Lovenox for bridging with a Mechanical Valve

[marc_kowal]

Greetings all,

Next month I need to have an outpatient procedure done and when my Gastro received the cardiac clearance from my cardiologist, the instructions were to stop my warfarin 3 days prior to the procedure, no bridging mentioned. I sent my cardio a message asking about that and that in the past my former cardiologist had me bridge with Lovenox for a colonoscopy, so can I bridge for this procedure. He said we can bridge if I wish and asked if I had been hospitalized for IV heparin or given Lovenox as an outpatient. I said Lovenox, and he mentioned that Lovenox for mechanical valves has been questionable. I'm waiting to get some more information from him about that, but I'm wondering if others have had conversations with their doctors about bridging with a mechanical valve.

 

[MdaPA]

I'm wondering if others have had conversations with their doctors about bridging with a mechanical valve.

My wife (mechanical AV and MV) has bridged using Lovenox for several procedures when she was below her therapeutic INR range per DR's orders.

He said we can bridge if I wish and asked if I had been hospitalized for IV heparin or given Lovenox as an outpatient. I said Lovenox, and he mentioned that Lovenox for mechanical valves has been questionable.

Please ask you doctor to clarify what he means by "Lovenox for mechanical valves has been questionable" and then post back if you can. Perhaps he can reference a particular study or publication? Or is he questioning bridging for just the colonoscopy?

 

[Protimenow]

Lovenox IS questionable.

There's another ongoing thread (Bridging with Lovenox) that goes into more detail about this.

I had a pacemaker implanted yesterday. Before the surgery, I missed two doses, I didn't bridge. I took 1.5 times my usual dose when I got home and will resume my usual dose tonight. I expect my INR to be back in range in another day or two,

Please check out the current ongoing thread for a lot more discussion about bridging.

 

[pellicle]

Hi Marc

but I'm wondering if others have had conversations with their doctors about bridging with a mechanical valve.

so, quite a recent conversation here

https://www.valvereplacement.org/threads/bridging-with-lovenox.889137/post-925012
In case you didn't know lovenox is heparin.

Worth reading that thread IMO

Also my blog post here about what I did
https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
and my blog write up of what Chuck did
https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
both quite detailed.

HTH

 

[JLmatus]

Over the past 6 years I have bridged with lovenox several times for various medical and dental procedures. Bridging with Lovenox is a standard procedure for mechanical heart valve patients. I would ask your doctor why he/she feels that bridging with Lovenox is questionable. As mentioned before Lovenox is heparin. I have an ON-X valve.

 

[MIB]

The last 2 procedures I have had, I was required to bridge with Lovonox. ON-X valve

 

[Protimenow]

REQUIRED TO?

Would they have refused you treatment if you hadn't bridged?

The people doing the procedures were in CYA mode.

It takes more than the few days it takes to bring your INR back in range to form a clot on your valve.

On-X valves supposedly have an even lower risk.

Pellicle gave a link to research that showed worse outcomes for people who bridge than for those who don't.

I don't bridge anymore. My surgeon seems to be okay with it -- or at least he honored my request not to bridge.

Lovenox (Enoxaparin) is low molecular weight heparin. The injection site is painful for many minutes, blood often seeps out of the needle's track, and is probably unnecessary.

If you take an antibiotic after your procedure, this may reduce your INR. If you don't self test, you and take an antibiotic, you should have your INR tested to see if the antibiotic keeps your INR low -- you don't want it below 2 for more than a few days.

(I had a pacemaker implanted two days ago and started back on my usual warfarin dose. By now my INR would be near normal -- I'm taking Clindamycin, and my INR is 1.6. I'm increasing my dose while I'm on this antibiotic. Here's another example of the value of self testing -- I can monitor and adjust dosing when necessary.)

 

[pellicle]

Here's another example of the value of self testing

We should start a list

101 reasons to self test INR

 

[pellicle]

Oh, and PS

REQUIRED TO?

Would they have refused you treatment if you hadn't bridged?

In my case for the colonoscopy the proctologist (under used word) said if my INR wasn't ≤ 1.4 she wouldn't do it and I'd need to reschedule.

