INR

[Protimenow]

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.

Your message concerns me. The bottom of the range is especially troubling -- CoaguChek XS sometimes reports values that are slightly higher than blood draws (there are numerous reports about this - and my past testing also demonstrates this). It's no problem if your values are above, say, 2.4 or so, but it is possible that a 2.0 on the meter may be 1.8 in a blood draw - a worrisome number. You should go for a minimum that is no higher than 2.5, in order to fully protect yourself.

You shouldn't feel safe if they keep your INR between 2.0 and 2.5. That's below clinical recommendations and some people (including me) would consider this to be taking an unnecessary risk.

You may be able to convince your lab to try to keep your range ABOVE 2.5.

If possible, you should have your clinic test your INR weekly. Those who test weekly are shown to stayin range much more consistently than people who test less often.

 

[LondonAndy]

I completely agree with Leadville, and just wanted to add that antibiotics ARE NOT off the list. Being aware that they affect our INR level means that we know some adjustment to the Warfarin dose is likely to be needed, but it is not a dramatic change (in my case 1mg or less once I see the effect of the antibiotics) and using my home meter I increase my testing frequency to something like every 3 to 5 days. Generally people are only on antibiotics for a week or two, so this is not a big deal and quickly returns to normal once they are stopped.

 

[tom in MO]

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.

As already stated, my 2-2.5 range is supported by multiple physicians. The change in INR from 2-3 to 2-2.5 came after the 2010 card was printed and the 2012 article was written. I've had success for 7 years with 2-2.5 and my new cardiologist supports this range.

The EU doctors recommend one range, the US doctors another, the internet pundits have their own ideas. It's pretty obvious what is correct...the lowest doctor approved range works, people aren't dying, including myself.

 

[pellicle]

As already stated,

Merry Christmas Tom

 

[LondonAndy]

thrombogenicity. Now THAT'S a word.

 

[Protimenow]

As already stated, my 2-2.5 range is supported by multiple physicians. The change in INR from 2-3 to 2-2.5 came after the 2010 card was printed and the 2012 article was written. I've had success for 7 years with 2-2.5 and my new cardiologist supports this range.

The EU doctors recommend one range, the US doctors another, the internet pundits have their own ideas. It's pretty obvious what is correct...the lowest doctor approved range works, people aren't dying, including myself.

It's rather cavalier to say that 'people aren't dying' unless you REALLY know this. You can say, with full confidence, that YOU haven't died; but it's probably hard to monitor the others at that crazy range. If they die, they stop being tracked. The ones that lived stay on the study -- if there even WAS a study.

The doctors can say, with absolute confidence, that their living patients at that range haven't died.

Personally, I don't believe that 2 - 2.5 is a safe range, long term. I doubt that the 'multiple physicians' (one orthopedist, one gynecologist, one dermatologist and, perhaps, one proctologist - which may also constiture a group of 'multiple physicians') doesn't mean that they necessarily know much about prosthetic valves or anticoagulation. It certainly doesn't suggest that they know more, from their anecdotal experience than the scientists who contributed to the 2012 and later studies.

And, I repeat for the 10th? time that relying on a meter to determine that your INR is 2.0 is a dangerous act - your meter may show 2.0 when your actual INR is closer to 1.7. INR testing isn't exact, and even a good lab's values aren't exact.

In my mind, it's risky to get too close to 2.0.

And, as many others here have tried to convince you, there are really NO life changes in having a 2.5 - 3.5 INR versus a 2.0 - 2.5.

But, if you have more faith in the 'multiple physicians' who recommend 2.0 - 2.5 than in the information on the card that came with your valve, the studies to date that say to shoot for 3.0 plus-or-minus .5, and the ABSOLUTE ACCURACY of your meter, stay at that dangerous range. But it may be worthwhile to contact St. Jude and see if THEIR recommendation has changed (of course, they're not as smart as your 'multiple physicians', but you may give them a try).

It's your life.

I hope you don't drop off their study because you've had negative results from this low INR - they'll probably keep recommending it because ALL of their living patients are still alive (until they're not).

