightly lower than it would be if your INR was 3. So, you may be right - if one of these things happens to you if your INR is 2.0, the intracranial bruising would only be twice as large as it would be if your INR was 1.0. A 2X brain bleed compared to a 3X brain bleed would obviously be much, much safer. Right?

Living your life as if you're destined for a head injury isn't really living. Is it? Avoiding things that my increase your risk of head injury (like the headers that you mention) certainly makes sense - but not for people whose risk of head injury is probably the same as the remote risk of, say, getting hit by a car when you're crossing the street.

I've cited recommendations from the most recent publications, recommending INR with a target value of 3.0, and a range of 2.5 - 3.5. Others on this forum have, too. I don't know where you get the idea that the 'US Medical Community' recommends an INR of 2.0 - 3.0, unless this 'Medical Community' is the doctors you're seeing. (And, as we all know, doctors are never wrong.)

You're right. I doubt that we'll ever agree on this -- unless I see some reliable research that negates decades of research into safe INR levels and somehow convincingly recommends INR of 2.0 - 2.5. I doubt that we'll ever agree until I see something conclusively demonstrating that an INR of 3.0 is much more dangerous than an INR of 2.0 - 2.5.

But, as I said earlier - it's YOUR life.

 

[Superman]

My dentist had a garage door fall on him and he died of a brain clot. A friend had a walnut headboard he was putting up into an attic fall and it gave him a brain clot that lasted for months until it was shrunk by drugs. If their INR was 3, their clots would have been 3X larger.

Personally, I’m more of a whatever helps you sleep at night kind of person. As long as you and your doctors are on the same page and managing and testing consistently.

Just confused by the above. Were these individuals taking Warfarin? If their INR was higher, clots may have never formed. That’s what Warfarin is designed to prevent.

Maybe a brain bleed instead of a clot. The prospect of either isn’t too exciting. I wouldn’t expect a larger clot to form though. I’m guessing an anti-coagulant was used to shrink your friends clot. Didn’t make it bigger.

 

[Protimenow]

Hey, Superman. I can't respond to what Tom was writing. I'm guessing that the dentist who had the garage door fall on him probably wasn't taking warfarin. I'm guessing that the friend who had a headboard fall on him also wasn't taking warfarin.

I agree with you that these poor head injury victims probably got warfarin (or heparin) to break up the clots.

And I'm with you about the likelihood of a brain bleed, rather than a clot after a head injury. (I had a situation a decade ago, when I was helping a customer (a part time job) put a dishwasher in the back of his car - he let go, and the box hit me in the head. I had a minor concussion, but I was concerned about a brain bleed (not a clot).

For those of us on warfarin, if we get head injuries, the concern is about bleeds - not clots. I don't know if the prognosis is better for a person with a brain bleed than it is for a brain clot -- but I wouldn't be surprised. If anticoagulants are used to break down clots, potentially breaking the clots into free blood, then what's the difference if a small bleed is absorbed over time? Warfarin may, in a strange way, be protective.

Superman - Tom is clearly convinced that his low INR is safe for him. I can't change his mind. I stopped trying months ago and have to remind myself that what he does, he does by choice.

 

[LondonAndy]

What are the risks. I don’t understand INR . Why would a low INR cause a stroke? I’m trying to learn and really appreciate all of your advice. This is happening so fast and I’m trying to make the right decisions and be as informed as I can be.

This analysis by the UK's "National Institute of Clinical Excellence", which sets best practice protocols for our NHS, might be helpful to understand the importance of INR range and consequences of deviation: http://bit.ly/NICEreport and explains why many of us have our own home meters (hand held, finger prick devices) and test weekly.

(There is a two page amateur summary by me, for us non-medical bods, then link to the full 42 page report)

 

[Protimenow]

LondonAndy - this is a good summary, but I wish you would have included the recoimmended ranges for INR (if it was there, I missed it).

 

[LondonAndy]

LondonAndy - this is a good summary, but I wish you would have included the recoimmended ranges for INR (if it was there, I missed it).

