Low INR question

[tom in MO]

Thanks for the clarification of the veracity of your claims. I'm going to follow your advice and accept what is the main stream medical opinion.

Best Wishes

Main stream medical opinion for my St. Jude mechanical valve is 2-2.5 range with 2 week testing.

By parsing my response, you make it seem the recommended dose range was 2-3. That's not what I said and it's a misrepresentation of my point. Ranges change, a low range is not dangerous, you can keep in a 0.5 spread and your surgeon (or the internet for that matter) may not be the best source for a warfarin therapy plan.

 

[Protimenow]

I wouldn't be reassured by the PROACT study. The study doesn't provide longterm follow-up. It was too small a population to be statistically significant, and it appeared that the goal was to support the idea that it's okay to maintain an INR between 1.5 and 2.0. I just don't get how keeping an INR between 1.5 and 2.0 would be any better than the recommended 2.0-3.0 for other, long-proven mechanical valves. If I had an On-X, THIS study would NOT reassure me in the least.

We've recently had a post by a user of the ON-X who had a nightmare series of clotting events when she allowed the INR to drop below 2, as recommended by her doctors.

I'm glad to see that you're keeping your INR around 2.2 - please don't let it drop below 2.0. There's no tangible benefit to dropping it that .2 - .5 points, and a hell of a lot of risk.

Marketing a valve because an incomplete study suggests that you can keep your INR below 2 - when there's no reason to NOT keep it above 2, is irresponsible and, as has seen at this site, potentially very dangerous.

 

[Protimenow]

Main stream medical opinion for my St. Jude mechanical valve is 2-2.5 range with 2 week testing.

By parsing my response, you make it seem the recommended dose range was 2-3. That's not what I said and it's a misrepresentation of my point. Ranges change, a low range is not dangerous, you can keep in a 0.5 spread and your surgeon (or the internet for that matter) may not be the best source for a warfarin therapy plan.

You keep quoting what you call 'main stream' (should be a single word), but not saying who the hell comprises the mainstream. Where are you seeing the recommendation to test every two weeks? Where did you see a mainstream recommended range of 2.0 - 2.5?

Self-testing every two weeks is NOT a 'mainstream' recommendation. Studies show a higher percentage of the time that patients are in range if they self-test weekly. I believe that both Roche and Coagusense recommend self-testing weekly -- and it isn't just to sell strips. And, for that matter, even if it was, what's an extra $130 a year (26 weeks at $5 a week) compared to the costs and risk of having a stroke during the 'off' week?

The mainstream that I've cited was from medical journals - not an anecdotal 'main stream.'

I agree with you: surgeons are probably NOT the 'best source for a warfarin therapy plan,' but you seem to keep quoting them.

Give it up, Tom. Maintaining a range 2.0 - 3.0 (or, as you seem to insist) a range of 2.0 - 2.5 is much safer than the 1.5 - 2.0 that On-X keeps trying to push. If I had an On-X valve, I sure wouldn't want to risk a stroke just because a sales rep convinces a doctor that the range is safe - when it's really no different to keep the INR in a safe range of 2.0 - 2.5 (or higher). And, yes, weekly testing is a recommended best practice.

 

[pellicle]

Main stream medical opinion for my St. Jude mechanical valve is 2-2.5 range with 2 week testing.

So you say. You are welcome to believe that. I believe main stream opinion is evidenced by a review of the medical literature, not asking mt cardiologist (or mum) in isolation. I believe Google is simply a tool to search literature in key words in text, not a repository of knowledge (as you seem to imply by saying believe Google).

By parsing my response, you make it seem the recommended dose range was 2-3. That's not what I said and it's a misrepresentation of my point.

That was not my intention, anyone who read your post would be clear you dont believe that. I took the context I wished to highlight and responded. I responded to the part where you wrote that your Surgeon initially suggested the (what I believe is the mainstream medical opinion) range of 2~3 but you (subsequently wrote) that you chose to go with your cardiologists view ... strange that its divided.

Anyone stupid enough to think what I quoted represented what you said or believe is not much of a "listener" (reader) as conversations go.

And, yes, weekly testing is a recommended best practice.

Strange then that you chose to say fortnightly and punctuate that citing your insurance company (adding they would comply with weekly if demanded) as if you were suggesting fortnightly testing is best practice.

