Mini Stroke - OnX valve - on warfarin INR range 2-3

[vivekd]

thanks pellicle

 

[LondonAndy]

An interesting thread - thanks to everyone for comments, and I am sorry Vivekd has the problem.

I am not sure if my point adds anything to the discussion, but before I was discharged (in Sept 2014) my surgeon emphasised to me the importance of keeping my INR in therapeutic range (2.5 to 3.5) and strongly said that if i fell below range to get Heparin injection(s). He even wrote this as a treatment in my INR management book, so that I could show this to clinic staff if ever needed, saying "anticoagulation clinic staff just don't get it" - by which he meant the importance of staying within range. Sure enough, a few months after I got home, I did indeed drop below (to about 2.0 if I recall, which I found by self-testing), and so I went off to my local hospital's anticoagulation clinic expecting Heparin to be prescribed. But no! They refused, saying this was not the protocol at that hospital.

So I went to the hospital where my operation had been carried out, explained this and waited for the surgeon to emerge from theatre. He wrote a prescription for the Heparin on the spot, and deliberately prescribed a quantity sufficient for me to keep a supply at home should it happen again (it has not).

I am also on a daily baby aspirin, and although my blood pressure was a bit low, occasionally causing dizzy spells as I stood up, they insisted that I continue to take a beta blocker, which I reluctantly do. I also take Ferrous Fumarate tablets (iron tablets) as my valve damages red blood cells and can leave me a bit anaemic. So I am on Warfarin, Aspirin, Lisinopril blood pressure tablet, Nebivolol Beta blocker, a statin, and the iron tablets, plus assorted other stuff for being an insulin dependent diabetic!

Pellicle's post about platelets seems to suggest to me that Aspirin should be considered routine for mechanical valvers?

 

[vivekd]

My cardiologist has agreed to give me a prescription for lovenox so that i can keep it at home, if my INR goes below 2.0. Now I've to find somebody who can administer lovenox injection. I'm scared of needles, and can't see myself administering it myself. I've talked to Urgent care, CVS and Publix pharmacies, but they are not ready to administer it (if and when i need it).

I'm looking for home nurses (who can help me with Lovenox administration, if it ever happens).

I'm planning to make following changes:
1) Change INR range to 2.5 - 3.5
2) Add Baby aspirin
3) Switch to weekly INR check at anticoagulation clinic (instead of self test to avoid possibility of strip recalls)
4) Test at home midweek
5) Get Lovenox prescription and keep it in the fridge (it has shelf life of 2 years)
6) If INR < 2.0, increase warfarin dosage and get lovenox administered
7) Now I need to find somebody who can help me administer lovenox?

Has anybody found a way to get heprin / lovenox administered?

 

[pellicle]

Hey Andy

...Pellicle's post about platelets seems to suggest to me that Aspirin should be considered routine for mechanical valvers?

as you may know I've long sat on the fence about aspirin. Studies I've found suggest its helpful others suggest its not. I've previously taken it but stopped in about 2013 because my box ran out and I just kept forgetting to go get some more (and baulked a little on the prices of it compared to 500mg tablets at the supermarket)

Recently I found this very interesting study:
https://thrombosisjournal.biomedcentral.com/articles/10.1186/1477-9560-2-1

I strongly recommend it, but its easy for one to "fuzz out" with the terms (it is a biochem journal after all, but a quick "dramatis perosna" on a piece of paper beside you (and maybe my old friend the colouring in pencils to colour code terms on a printed PDF allows easier digestion.

The points of interest to me were:

• Aspirin acts primarily by interfering with the biosynthesis of cyclic prostanoids: TXA2, prostacyclin, and other prostaglandins.
• It irreversibly inhibits COX-1 by acetylation of serine-530 and induces a long-lasting functional defect in the platelets.
• The plasma half-life of aspirin is only 20 min in circulating blood
• Because platelets cannot generate new COX, the effects of aspirin last for the duration of the life of the platelet [10 days].
• After a single dose of aspirin, platelet COX activity recovers by 10% per day in parallel with platelet turnover.
• Although it may take 10 days for the total platelet population to be renewed, it has been shown that if as few as 20% of the platelets have normal COX activity, hemostasis may be normal.
• Aspirin reduces the risk of secondary events by about 25% in cardiovascular diseases, but some patients have recurrent vascular events in spite of aspirin therapy. It has been proposed that these patients are resistant to aspirin's antithrombotic effect.
• Failure of aspirin to produce the expected inhibition of platelet function might be attributed to several mechanisms.
  * Many individuals treated with aspirin do not achieve the inhibitory response anticipated on the basis of laboratory measurements of platelet activation and aggregation, a phenomenon termed "aspirin resistance".
  * Antiplatelet drugs that are effective and safe in one individual may be ineffective in another.
  * Aspirin is a weak platelet inhibitor, so on its own it does not provide sufficient antithrombotic therapy in some clinical or experimental circumstances.
  * It seems that resistance to aspirin may be associated with an increase of arterial thrombotic events in spite of chronic intake.
  * However, in several patients, aspirin does not afford the degree of platelet inhibition needed to preclude events according to in vitro assessments.
  * Aspirin non-responder status may contribute to failure of aspirin therapy in the secondary prevention of cerebrovascular incidents in as many as 30~40 % of patients
  * Aspirin may not be cardioprotective in patients with hyperlipidaemia
  * Experimental models have also shown that aspirin fails to prevent thrombosis-related activities.
  * As was also suggested by Bertele et al. our study indicated no correlation between platelet function and thromboxane level, implying that aspirin does not prevent an agonist potentiation effect when low doses or a daily high dose are administered. These results are in line with those obtained by Cerletti et al
  *

Best Wishes

 

[jwinter]

OK so now will add that I do not take any aspirin. My surgeon from first AVR did have me take it after surgery with porcine valve but nothing ordered after my mechanical. I think it my case (and maybe my case only) they want nothing going in that could cause irritation of any kind for my liver.

My meds are:
warfarin: 2.5 mg 5 days per week and 3.5 two days per week
multi vitamin: one per day
probiotic: one per day
Gentle Iron: two times per day
I also take a liquid med 2 times per day to help liver keep ammonia levels down (this only because I have shunt in liver for PBC)

Oh and mostly I want to tell you I think you should give the Lovenox a try. I get a little funky about needles also but if (and I mean IF) you find someone that seems caring at coumadin clinic to sit and explain it at length for you you could at least give it a try. For mine, I get the pre-loaded syringes, wipe with alcohol a good spot (pinch a pinch of fat) and I use a "smile" from smiley face pattern, placing each injection along side of the one before, right below my navel. Count to 3 and slightly push.....such a tiny needle I don't even feel it go in and then push slowly until syringe stopper pops at end of med. Pull it out and massage a bit around area. Never hurts to try as I surprised myself even! Now it is not ever a worry to me and with your protocol would be far less nerve wracking than going in to have it done. Some at hospital arent any good at it either, lol

Good luck to you and let us know how it goes.

 

[LondonAndy]

pellicle - wow! If that is the easy explanation about aspirin then I will skip the learned article I think! It is a good point that people react differently to medications. Generally speaking I have had no problem with any of mine (though a change of Beta Blocker was a good thing, having less tiring effect), but my neighbour (a female in her 60s with some similar meds) has no end of trouble finding one that suits her.

 

[pellicle]

Hey Andy

pellicle - wow! If that is the easy explanation about aspirin then I will skip the learned article I think! It is a good point that people react differently to medications. ... but my neighbour (a female in her 60s with some similar meds) has no end of trouble finding one that suits her.

indeed, and I think that's the summary I was intending.

While advertised as a Panacea it is indeed no better than buying a suit labelled as "one size fits all"

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[Paul1972]

Hi all , my surgeon told me to stop aspirin 2 weeks before I had my really bad double vision episode that lasted about 10 mins which I haven’t had found out as to what is was . Do you think coming off aspirin after a year could cause such an event .

 

[tom in MO]

Hi all , my surgeon told me to stop aspirin 2 weeks before I had my really bad double vision episode that lasted about 10 mins which I haven’t had found out as to what is was . Do you think coming off aspirin after a year could cause such an event .

You might want to check that out with your cardio. My anticoagulation therapy was started by the surgeon but is maintained by my cardio.

 

[tom in MO]

Not as I see it. If there is thrombosis present in the valve it's not going anywhere soon.

jwinter

I would describe you as brave, but not a fool.

It's correct what you say, however it's important to remember all you ever get from a medical professional is an opinion, just the same. You may even find examples here of crappy opinions being delivered. I do not myself pretend to be a surgeon nor a cardiologist, but I do actually explain my opinions and where I formed them.

Many medical professionals don't do as much. "Trust me, I'm a doctor"

It's up to the patient to also do due diligence on the opinions they choose to accept.