Apologies - I put my range in the the "Heading for a new aortic valve" thread, but relevant here too: 2.5 to 3.5. I think that you have commented in the past that this is higher than in the US for a St Jude, but my surgeon (who at the time was the only non-US guy to receive some prestigious American award that I forget the details of now!) was insistent on, and my post-surgery research (particularly on this forum) has concluded there is no need to lower it anyway. I would rather have a slightly high INR than a slightly low one.

 

[Buckeye]

Thanks for all the information, but a lot of you are confusing me. With the on x valve would a lower inr be safe? They “on X” say their design and polycarbonate pieces Reduce the formation in clots? If this is truly newer technology then why not lower your inr with this valve only. I’m still not understanding.

 

[pellicle]

Hi

Thanks for all the information, but a lot of you are confusing me. With the on x valve would a lower inr be safe?

This is their claim, but you need to be quite specific in what you mean by "a lower INR" (as indeed they are in turn QUITE specific on what levels of INR, what levels of monitoring, what concurrent drugs need to also be taken, who it was demonstrated to be safe for and also consider what amount of time they demonstrated it for).

My feeling is no more safe at lower INR than any other similar valve (ATS, Cabometrics, St Jude ...)

They “on X” say their design and polycarbonate pieces Reduce the formation in clots? If this is truly newer technology then why not lower your inr with this valve only.

firstly its pyrolytic carbon, not polycarbonate. It is not new and is not unique to their valves. My ATS (purchased by Medtronic) has it, and so too the other valves I mentioned. I'd go as far as saying every modern "bi-leaflet" mechanical valve is made of pyrolytic carbon.

https://en.wikipedia.org/wiki/Pyrolytic_carbon


https://www.medtronic.com/us-en/hea...rgical/open-pivot-mechanical-heart-valve.html

The bottom line is that no matter what valve you have you will be safer maintaining an INR between 2 ~ 3 (which is still the recommendation of the Society of Thoracic Surgeons) but you can use their findings to give you a sense of ease that if you discover your INR to be (say) 1.7 then there is no need to panic / worry / freak out ... but just take action to calmly steer it towards the goal of 2.5 (mid way between 2 and 3 right?)

I believe you'll find that's the consensus view not only for the Society of Thoracic Surgeons, but also among many other researchers and most of use here on this forum.

 

[Buckeye]

Okay.

In a rather large nutshell, this is the thing about INR and heart valves.

Prosthetic heart valves (Medtronic, On-X, St. Jude's, etc.) have surfaces inside them where blood can connect. At the surfaces where the large vessels connect to the valves (they're sewn together), clots can form. Even with On-X valves, which reportedly don't have as big a problem with clots forming, clots can still form.

The problem with the clots that form is that they can break off, and go into the bloodstream. These clots floating through the bloodstream could end up in the brain, clogging blood supply and potentially causing a stroke, or can end up doing damage in the lung (pulmonary embolism). Peole with prosthetic valves take an anticoagulant (warfarin) that prevents the clots from forming.

INR - International Normalized Ratio is a ratio between the length of time that it takes the blood to clot, divided by a value for the particular chemical (reagent) that promotes the clotting. An INR of 1.0 is approximately the value for normal, un-anticoagulated blood. An INR of 2.0 is an indication that blood takes twice as long to clot as blood with an INR of 1.0. And so on - the higher the INR, the longer it takes for blood to clot.

From personal experience, and the reported experience of hundreds - if not thousands - on this forum, having an INR between 2.5 and 3.5 (for example), is no big deal. It doesn't change your life. It's not the nightmare that some marketers would want you to believe. It's not like taking 'rat poison' - and being instantly fatal if you take a bit too much. It isn't really that big a deal.

Unlike the way it was twenty or more years ago, there are now meters that you can own, and do self-testing.

I have a St. Jude valve. I got it in 1991. If I had an On-X today, I'd prefer not to take the risk of maintaining a low INR, or just taking aspirin (on the possibly rare likelihood that this low INR wouldn't increase my risk of a clot form, or throwing a clot) and would STILL want to maintain an INR of 2.5 - 3.5.