The bowel prep was a sincere motivator for me to get that right...

 

[Protimenow]

The issue here isn't about lowering your INR for a procedure -- it's about bridging. I lowered my INR to 1.4 before my new pacemaker was implanted. I didn't bridge -- my issue is that I'll be taking an antibiotic for five days, and this reduces my INR. I'm increasing my dose for a few days to compensate for the effects of the antibiotic and testing daily.

If my INR goes high, I won't be alarmed -- reducing a dose is simple -- I prefer an INR of 4 to one of 1.4.

 

[pellicle]

The issue here isn't about lowering your INR for a procedure -- it's about bridging.

yes, I know ... and I was just saying that's as close to "they won't do it" as I've had.

However if I hadn't stood my ground with the receptionist about bridging (after meeting with the Dr) and asked her to call the Dr she was going to cancel my appointment for the procedure if I didn't bridge.

If I encounter that again I'll just smile and take the script, won't fill it and do what I want to anyway.

 

[Protimenow]

My experience was similar. When I was called to confirm the date of my surgery and the subject of bridging came up, I said that I don't want to bridge.

My doctor understood and honored my request. His only condition was for me to lower my INR before the surgery (which I planned to do anyway and made perfect sense).

If I wasn't self testing and managing my INR, I would have run into a major issue: I was also prescribed an antibiotic. The effects of antibiotics on INR were discussed on other forums, so I knew to test daily in case the antibiotic messed with my INR. It does. I had to increase my dosage.

If I was just refusing to bridge on principal, it would have been OK as long as I wouldn't be taking an antibiotic. I'll let my doctor know about the antibiotic issue -- he wanted bridging on the day of the surgery -- the real risk arises AFTER the surgery, with the antibiotic causing the problem.

Although my INR would be below 2 for f 6 or 7 days maximum. this is a risk that is easy to avoid and that I didn't want to take.

Again, this wouldn't have been possible if I wasn't self testing and managing.

 

[pellicle]

Again, this wouldn't have been possible if I wasn't self testing and managing.

surprised you avoided an angry face on that assertion.

 

[Chuck C]

Personally, if their guidance is to hold warfarin instead of bridging, then I would go with that.

I had a thyroid procedure, for which I held warfarin and did not bridge. But, I self test, so rather than just hold for a certain number of days and guess what my INR was, we agreed that I would target an INR of under 1.5 for the procedure. We all metabolize warfarin at a different rate. From my experience, 3 days off of warfarin for my procedure would be overkill, as my INR drops significantly from just one day of holding- even when I reduce my dose by 30%, I see a significant INR drop within 24 hours.

Pellicle documented the method I used in the link provided in his post earlier in this thread. The link is titled Rapid Dust off Perioperative INR Management. I was able to achieve the target INR by reducing my dosage, without completely holding my warfarin for a day. This enabled me to get just under the INR and bounce it back up fairly quickly. I held my morning dosage the day of the procedure, but dosed a couple of hours afterwards. In the days leading up to my procedure, the day of and the days after, I tested my INR often, as I always wanted to know where it was at, the direction it was heading and the velocity with which it was headed in that direction.

There is growing evidence that lowering INR has better outcomes than bridging, for most procedures. See link below:

“An INR < 1.5 is generally acceptable except for neurosurgery, ocular surgery and procedures requiring spinal anesthesia or epidural analgesia.1”

https://www2.gov.bc.ca/gov/content/...gist,spinal anesthesia or epidural analgesia.

 

[Protimenow]

My issue post-op was that I was taking an antibiotic. Doctors don't seem to think about the effects antibiotics have on INR. If I WAS bridging, my doctor may have had me stop a few days after the procedure when it's assumed that the INR would be back in range.

Although a few days with an INR below 2 isn't particularly dangerous, why take the risk?

Rules change whenever we take antibiotics -- especially powerful ones.

 

[tom in MO]

Whether one bridges or not depends upon one's valve and how it is behaving. I am having a spinal injection on Friday for which I stopped warfarin on Sunday w/o bridging to get my INR to 1. The doctor's nurse mentioned my last echo results indicating I can just stop the warfarin for 5 days w/o any other treatment. I also was told to stop the 80mg aspirin. I did the same a little over a year ago w/o any difficulties.

