INR

[tom in MO]

It is interesting that they told you 2-2.5 for a St. Jude Valve and told me 2.5-3.5. I had mine implanted in 2004. When did you get yours? Protimenow got his in 1991 and has successfsully used 2.5-3.5 . My Coumadin clinic got the recommendation from St. Jude's and I have seen it in medical literature as well. I note that in your post, you said you also got the recommendation from your Coumadin Clinic and Cardiologist.

Pellicle's chart shows that 2.5 to 3.5 is the low danger zone for people with artificial heart valves but does not distinguish between types of artificial heart valves.

Interestingly, at Kaiser, the cardiologists defer to the recommendations of the Coumadin Clinic pharmacists.

I noticed the comment above that "Tylenol is pretty safe." It was for me also until I made the mistake of taking a lot of it for muscle pain. I developed two fist sized hematomas in my thigh muscles. My Coumadin clinic then warned me to stay at or below 2 mg a day. "Relatively" new research shows that it can amplify Coumadin at higher dose levels. Anything more requires being closely monitored as it can do things that amplify Coumadin. My mistake is more reason to follow the recommendations here to monitor weekly. Sometimes the "safety" of things can change.

Walk in His Peace,
and Have a Quiet Christmas
ScribeWithALancet

My valve was implanted 7 years ago. They had just changed the range from 2-3 to 2-2.5. It was a result of historical studies I think. My surgeon told me 2-3, I had read that it was changed to 2-2.5 and asked my Cardio. He said that 2-2.5 was the new range. I asked my surgeon and he told me to do what my Cardio said, as a surgeon he was only concerned with INR directly after surgery. My valve is a St. Jude Mechanical Model 23AFGN-756 in the aortic position. You may have the same general type because my valve is "proven" that's why they adjusted the INR range. I also had a surgery without any bridging, by just dropping my INR, due to the valve's good historical performance.

 

[pellicle]

Hi

I had read that it was changed to 2-2.5 and asked my Cardio. He said that 2-2.5

being unable to find any literature which supports that, could you please fish out the link to what you read or what guided your cardio? Because I suspect that a mistake has been made and that someone read the target for Aortic Valvers is 2.5 and that may have been mixed up with the range of 2~3 yielding the possibly mistaken 2~2.5 range.

 

[Protimenow]

I'll repeat a few things that some may choose to not acknowledge:

There's no perceptible difference in the way we live our lives if we choose a range of 2.5 - 3.5. It's really NOT that much different. But it can help protect us from serious injury or death if we maintain our INR in that range.

If you use the CoaguChek XS meter, it is possible that a 2.0 on the meter may translate into a 1.8 or so at the lab. It's probably a good idea, when using that meter for testing, to aim for a MINIMUM of 2.2 -- if your target is 2.0. Again - I don't think 2.0 - or 1.8 - are safe. If testing on a CoagSense, a 2.0 may be slightly higher - perhaps 2.1 or 2.2. Again - 2.5 makes no perceptible difference in how we live and can be protective.

And, like Pellicle, I'd like to see a reference to whatever paper now suggests a safe range of 2.0 - 2.5.

 

[tom in MO]

Hi


being unable to find any literature which supports that, could you please fish out the link to what you read or what guided your cardio? Because I suspect that a mistake has been made and that someone read the target for Aortic Valvers is 2.5 and that may have been mixed up with the range of 2~3 yielding the possibly mistaken 2~2.5 range.

There is no target. The range of 2-2.5 is not for "Aortic Valvers". The range is specific to my valve, "St. Jude Mechanical Model 23AFGN-756 in the aortic position."

I first read of the change to a 2-2.5 INR here ~7 years ago. Somebody posted the good news and maybe a link. It's buried in the depths of the old forum and my brain

Per my surgeon and first and second cardios, "St. Jude valves" are an older "proven design" that are "robust" in that they can handle low INRs w/o throwing clots. That's why my surgeon said he'd put in an On-X valve for me, but he liked St. Jude because of its long positive history. On the US FDA database, for my model there is only one reported valve failure. It resulted in death. That's why I chose the St. Jude valve.

The stability of the St. Jude valve is why I could have surgery w/o needing to bridge, just stopping Warfarin for about 4 days. That's why my coumadin management clinic doesn't get worried when my INR drops low, doesn't require me to bridge and only doubles up on a single day's dose with a retest in 5 days and then 10-days.