To me, it's not worth the risk to have a low INR to support the On-X marketing machine and possibly risk major, life-changing results. IF and WHEN there's proof in long term, independent, retrospective studies that demonstrate little or no risk for ON-X users to keep INR's around 1.5 (or just taking an aspirin a day), I may be more comfortable with a low INR. But keeping a slightly higher INR will reduce or eliminate that risk, so even if such a study existed, I may not shoot for a lower target INR.

I hope this gives you more information than you need.

Thank you

 

[Buckeye]

Hi


This is their claim, but you need to be quite specific in what you mean by "a lower INR" (as indeed they are in turn QUITE specific on what levels of INR, what levels of monitoring, what concurrent drugs need to also be taken, who it was demonstrated to be safe for and also consider what amount of time they demonstrated it for).

My feeling is no more safe at lower INR than any other similar valve (ATS, Cabometrics, St Jude ...)


firstly its pyrolytic carbon, not polycarbonate. It is not new and is not unique to their valves. My ATS (purchased by Medtronic) has it, and so too the other valves I mentioned. I'd go as far as saying every modern "bi-leaflet" mechanical valve is made of pyrolytic carbon.

https://en.wikipedia.org/wiki/Pyrolytic_carbon


https://www.medtronic.com/us-en/hea...rgical/open-pivot-mechanical-heart-valve.html

The bottom line is that no matter what valve you have you will be safer maintaining an INR between 2 ~ 3 (which is still the recommendation of the Society of Thoracic Surgeons) but you can use their findings to give you a sense of ease that if you discover your INR to be (say) 1.7 then there is no need to panic / worry / freak out ... but just take action to calmly steer it towards the goal of 2.5 (mid way between 2 and 3 right?)

I believe you'll find that's the consensus view not only for the Society of Thoracic Surgeons, but also among many other researchers and most of use here on this forum.

Thank you

 

[carolinemc]

Never said I was an expert, just that I follow a team of expert's conclusions that I vet using this forum and mostly on-line literature...Thank You ValveReplacement.org!

If my valve required an INR in the range of 2-4, I'd shoot for 3, but it doesn't. For my valve that is 2-2.5. That range is too narrow to shoot for a target, I just shoot for the range.

"Danger" is your word not mine. I believe in using the amount of drug to get the desired therapeutic effect. There are non-therapuetic effects of an elevated INR. You prefer to ignore them. I however have put my head into a windshield as a passenger and the head of a friend into a windshield when I was a driver. You prefer to ignore this possibility...It's YOUR brain.

I place absolute faith in no human. You must have missed some of my posts. I've related personal stories of physician errors that have effected me and killed two family members. Doctors are humans and when doctors make mistakes the consequences can be tragic, however the consequences of valve disease w/o doctors is always tragic.

What it is, that everyone uses the range that they feel is safe. I go by my lab cause they use what you do. And they go by the set range, 2.0 to 3.0. I feel comfortable with that range. Been doing that since 2001. But you do what you feel safe with. Most people want to pick on those who are comfortable with their set range. I would never do that to you. We are all different, and as long as we do our due diligence, being careful otherwise, I see nothing wrong with the set range you have set for yourself. Never let anyone tell you that you should do different. I am also a type 2 diabetic and at times I eat salads, not often, and never been a big problem. Antibiotics are different. OTC are different. But I always keep an awareness of I am doing as it affects the INR. increase activity, antibiotics and medications.
So Tom, just keep doing what you are doing. Everyone will learn what they feel comfortable. And it is bad with doctors do make mistakes or get of line. I got tricked in the Cardiac department at the hospital I go to and will be soon talking to the cardio about it, trying to diagnose me with Cushings disease, which I do not have. And to get another PC , cause that doctor is not helpful on my diabetes and had me take an HIV/AIDS test, since I had a blood transfusion in 1973. I think I would be dead already if I had HIV/AIDS.
Just had to vent. Sorry.

 

[Protimenow]

Apologies - I put my range in the the "Heading for a new aortic valve" thread, but relevant here too: 2.5 to 3.5. I think that you have commented in the past that this is higher than in the US for a St Jude, but my surgeon (who at the time was the only non-US guy to receive some prestigious American award that I forget the details of now!) was insistent on, and my post-surgery research (particularly on this forum) has concluded there is no need to lower it anyway. I would rather have a slightly high INR than a slightly low one.