I get a lot more from the medical professionals in my life than just an opinion. Sometimes they tell me facts, like my valve is bad, I have a bladder stone, my colon is rotten, you have a hernia, you have sleep apnea. Sometimes they care for me in the hospital, in rehab, at home and in their offices. Medical proffessionals are humans and make mistakes and doctors are no better than other humans, but they do more than deliver opinions.

I think the brave fool is the one who doesn't take a simple 80mg aspirin that in the US costs me $1 for 40 at the dollar store and is the same brand they give me in the hospital

 

[Paul1972]

Hi Tom, I haven’t seen a cardiologist since before my surgery’s I’ve always seen my surgeon. I will have to try to get an appointment to see a cardiologist but I’m sure it will take a couple of months to get a date, in the mean time I’ve decided to start taking aspirin again off my own back just in case .

 

[tom in MO]

Hi Tom, I haven’t seen a cardiologist since before my surgery’s I’ve always seen my surgeon. I will have to try to get an appointment to see a cardiologist but I’m sure it will take a couple of months to get a date, in the mean time I’ve decided to start taking aspirin again off my own back just in case .

After my surgery, the surgeon set the INR range and told me up front that the cardio would handle maintenance. When I read that my valve's range was changed from 2-3 to 2-2.5 about 6 months after implantation, I talked to my cardio about the new range. He knew about it, but got a second opinion from the surgeon just to make sure before changing my range to 2-2.5.

 

[Paul1972]

Cheers for the information Tom I really appreciate it .Regards Paul

 

[pellicle]

I get a lot more from the medical professionals in my life than just an opinion.

Well gee Tom ... (looks around) ... that's probably because

1. this is a forum and all we can do is talk (sometimes we even tell people the facts as we see them)
2. because we can only type to each other we can't actually do much
3. sometimes people come here to talk between medical visits or to ask us questions
4. sometimes those questions are stuff like "my cardiologists opinion sounds sus , do you agree?"
5. to the best of my knowledge stuff quoted verbatim from peer reviewed science journals are either facts or substantiated opinions (you should look up the difference that substantiated makes in that)

I laugh heartily every time someone says (usually after I've said something) "remember we are all patients here, all we can do is offer an opinion" ... as if that wasn't the premise the entire effing time.

I think the brave fool is the one who doesn't take a simple 80mg aspirin that in the US costs me $1 for 40 at the dollar store and is the same brand they give me in the hospital

that's your opinion, who knows others may have different ones. Even wilder is the idea that someone may change their opinion over time so what if they read your opinion from 10 years ago and it was different?

Why not ask @surfergirl her opinion? That must be more valuable right?

 

[pellicle]

Hi Tom, I haven’t seen a cardiologist since before my surgery’s I’ve always seen my surgeon. .

actually Paul that's how it was originally in Australia. I only ever saw the surgeon back in the 70's 80's and 90's ... indeed reading on this site you can find many people disgruntled with Cardiologists. That's because not all of them are clones of each other and some are good and some are not.

you know ... like everything else in the real world.

I see nothing wrong with your seeing your surgeon until you feel that the surgeon is not giving you proper attention. As it happens I like and trust both my Surgeon and my Cardiologist.

To answer your earlier question about coming off aspirin being the cause of your vision: I'd say I wouldn't have thought so. However I wouldn't have expected TB vaccination to be a source of endocarditis either (and indeed we still don't know enough of those pesky facts around that to know stuff like if that was the only case or if that's a serious risk ... but then ... I suppose that's just my opinion)

Best Wishes

 

[Paul1972]

Hi Pellicle hope you are well, once again thanks for your reply, your Reply’s you put on to all the members of this community are priceless and I always respect and take in what you have to say .I do have faith in my surgeon but it’s always good to here opinions from you all that have been though the same as me . Good health to you all .Regards Paul

 

[pellicle]

Hi Pellicle hope you are well, once again thanks for your reply,

Your welcome, and thanks for the kind words mate. I recall what it was like when I was a lad and while the surgeons who did great work on me gave me much, there was little or no guidance on many things. Sometimes that set me on paths (which I knew at that time were errant, but) that took years to smooth out.

 

[vivekd]

Just got results from my TEE.
No blood clots

 

[pellicle]

Just got results from my TEE.
No blood clots

that's good news ... so if there is a valve related problem then its micro-emboli

I understood this will still show in a d-dimer blood test