 

[MIB]

REQUIRED TO?

Would they have refused you treatment if you hadn't bridged?

The people doing the procedures were in CYA mode.

It takes more than the few days it takes to bring your INR back in range to form a clot on your valve.

On-X valves supposedly have an even lower risk.

Pellicle gave a link to research that showed worse outcomes for people who bridge than for those who don't.

I don't bridge anymore. My surgeon seems to be okay with it -- or at least he honored my request not to bridge.

Lovenox (Enoxaparin) is low molecular weight heparin. The injection site is painful for many minutes, blood often seeps out of the needle's track, and is probably unnecessary.

If you take an antibiotic after your procedure, this may reduce your INR. If you don't self test, you and take an antibiotic, you should have your INR tested to see if the antibiotic keeps your INR low -- you don't want it below 2 for more than a few days.

(I had a pacemaker implanted two days ago and started back on my usual warfarin dose. By now my INR would be near normal -- I'm taking Clindamycin, and my INR is 1.6. I'm increasing my dose while I'm on this antibiotic. Here's another example of the value of self testing -- I can monitor and adjust dosing when necessary.)

I had shoulder replacement surgery. I didn't find the Lovonox to be a problem. I'd taken it previously with knee replacements. I'd rather be safe than sorry. I don't see it being worse than wsrfarin.

 

[Chuck C]

More studies need to be done, but I believe the linked publication below is worth a read and something that folks might want to discuss with their cardiologist and surgeon before a procedure. As has been noted before, I had a thyroid procedure about 18 months ago and did not bridge. The consult with my surgeon was consistent with the linked article below. Growing evidence that more harm than benefit comes from bridging for most procedures.

“Reductions in thromboembolism from bridging remain theoretical, but the increased risk of bleeding is consistent across studies and clinically important.”

“We feel confident in saying that there is an increasing body of evidence, and an increasing consensus, that the overwhelming majority of patients will receive net harm from bridging. Bridging should only be offered after careful consideration, and for highly selected patients. Patients should be informed that the practice of bridging is nonevidence-based. Although we may fear the consequences of a thromboembolic event—and justifiably so—no study has ever shown that bridging reduces this risk, and every study that has been completed to date suggests a marked increase in bleeding from bridging.”

A Call to Reduce the Use of Bridging Anticoagulation​

https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.115.002430

 

[pellicle]

More studies need to be done, but I believe the linked publication below is worth a read and something that folks might want to discuss with their cardiologist and surgeon before a procedure. As has been noted before, I had a thyroid procedure about 18 months ago and did not bridge. The consult with my surgeon was consistent with the linked article below. Growing evidence that more harm than benefit comes from bridging for most procedures.

Wow, echoing the studies I cited in 2017

Talk about changing directory of an iceberg. From the article (my bold)

Abstract​

Because of the recent publication of several important studies, there has been a major change in how we think about perioperative management of anticoagulation. Because of these changes, existing consensus guidelines are suddenly out of date and can no longer be used as is, particularly the 2012 American College of Chest Physicians Antithrombotic Guidelines, version 9. We estimate that well over 90% of patients receiving warfarin therapy should not receive bridging anticoagulation during periprocedural interruptions of therapy, except under unusual circumstances and with appropriate justification. Accumulating evidence also suggests that bridging is not indicated among patients receiving direct-acting oral anticoagulant therapy. The large number of patients potentially affected represents an important safety concern and requires an immediate change in practice.​

 

[Protimenow]

Whether one bridges or not depends upon one's valve and how it is behaving. I am having a spinal injection on Friday for which I stopped warfarin on Sunday w/o bridging to get my INR to 1. The doctor's nurse mentioned my last echo results indicating I can just stop the warfarin for 5 days w/o any other treatment. I also was told to stop the 80mg aspirin. I did the same a little over a year ago w/o any difficulties.

FIVE DAYS???

WTF?

That's a sure way to get your INR to 1.0 or so, but it's overkill and seems unnecessary.

Are you sure your doctor is up to date on anticoagulation, or reading from a 30 year old protocol?