Inr

[dick0236]

Fewer bleeds with the lower INR. That counts minor and major bleeds.

But, 3x as many strokes, with the lower INR range.

I have been on warfarin longer than most (56+ years) I have a very old design aortic mechanical valve. My INR range has been 2.5-3.5 since the INR system was developed in the 1980s........and about 18 seconds PT(1.6 INR) before the INR system. I've never had an uncontrollable bleed that required more than first aid and/or some stitches. I've had one stroke (1974) due to a low INR and my ignorance of ACT that left me permanently partially blind.......that ain"t no fun. I only fear INR numbers below 2.0 and never let my INR stay around 2.0 or below. There is an old saying about bleeding and clots......" blood cells can be replaced but brain cells can't".

BTW, with the full approval of my cardio and PCP I try to keep my INR at, or above 3. I fell about 3-4 months ago and broke three ribs......but didn't bruise. So much for that "old wives tale".

 

[carolinemc]

I'm new to this (surgery 09/14/2023), so I am targeting INR in the range of 2 to 3 for these first 3 months. I have an On-X aortic valve, and my Coagulation clinic said we'll lower my target range to (I think) 1.5 to 2.5 after 3 months. Since this is still a couple months away, I have not yet discussed it with them.

What benefit might I get from an INR range of 1.5 to 2 rather than a range of 2 to 3? I still need to test INR weekly, and I still need to take warfaren every day. Would the lower range cause less bruising when I am struck while training martial arts? Will it mean I don't need to worry about the buffalo grass cutting my legs when I work in my yard? Are there some other examples someone can give of a life style benefit of the lower INR range? Currently I'm thinking I'd rather stay at a target range of 2 to 3 and just and just consider the 1.5 value as an extra safety margin.

In any case, since I had an episode of afib during cardiac rehab last week, my cardiologist recommends that I stay at an INR target of 2 to 3. Which sound very sensible to me.

Also, I greatly appreciate threads like this. I am learning a lot, which will help me when I have discussions with the nurse at the Coagulation clinic, my cardiologist, etc. Thank you!

Mine is the same way, in my clinic where I get my INR done, it is between 2.0 to 3.0. Can vary where they feel it is fine. But when it is below 2.0 and over 3.0, they will have me get a blood draw an the blood lab, and come back within a week, since I do not have a monitor at home. It gives me a chance to get out of the house and give my doggo a break doing this also at the lab.
It is great that you have a med team to talk to and ask questions. Welcome to the group.

 

[Beach77]

I have an On-X valve too (Dec 2020). A Coumadin Clinic monitors my INR from lab draws. (usually every 6 to 8 wks). But I bought a meter off ebay and monitor myself weekly. (My clinic is aware of the meter and it's why I don't go monthly for lab draws. My surgeon and the clinic wanted my range to be 1.5 to 2. But I wanted 2 to 3, which was "approved". What I wanted was to target 2.5 but the clinic was keeping me around 2. My cardiologist, per my request, changed my range to 2.5 to 3. Like most everyone else, being near the cliff of 1.5 is not worth it to me. I really do not want a stroke because my INR is low. I don't see any purpose in keeping my INR that low. My range keeps me in the worry-free zone.

 

[user 15848]

I'm new to this (surgery 09/14/2023), so I am targeting INR in the range of 2 to 3 for these first 3 months. I have an On-X aortic valve, and my Coagulation clinic said we'll lower my target range to (I think) 1.5 to 2.5 after 3 months. Since this is still a couple months away, I have not yet discussed it with them.

Hi, i also got an OnX back in 2015, also had AFIB 2 days after surgery it went away after 2 weeks with a bunch of pills they gave me and that was that for the AFIB. As per the INR, i did use the 1.5 -2.0 for one year but i found it stressful because if it moves down/up , and it does some times regardless, then is a very tight narrow margin, but i did it first year because was afraid of warfarin and bleeding. Once i felt comfortable about it, i moved my target range to 2 - 2.5; so , if it goes down to 1.5, and it has happened to me, i am covered, and if it goes up, well from 2 to 3.5 there is no reason to be worried about. By "ideal" number is 2.0; but during past 7 years, it has gone for different reasons or no reasons at all from 1.6 to 3.5; no problems. Everybody is different, but you will get to manage it easy; specially if besides the lab get a "home test" machine, that is always 2 steps away from you. Lots of good articles here, specially by Pellicle;

 

[user 15848]

Welcome to the forum Paul!

Like you, I have a mechanical valve in the aortic position. My INR range is 2.0 to 3.0, which is pretty standard. I have a St Jude and one study found that St. Jude can be safely maintained at 2.0 to 2.5. Some target this range, and I will sometimes try to keep that tight range if I am actively doing jiu jitsu.

