Looking for advice....

[Fburns]

I'm AVR (mechanical) since 1999 but having a little trouble with my INR, resulting in fortnightly testing.

The clinic are acting on a target range of 2 to 2.5, and I'm having trouble keeping it within that range (and they tend to over-react if it strays outside that). My own view is that this is too narrow a range; the Clinic says that this is the range recommended by the surgeon in 1999. However, my cardiologist (verbally) advised 2-3 as target.

So the advices I'm looking for is...

Who is best placed to set the target range.. Surgeon, Cardie, GP ... ?
Does a target of 2-2.5 seem to narrow ? And if not, is it really worth getting excited if it drifts - say - between 1.75 and 2.75 ?

Many thanks,
Frank

 

[Ross]

2 to 2.5 is nearly impossible to hit and yes, it is too narrow. 2 to 3 would be better and most all of us would like it to be closer to 3. Never let it fall under 2! Anything below that and your going to start clotting on the valve.

My range is 2.5 to 3.5, but I do not get upset or change doses if I hit 2.0 to 4.0. It's a no wonder your having trouble with that narrow window. There is very little difference between 2 and 2.5. It's almost insignificant.

The one who is best placed to set your range is the Valve manufacterer, not the Doctors. Normal AVR range without predisposition for clotting is 2.0 to 3.0, for those with predispostion to clotting such as myself, 2.5 to 3.5.

I guess the better question to you would be, are you staying between 2.0 and 3.0?

Here is a guide by the american heart association. If they want to argue with them, then it's time to find a new Physician:

http://www.acc.org/clinical/guidelines/valvular/Pvalvulr.pdf See page 35!

 

[Karlynn]

Do they keep adjusting your dose any time you are above 2.5? If so, then it's no wonder you are having problems staying in range. Ross is right - AVR range is usually 2 - 3. With my MVR it's 2.5 - 3.5. So that would tell you that anything 3.5 or below is just fine. Like Ross, I don't get disturbed or change anything if it's below 4. The last month my INR was 4.6 so I dropped my dose a bit, then it was 4.3, so I dropped it 5%. Yesterday it was 3.7, so I'm holding at that.

 

[Nancy]

I agree with Ross. And also it would be better if you didn't drift lower than 2.0. That should be your minimum, bottom number. Getting a little higher is not as bad as getting a little lower.

My husband's target range is 2.5-3.5 due to two mechanicals and intermittent afib/flutter and a history of TIAs.

Right now he tested last at 1.8. That is approaching stroke range for him. Not too happy with that reading.

Much of his INR fluctuations come from his CHF and subsequent diuresis.

 

[Fburns]

Many thanks for those very helpful replies.

My own instinct was that 2-2.5 was too narrow - unachievable in fact. And yes, I'm having fortnightly tests and endless adjustments. For example, my latest test was 2.7, and I got a phone call (with a sense of urgency) to drop down immediately.

This is something I will now raise formally with my cardiologist,

Many thanks again to all.

Frank

 

[Ross]

Frank 2.7 is 100% fine and no reason at all to adjust the dose. When your testing, remember it takes 3 days for a dose to show in the test, so if your testing more then twice a week and adjusting doses just as often, your chasing your tail and it's never going to be stable.

 

[Guest]

The only thing that a range more narrow than 1 whole number does for a patient is to assure them that most of the readings will be outside the range.

Anyone who would tell someone to lower their warfarin dose for an INR of 2.7 is demonstarting that the lack much understanding of warfarin. Instead of treating you like a person, they are oiling you like a robot (the manual says ...)

 

[Gemma]

Frank,

I would get in touch with either your cardio or GP and ask him/her to write to the clinic (and send you a copy) saying that your target range should be 2-3. They tend to prefer things in writing...

I'd also consider asking why they get so over-excited about an INR of 2.7. I'm not sure who exactly is best to talk to about it without causing problems for you as a patient, but it seems like someone in that clinic doesn't really know what they're doing.

Good luck!

Gemma

 

[Fburns]

Once again, many thanks for all the advice. I've now contacted my cardie and asked him to write to the Clinic (incidentally a dedicated Warfarin Clinic - so it's a little worrying that they seem to lack the good understanding that's so evident with the members here).

Ross, Many thanks for the reference to the AHA publication. I note in that they seem to be recommending aspirin in addition to the Warfarin; this is new to me (in fact I've been advised to stay away from aspirin), and I was wondering if there is any insight / advice fom the members, on the use of aspirin as a supplement to the Warfarin ?

Frank

 

[Ross]

Just about all of us are on aspirin regimens also. I take 81mg low strength once a day. Some Doctors have their patients taking regular strength 325mg once daily. Yet another thing, some have us on Plavix, Coumadin and Aspirin!

You might want to see these two articles by Al Lodwick on his site:

http://warfarinfo.com/aspirinwithwarfarin.htm

http://warfarinfo.com/warfasaclop.htm