No. I did not comment that the range for a St Jude is lower -- I've had 'disagreements' with Tom in MO who insists that the range for On-X (admittedly a different valve) should be 2.0 - 2.5. I STRONGLY support 2.5-3.5 as the appropriate range regardless of which mechanical valve you have. I also stated that there is really little life style impact from increasing the INR from a somewhat risky 2.0 to a much safer 2.5.

 

[Protimenow]

What it is, that everyone uses the range that they feel is safe. I go by my lab cause they use what you do. And they go by the set range, 2.0 to 3.0. I feel comfortable with that range. Been doing that since 2001. But you do what you feel safe with. Most people want to pick on those who are comfortable with their set range. I would never do that to you. We are all different, and as long as we do our due diligence, being careful otherwise, I see nothing wrong with the set range you have set for yourself. Never let anyone tell you that you should do different. I am also a type 2 diabetic and at times I eat salads, not often, and never been a big problem. Antibiotics are different. OTC are different. But I always keep an awareness of I am doing as it affects the INR. increase activity, antibiotics and medications.
So Tom, just keep doing what you are doing. Everyone will learn what they feel comfortable. And it is bad with doctors do make mistakes or get of line. I got tricked in the Cardiac department at the hospital I go to and will be soon talking to the cardio about it, trying to diagnose me with Cushings disease, which I do not have. And to get another PC , cause that doctor is not helpful on my diabetes and had me take an HIV/AIDS test, since I had a blood transfusion in 1973. I think I would be dead already if I had HIV/AIDS.
Just had to vent. Sorry.

Caroline - it's okay to occasionally vent.

So, if a person is comfortable with an INR of 1.0, just let that person do it. Right? Is that what you're saying?

If someone is locked in at an INR of 2.0 (which may be more like a 1.8 if the test is done with a CoaguChek XS), and someone else suggests that 2.5 is safer, would that person be wrong in commenting that the one locked in at 1.8 may be safer with a higher INR? As long as that person is comfortable with 2.0 (even if unsafe compared to a slightly higher INR), then don't interfere?

Your logic eludes me.

A person can be comfortable with a 1.8, and will be even more comfortable after having a stroke. Right?

If a person is comfortable running with scissors, is it wrong to suggest that they don't do this?
If a person is comfortable skydiving without a parachute, is it wrong to suggest that they either don't skydive or take the dramatic step of jumping WITH a parachute?

As long as they're comfortable.

Personally, I see a risk - whatever mechanical valve is used - to NOT shoot for an INR of AT LEAST 2.5.

But, as you suggest, I should just SHUT UP, so that I don't offend anyone, and let the 'comfortable' person take his own risk.

 

[Buckeye]

Okay guys I have another question about taking warfarin. What do you do when you get sick? Looks to me like everything is off the list to take. Can you take any otc medicine or do you have to run to the doctors office? I see also antibiotics is another no-no. What do doctors prescribe for illness? I have asthma as well and if I get sick I’m really bad. Thanks again.

 

[user 16827]

Okay guys I have another question about taking warfarin. What do you do when you get sick? Looks to me like everything is off the list to take. Can you take any otc medicine or do you have to run to the doctors office? I see also antibiotics is another no-no. What do doctors prescribe for illness? I have asthma as well and if I get sick I’m really bad. Thanks again.

Hi, the thing with Warfarin is that it's an unstable drug at the best of times
There is not one best option with our problem, either possible multiple surgeries with the risks that go with it or taking lifelong warfarin.

Your INR will change with a common cold, certain drugs can be more problematic and certain foods.
The climate and flying may affect it too.

That is why many of us endorse self testing and self monitoring.

So to answer the part of your question ' can you take OTC medicine, in short , Yes

if your INR changes you simply re dose, monitor and get back on track.

As an example, recently i've dramatically changed my diet.
This has sent my INR off whack

I have re dosed myself and tested every 5th day until i got back to my new regular dose

I used to take 15mg daily to maintain INR ~3
I now need 13.5mg to do the same job........

You learn to avoid the what ifs and spooky stories and you adapt and bend with the breeze if something alters your INR.

Initially it seems complex, but it really isn't