 

[pellicle]

It's rather...

Dude, its christmas, can't the arguments wait?

 

[Protimenow]

What is?

 

[Protimenow]

Pellicle:

You're right. I told myself that I would stop trying to convince the unconvincable -- but there I go again.

'Happy Christmas to all, and to all a good night' (no matter WHAT winter solstice events you celebrate, or your time zone).

 

[Superman]

....and Festivus for the rest of us!

 

[tom in MO]

It's rather cavalier to say that 'people aren't dying' unless you REALLY know this. You can say, with full confidence, that YOU haven't died; but it's probably hard to monitor the others at that crazy range. If they die, they stop being tracked. The ones that lived stay on the study -- if there even WAS a study.

The doctors can say, with absolute confidence, that their living patients at that range haven't died.

Personally, I don't believe that 2 - 2.5 is a safe range, long term. I doubt that the 'multiple physicians' (one orthopedist, one gynecologist, one dermatologist and, perhaps, one proctologist - which may also constiture a group of 'multiple physicians') doesn't mean that they necessarily know much about prosthetic valves or anticoagulation. It certainly doesn't suggest that they know more, from their anecdotal experience than the scientists who contributed to the 2012 and later studies.

And, I repeat for the 10th? time that relying on a meter to determine that your INR is 2.0 is a dangerous act - your meter may show 2.0 when your actual INR is closer to 1.7. INR testing isn't exact, and even a good lab's values aren't exact.

In my mind, it's risky to get too close to 2.0.

And, as many others here have tried to convince you, there are really NO life changes in having a 2.5 - 3.5 INR versus a 2.0 - 2.5.

But, if you have more faith in the 'multiple physicians' who recommend 2.0 - 2.5 than in the information on the card that came with your valve, the studies to date that say to shoot for 3.0 plus-or-minus .5, and the ABSOLUTE ACCURACY of your meter, stay at that dangerous range. But it may be worthwhile to contact St. Jude and see if THEIR recommendation has changed (of course, they're not as smart as your 'multiple physicians', but you may give them a try).

It's your life.

I hope you don't drop off their study because you've had negative results from this low INR - they'll probably keep recommending it because ALL of their living patients are still alive (until they're not).

You really don't read what I and others write.

I am not participating in a study.

I do not have a card that tells me a higher INR range than my cardios.

My multiple physicians do not include "one orthopedist, one gynecologist, one dermatologist and, perhaps, one proctologist" all are cardiologists and one is a surgeon. The range of 2-2.5 comes from St. Jude per my doctors. My physicians in charge of my anticoagulation believe the range has been proven. My valve is in the aortic position, it may be different for mitral.

Your belief in the fallibility of INR home meters is not supported by data. Each meter maker has to report about they medical device problems every year. If they were as inaccurate as you purport, they'd be off the market.

Going beneath 2.0 will not result in a stroke. I've been there, done that. Did it on purpose for surgery, did it because of life a couple of times. My coumadin clinic did not go crazy, order lovenox, etc. It wasn't a big deal, except I needed to test in 5 days. But again, my valve is in the aortic position, it may be different for mitral.

As far as being too high with anticoagulation with an INR higher than needed, you ignore the obvious draw backs. I guess you live in a world w/o car accidents, head trauma, internal bleeding, infections due to poor wound healing...

Many of what you state as facts are anecdotes or unfounded opinions and some are contrary to accepted anticoagulation practice in the US.

 

[Protimenow]

Tom - I told myself not to bother responding to you, but I'm making another exception here.

I DO read your posts. I never suggested that you are participating in a study.

My belief in the fallibility of meters is extremely well documented.

I didn't suggest that an INR below 2.0 would cause a stroke --- you and others (including me) have had an INR below 2.0 for a short time. It's not unsafe to have an INR below 2.0 for a few days. I've lowered my INR to 1.5 or so for procedures, and used my regular dose to raise the INR in two or three days.