 

[pellicle]

Somebody posted the good news and maybe a link. It's buried in the depths of the old forum and my brain

Ok, thanks.

There's no doubt the St Jude is a reliable valve

I guess these guys don't know what they're talking about
________________________________
https://academic.oup.com/ejcts/article/42/4/S1/606787

Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)


11.2.2.2 Target INR
In choosing an optimum target INR, one should consider patient risk factors and the thrombogenicity of the prosthesis, as determined by reported valve thrombosis rates for that prosthesis in relation to specific INR levels (Table 20) [203, 219]. Currently available randomized trials comparing different INR values cannot be used to determine target INR in all situations and varied methodologies make them unsuitable for meta-analysis [220–222].

Table 20:
Target international normalized ratio (INR) for mechanical prostheses

a Prosthesis thrombogenicity: Low: Carbomedics, Medtronic Hall, St Jude Medical, ON-X; Medium: other bileaflet valves; High: Lillehei-Kaster, Omniscience, Starr-Edwards, Bjork-Shiley and other tilting-disc valves.
b Patient-related risk factors: mitral or tricuspid valve replacement; previous thromboembolism; atrial fibrillation; mitral stenosis of any degree; left ventricular ejection fraction <35%.
______________________________________________

Target is discussed with relation to range throughout that document ... but no need to read it because you have a memory of the good news here.

 

[Protimenow]

Perhaps some over-eager St. Jude sales rep told the doctors of the 'new' range for this reliable valve - to compete with the On-X claims that 1.5 is safe. Perhaps these doctors bought in, hook, line and sinker.

I would be surprised if St. Jude Medical endorses this new range for any of its valves.

I've said this many times before:

1. Sticking to a range of 2.5 - 3.5 won't make any difference to the lifestyle of a person with a narrow 2.0 - 2.5 window. The slightly (and really slightly) higher INR of 2.5 is protective against stroke.

2. Depending on the meter used to test your INR, your INR could actually be 1.8 or lower, when compared to a blood draw. Going with a 2.0 is like walking on a tightrope. I hope your balance is good -- personally, I wouldn't bet my life on it - no matter WHAT some doctor says.

 

[Superman]

https://www.mayoclinic.org/tests-procedures/prothrombin-time/about/pac-20384661
From the Mayo Clinic. Says 2.0 - 3.0 is for conditions like AFib and other clotting disorders and the “slightly higher” for mechanical valves (2.5 -3.5 standard?).

https://www.acc.org/latest-in-cardi...58/anticoagulation-for-valvular-heart-disease
American College of Cardiology says 2.0 to 3.0 for Aortic and 2.5 - 3.5 for Mitral.

Given the now well known incidence chart, I’m not sure why at upper limit much below 4.0 would even matter.

 

[Superman]

I guess these guys don't know what they're talking about.

Well, they ain’t American!

 

[pellicle]

Well, they ain’t American!

that's for sure ... they're very likely to be very "un-American"


To quote Superman (the other one)
Truth, Justice ... and the American Way

 

[Superman]

It’s okay. I linked a couple American sources. Probably where your people got their info from anyway.

....and no, you’re right. I said that. There is no other one.

 

[pellicle]

Probably where your people got their info from anyway.

I'll give them strict instructions to follow proper citations from now on ... thanks superman

 

[Protimenow]

that's for sure ... they're very likely to be very "un-American"


To quote Superman (the other one)
Truth, Justice ... and the American Way

Actually, Superman didn't say that -- it was the announcer during the TV show's titles. (Maybe the radio show also had that - I'd have to go back to some of my more than 1100 Superman shows, and maybe the words were in the comic books).

 

[Protimenow]

It can be a bit difficult knowing when your INR hits 4.0 if you're testing with a CoaguChek XS - there's a known issue with variance from lab to meter increasing the higher the INR gets. (In other words, a lab may say 2.6 and the meter may say 4.0). The Coag-Sense doesn't have that problem with errors at higher INRs. (The Coag-Sense if my meter of choice -- but if I had some CoaguChek XS strips, I'd use it to compare INRs every few weeks).

Agreed, we probably shouldn't be too concerned with bleeding if our INRs are below 4.0.