Myself I like to give a consistent message about best practice:

• weekly testing
• INR between 2 and 3 for AVR is mainstream recommendations
• you may vary your chosen INR range based on medical guidance
• various studies have shown that an INR dropping low (say to 1.7 or even 1.5) is not a cause for panic but just a signal to steer it back up

as well I usually advise to NOT micro-manage your INR and if its in range do not adjust dose without some reason based justification. I've written this here and on my blog consistently for years now (citing the significant literature for veracity where required).

Simple really

 

[Protimenow]

Hey, Pellicle.

I think that you're wasting your time with this person. He believes what he wants to believe.

Reason, logic, documented fact, published research results, etc., bear no weight. He's comfortable quoting 'mainstream' without any evidence to back it up. This is probably the rigorous evaluation of options that gave America its current President (last of my political talk here).

Although it's important that others don't adopt the reckless practice of testing every fortnight (14 days for those of us who don't know the term) or every month, he seems to advocate for it because 'someone' he apparently trusts more than medical evidence said so. Although having an INR range for any mechanical valve of AT LEAST 2.0 (and between 2.0 and 3.0) is protective, his source assures him that it's safe to drop below 2.0 as long as he takes his nightly 81 mg aspirin.

But, after all this back and forth, it's clear that the debate cannot be won.

I don't think I'll waste my time with him anymore.

So -- here's what actual research has yielded as recommendations:

Self-test weekly.

Don't let your INR drop below 2.0, regardless of which mechanical valve you have in your chest. For Aortic valves, shoot for a target of 2.5 -- although an INR as high as 3.5 or so isn't much of a problem (but, still, shoot for 2.0 - 3.0.

And disregard the erroneous stuff that some on this thread seem to insist on.

 

[pellicle]

I think that you're wasting your time with this person. He believes what he wants to believe.

I respond for the lurkers and non-commenters.

This is a public forum which has influence over more than many think. So there is that.

 

[dick0236]

I've been on warfarin for over 52 years for my old mechanical valve. I try to hold my INR in low 3s and have NEVER had a serious bleeding incident. Many years ago, 7 years after surgery, I had a stroke due to a low PT (INR had not been invented yet). That stroke permanently altered my vision.......and I sure as hell won't take a chance of having another. Years ago, on this forum, I saw a quote that has stuck with me........."you can replace blood cells, but you cannot replace brain cells". If you choose to maintain a low INR.......so be it........I sure as hell won't.

 

[Protimenow]

Dick - I also keep thinking about that quote. It sums up the issue pretty well.

Pellicle -- you're right. It can't be a dialog with one neanderthal. Reinforcing the point that INRs for ANY mechanical valve should be AT LEAST 2.0 (and not all meters get a 2.0 accurately), and should ideally be around 2.5, and INRs can pretty safely be held as high as 3.5 or 4.0 without negative effects will, I fear, become an exercise in repetition, just to be sure that lurkers get the right range for their valves and don't fall into the On-X, low INR trap. Also, of course, strongly suggesting that, if the lurkers or others are capable of self-testing, they should get a monitor (the one I prefer is Coag-Sense, but CoaguChek XS is also a very good meter with an extremely large user base), and test weekly.

As long as we have members who insist that they KNOW mainstream recommendations (without stating where they KNOW this from), and recommend potentially dangerous INR ranges and testing frequency, some of us here still have to correct this stuff to make sure that an occasional visitor doesn't accept the wrong information and, potentially, cause him or herself some harm.

 

[tom in MO]

I guess I must be the pig Thank you both for your service...

 

[pellicle]

View attachment 887215

I guess I must be the pig Thank you both for your service...

I always fancied myself in that role ... but if you must I acquiesce to you.

 

[pellicle]

. It can't be a dialog with one neanderthal.

personally I eschew name calling, and from what is emerging in current analysis of archaeology the Neanderthal were quite caring groups. We know nothing of their adaptability or capacity for accepting change.

 

[Protimenow]

From what I've seen, the Neanderthals didn't really disappear -- we very likely have some neanderthal in all of us. I wouldn't be surprised if some of them, with a larger percentage of Neanderthal genes, have aspired to high political office.

Gee - was I that specific that someone actually thought I was referring to her?

 

[Protimenow]

View attachment 887215

I guess I must be the pig Thank you both for your service...

Sometimes it's fun wrestling with the pig. (But the pig probably has more endurance than you do).

 

[ValveAdmin]

Everyone, I've closed this thread as it is deteriorating past civil and caring conversation.