In my case, I had a meter that reported 2.6 when the hospital's tests revealed an actual INR of 1.7. II was tested in the hospital because I HAD A TIA because my INR was probably around 1.7 or so for a few weeks. According to a paper published by the Duke University Clinic, maintaining an INR below 2.0 for 10 or more days, greatly increases the risk of stroke.

The drawbacks (one word - not two) of having an INR of 3.0, versus those for an INR of 2.5 are negligible, if completely nonexistent. Ask your genius doctors if there's a difference. Ask your cardiologist savants of the difference it would make if you were in a car crash if your INR was 2.0 versus what would happen in the same accident if your INR was 3.5. And, of course, we all know that we'll be in an accident every day -- so these negligible increases in INR that can prevent us from a stroke would be reason enough to keep the INR low. Hell, you may fall off a ladder and have a brain bleed (that's if you climb on ladders) or fall off your roof (if you climb on your roof), or you may fall out of an airplane and you'll bleed to death 30 seconds faster than you would with a lower INR. I really don't see the advantage of the lower INR.

Accusing me of using anecdotes or unfounded opinions is insulting and untrue.

I will revert to my commitment to not have to respond to you in the future -- if I can avoid your attacks and the BS that you write.

 

[carolinemc]

Last week, had the INR of 1.9 and retest two weeks, on January 6. They use Coagchek like a lot of you home testers. I do not have insurance to afford home testing, Medicare and SSDI. So I feel safer with them testing with their Coagchek.

 

[carolinemc]

Your message concerns me. The bottom of the range is especially troubling -- CoaguChek XS sometimes reports values that are slightly higher than blood draws (there are numerous reports about this - and my past testing also demonstrates this). It's no problem if your values are above, say, 2.4 or so, but it is possible that a 2.0 on the meter may be 1.8 in a blood draw - a worrisome number. You should go for a minimum that is no higher than 2.5, in order to fully protect yourself.

You shouldn't feel safe if they keep your INR between 2.0 and 2.5. That's below clinical recommendations and some people (including me) would consider this to be taking an unnecessary risk.

You may be able to convince your lab to try to keep your range ABOVE 2.5.

If possible, you should have your clinic test your INR weekly. Those who test weekly are shown to stayin range much more consistently than people who test less often.

I do feel safer with 2.0 to 3.0 range. They use the same Coagchek as you do. I cannot afford to be tested weekly as I am on SSDI and Medicare. I feel better being monitored by people who are trained to monitor me. I am on SSDI so funds are quite limited if I needs, food, shelter, medicine, utilities, and other bills paid. I live alone with my dog and I will stick with the testing I feel comfortable. Please stop putting people down who do not home test. If they feel safe doing it at hospital setting, let them be.
And this is not an attack, just stop putting us that do things different than you, down. We know what we are doing.

 

[Superman]

I do feel safer with 2.0 to 3.0 range. They use the came Coagchek as you do. I cannot afford to be tested weekly as I am on SSDI and Medicare. I feel better being monitored by people who are trained to monitor me. I am on SSDI so funds are quite limited if I needs, food, shelter, medicine, utilities, and other bills paid. I live alone with my dog and I will stick with the testing I feel comfortable. Please stop putting people down who do not home test. If they feel safe doing it at hospital setting, let them be.
And this is not an attack, just stop putting us that do things different than you, down. We know what we are doing.

Personally, I don’t see it as an attack for going in. It’s more of a push for weekly testing, which, for many, is only feasible if testing at home. I learned about home testing on this site and was able to push for it years ago with my providers. They initially did not support.

With five kids, working full time plus working on my MBA at the time (and now teaching adjunct), getting to the lab was hugely inconvenient. Many times I’d go months between draws. Home testing made me much safer and a better patient.

If one can get to the lab weekly, or every two weeks at minimum, great. If home testing isn’t for you, no big deal. The discussion should still be ongoing so newer patients know what their options are.

I am surprised to hear Medicare isn’t covering home testing to the same level as lab draws. I always understood Medicare was on board very early with coverage.

 

[dick0236]

.........I am surprised to hear Medicare isn’t covering home testing to the same level as lab draws. I always understood Medicare was on board very early with coverage.