In that you have an On-x valve, some will push you towards an INR of 1.5 to 2.0. This was based on the outcomes from the PROACT Trial, which many experts believe is flawed. There have been lengthy discussions about this study on this forum. I will comment that I agree with @pellicle and @dick0236 and would personally avoid going below 2.0 in order to reduce the risk of stroke.

1.5 - 2.0 for OnX works just fine, but is hard to keep the 1.5 as the lower value; nothing else; But i understand your "opinion", the St Jude is an older valve and has proven to work great, OnX is just an improvement on St Jude, times change, engineering change, SOMETIMES for the better.

 

[pellicle]

OnX is just an improvement on St Jude,

I would phrase it as derived from and redeveloped. I would ask for evidence to support improvement, because I'm not seeing improvement.

Here I link and cite a study where specification claims are evaluated with actual performance
https://www.valvereplacement.org/threads/aortic-valve-choices.887840/page-2#post-902334
Basically as I see it the wheel is an old and unchanged for some time invention too.

 

[tom in MO]

1.5 - 2.0 for OnX works just fine, but is hard to keep the 1.5 as the lower value; nothing else; But i understand your "opinion", the St Jude is an older valve and has proven to work great, OnX is just an improvement on St Jude, times change, engineering change, SOMETIMES for the better.

Actually it's not an "opinion" but a fact that the St. Jude has proven itself through many patient years of use. That's why they changed the INR range from 2-3 to 2-2.5.

 

[Chuck C]

OnX is just an improvement on St Jude, times change, engineering change, SOMETIMES for the better.

Do you have evidence to support this claim?

The PROSE Study, published in 2022, was a head to head comparison of On-x vs St Jude. Both valves performed very well, with the conclusion that they did equally well.

See below quote and link to the study publication.

"Conclusions"​

"The On-X valve and St Jude Medical valve performed equally well in the study with no differences found."

https://www.jtcvsopen.org/article/S...ions,Developing more than Western populations

 

[Shiv]

Hello Paul. Sorry about your misfortune, but know that you have the right heart valve. I also have an On-X valve, and I ride an Indian Challenger (I love motorcycles of all makes and own others). As far as I'm concerned, my INR range is 1.5 to 3, although it's usually 1.9-2.7.

Contrary to what you might read on this forum, no one will "push" you to be 1.5-2. The PROACT trial did show that it is indeed safe, but keeping it in that narrow range is very difficult. The take-home message is that the On-X valve has design nuances that probably make is less thrombogenic than older valves, and a less thrombogenic valve is an advantage at whatever INR you happen to be at. The only time my INR has been under 1.5 was when I did it intentionally for a colonoscopy.

Best wishes and don't worry about the ticking. You won't hear it over that Harley anyway! I always say that it's not the motorcycles that are dangerous. It's all those other fools barreling down the road and not paying attention.

Do you have aortic or mitral?

 

[Shiv]

Thanks, Superman, for posting this. In two days I will celebrate the 56th anniversary (8/16/1967-8/16/2023) of my mechanical valve. My ONLY issue with my valve over all these years was a serious TIA seven years after my surgery. The stroke was caused by a clot due, almost certainly, to a low INR (PT in those days). I maintain an INR of 2.5-3.5 and have a little concern if I drop to 2 or go above 4.......which almost never happens......I adjust my warfarin dose to get away from those extremes.

Serious bleeds have never been a problem altho I've had my share of cuts (a few that have required stitches). Recently I had an "old mans fall".......broke 3 ribs but never bruised.....go figure!

An INR of under 2 for an extended period of time is walking too close to the edge of the cliff.

Aortic or mitral?

 

[vitdoc]

Things get repeated so they become true. On-X presented data to the FDA with a weird concocted statistic that added "bleeding episodes" to ischemic episodes. By doing this they showed that a low INR seemed OK. If you look at the data you can see that indeed there are fewer bleeding events but more stroke events. I was somewhat surprised that the FDA approved the lower INR suggestion of On-X based on this.
So if you are more worried about bleeding keep your INR low. If you are more worried about stroke not so low. St. Jude never ran a similar study (or at least reported it) to my knowledge. So it may have behaved similarly to the On-X behavior. We don't know. But even the On-X data didn't look so great from a stroke perspective. I personally would much rather worry about bleeding than a stroke. So I try to run around a 2.5 INR. As has been also said many times in this forum trying to run a 1.5 is very difficult without the INR dropping to a lower value. I think On-X is doing a disservice to the valve community by promoting these values primary to gain market share.

 

[dick0236]

Aortic or mitral?

I have an Aortic valve.