 

[pellicle]

(In other words, a lab may say 2.6 and the meter may say 4.0).

such variance is quite uncommon

 

[Agian]

Look up in the sky... it's a bird, it's a plane... click click click click...

 

[ScribeWithALancet]

My valve was implanted 7 years ago. They had just changed the range from 2-3 to 2-2.5. It was a result of historical studies I think. My surgeon told me 2-3, I had read that it was changed to 2-2.5 and asked my Cardio. He said that 2-2.5 was the new range. I asked my surgeon and he told me to do what my Cardio said, as a surgeon he was only concerned with INR directly after surgery. My valve is a St. Jude Mechanical Model 23AFGN-756 in the aortic position. You may have the same general type because my valve is "proven" that's why they adjusted the INR range. I also had a surgery without any bridging, by just dropping my INR, due to the valve's good historical performance.

My St. Jude valve is in the mitral position and yours is in the aortic position.

I do recall reading that aortic valves require less anti-coagulation then mitral valves because of the differences in blood flow speed and and turbulence in the blood passing thru the valve. That may be the reason for the difference in recommended INR.

When I had my surgery, my surgeon told me that my arteries were “clean as a whistle”. This was except at one place where the angles the blood vessels met at caused turbulence and that this condition always caused artery plaque. This was irregardless of what the arteries looked like elsewhere. The condition was so frequent for that junction of arteries that the heart surgeons had identified a specific place to get the replacement material from and how to do it super quick.

The article I had read was on turbulence and blood speed as design considerations for on a new technique to use 3-D printing to create models of artificial heart valves for blood turbulence testing (similar to wind tunnel testing - Blood tunnel testing?). I could not find the article but did find this quote in an older paper that said:

“However, high shearing of blood cells and platelets still pose significant design challenges and patients must undergo life-long anticoagulation therapy. Bioprosthetic or tissue valves do not require anticoagulants due to their distinct similarity to the native valve geometry and haemodynamics, but many of these valves fail structurally within the first 10–15 years of implantation.”

The latter paper was titled “FLUID MECHANICS OF ARTIFICIAL HEART VALVES” by Lakshmi P Dasi
at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752693/The author has an embargoed paper titled “Reduction of pressure gradient and turbulence using vortex generators in prosthetic heart valves”
So, they are still working on this.
Maybe by the time a follow up surgery would be guaranteed to kill me, they will solve it.
: - )
Walk in Peace,
ScribeWithALancet

 

[Protimenow]

such variance is quite uncommon

What I meant to type was that a meter may say 3.6, and the lab would say 4.0. This was a typo - sorry.

 

[user 16827]

I'm no wizard with regards to the different valves so i have checked my St Jude
implant card.

It's in the Aortic position ST Jude 25CAVGJ-514 00

Therapeutic range 2.5 - 3.0

 

[mecretired]

I have a grafted st Jude aortic valve—surgery date May 3, 2010. I had some afib after surgery for less than a week. My cardiologist wants my inr to be 2.5-3.5. For several years I went to the lab monthly. Since I don’t trust monthly testing I eventually bought my own Coaguchek xs and check weekly. I am so much more comfortable with weekly testing than monthly.

 

[carolinemc]

I DID read it carefully.

Now - the thing with the 1.8 ---- what I was saying is that, if a test performed on a CoaguChek XS tells you your INR is 2.0 - it's likely that the actual INR - verified by a good lab - may be around 1.8. The CoaguChek XS has been documented to often report INRs that are slightly lower than the lab values. Thus - with a CoaguChek XS, I'd feel safer with a 2.2 or higher.

The meter that I use, Coag-Sense often reports a value that is slightly LOWER than the labs. So, for that meter, a 2.0 may actually show up as a 2.2.

Neither meters or labs are guaranteed to be accurate - an error of 30% is supposedly acceptable. The method of testing INR isn't exact. This is why, from personal preference, if I used a CoaguChek XS, I'd feel safer with an INR of 2.3, and with the CoagSense, I'd like an INR of at least 2.0.

I do labs because of I cannot do home checks without a machine. They use Coagcheck at the lab I go to. We have the INR at 2.0 to 3.0. I have a aortic St. Jude's' leaflet and got in 2001. I feel safe they way we keep my INR. It is affected by activity and antibiotics. I never read stuff online from unreliable sources. Like you, I like safe numbers that makes sense.