I have been on Medicare for a long time. I have home tested weekly for 10-15 years and have always had it covered by MC. I have a co-pay of $4/test and receive all testing materials (meter, strips, lancets) free of charge. I test every Wednesday in the AM.....a 10 minute test in my pajamas. Weekly testing may be "overkill" since my INR is seldom out of range..........but maybe weekly testing helps me stay in range with only minor warfarin adjustments (seldom needed). My PCP is notified of my INR without cost to me. I think he receives a monitoring fee from my INR management company. IMO, if self-testing is feasible for you.......take a look at it.

 

[LondonAndy]

I feel better being monitored by people who are trained to monitor me. I am on SSDI so funds are quite limited if I needs, food, shelter, medicine, utilities, and other bills paid. I live alone with my dog and I will stick with the testing I feel comfortable.

Living in the UK I have no experience of MediCare or the rules that apply, but if they have any sense they should encourage people to test weekly at home because of the massive reduction in stokes and so on, hence saving on future healthcare costs whilst also being cheaper than lab testing anyway. So "win win". At the risk of boring regular readers, here is a link to my amateur, plain English summary of the UK "regulator's" report, which regards home testing as the "Gold Standard" treatment for those able to manage it. And it is very easy http://bit.ly/NICEreport . And I email my anticoagulation clinic my result once a month or so, and can go back to them if any issues in between.

 

[pellicle]

... I do not have insurance to afford home testing, Medicare and SSDI. So I feel safer with them testing with their Coagchek.

the only thing I can suggest to you is to develop a trust relationship with your Doctor, buy your own machine and your own strips and go from there. This is exactly what I did back in 2012. So over time then my machine has cost me $1.44 per test (well less because I've done a lot more than 52 tests per week) and the strips cost $6.15 per test

Every year that machine costs me less per test.

I find it interesting that people justify a $1,500 iPhone when my $200 Android phone is doing very well thank you (3 years later) but will baulk at paying one third of that for a unit which is actually involved in their personal health in a real way. Incomprehensible to me really.

 

[carolinemc]

the only thing I can suggest to you is to develop a trust relationship with your Doctor, buy your own machine and your own strips and go from there. This is exactly what I did back in 2012. So over time then my machine has cost me $1.44 per test (well less because I've done a lot more than 52 tests per week) and the strips cost $6.15 per test

Every year that machine costs me less per test.

I find it interesting that people justify a $1,500 iPhone when my $200 Android phone is doing very well thank you (3 years later) but will baulk at paying one third of that for a unit which is actually involved in their personal health in a real way. Incomprehensible to me really.

Can't afford the home machine. Limited income, SSDI does not make a lot of money. I have to make sure I have the money for my meds, rent, food, utilities and extra. I never spend $1500 for a cell phone. My next one will be from consumer cellular. And the test strips may not be covered by Medicare or Medicaid. Gotta think about the cost and limited funds.

 

[carolinemc]

Living in the UK I have no experience of MediCare or the rules that apply, but if they have any sense they should encourage people to test weekly at home because of the massive reduction in stokes and so on, hence saving on future healthcare costs whilst also being cheaper than lab testing anyway. So "win win". At the risk of boring regular readers, here is a link to my amateur, plain English summary of the UK "regulator's" report, which regards home testing as the "Gold Standard" treatment for those able to manage it. And it is very easy http://bit.ly/NICEreport . And I email my anticoagulation clinic my result once a month or so, and can go back to them if any issues in between.

Just be glad you have it better there. Medicare only cover 80% of medical expenses. So getting a home monitor is not so easy, moneywise, cause being SSDI, I am disabled and cannot work. And limited funds to live on. So not easy to have money to buy equipment that Medicare may not cover. And the test strips may cost a fortune. Someday we will have it better in America. But till then, it is hard to get necessary things to care for ourselves here unless you can pay the big bucks for medical insurance. On my little raise they gave us. after Medicare gets it share, I only got 15 dollars for a cost of living increase. And have to struggle to pay the 20% that Medicare does not pay. So sad in the medical arena in America.