Need INR at 1.8. Reducing Warfarin question..

[VWalk]

On Monday morning, I'm scheduled for a heart cath to determine if I have a coronary artery blockage. I have a St Jude's valve and religiously monitor my INR. My doctor wants me to stop taking Warfarin 3 days prior to the procedure, so my INR is 1.8 early Monday morning for the procedure. My normal dosage is 5mg and I like to keep my INR 2.6-3.0. My INR is fairly consistent.

Tue INR=3.0
I reduced my Warfarin Tue and Wed nights.
Wed morning INR was 2.6
Thur morning INR was 2.4
Thur night (last night) I took 5 mg.

So, here's my question (finally)....should I quit taking Warfarin 3 days prior to the procedure? My primary concern is my valve. I'm 54 yoa and am hoping to avoid another OHS. I spoke to the nurse and she advised the 3-4 day rule is "protocol". It seems to me if I didn't take Warfarin for 2 days, I would easily be at an INR of 1.8. On the other hand, I definitely don't want the procedure to be rescheduled because I'm above 1.8.

Thank you!

 

[dick0236]

I would think you will be OK with holding for three days, especially since you will be under medical care on Monday. I would test on Sunday to be sure your INR didn't fall off a cliff.......if it did let your doc know ASAP. Good luck on the cath.

 

[Protimenow]

If it was me, I'd stop taking warfarin for 3-4 days. The warfarin you take tonight will have effects on Sunday or Monday.

Having a low INR for a few days won't put you at risk of a stroke -- it takes a while for large enough clots to form on the valve. After your procedure, you'll probably have Lovenox injections for a few days to quickly raise your INR while the warfarin's effects develop.

I've had to drop my INR for a few procedures over the years. Two or three (or four) days without warfarin brought it down. One or two Lovenox injections protected me while the warfarin took hold.

If it was me, I'd follow the protocol -- thousands of patients probably have, and with considerable success. And, again, I wouldn't worry about the INR being below 2 for a few days.

 

[VWalk]

Thank you very much. I feel much better about it now!

 

[Keithl]

When I had my valve done in April it was over 3 days before my blood was thin enough on Heparin as they had me on too low of a dose and 6 days before the warfarin kicked in. They had me listed as a struck risk those first 3 days and nothing happened. Basically it seems like it takes a while for w. Lot to form so I suspect as previously said the protocol is based on years of data and proven results I would follow the protocol even though I too would be nervous the whole time.

 

[carolinemc]

Do as the cardio says. For you will be under their care in the hospital of anything happens. Good luck and they will watch you carefully. Hugs for today.

 

[vitdoc]

I don't think anyone knows exactly what the risks of a few days of lowish INR are for stroke or valve thrombosis. They seem to be very low however. If you are worried you can take Lovenox (low molecular weight heparin) the day or so prior to the procedure while the INR is low and for a day or two after. This actually doesn't show up on the INR but anticoagulates in a different way than warfarin. This has been done for years. I am not sure if there are great studies comparing doing this to just dropping the INR and having the procedure. Lovenox wears off in less than 12 hours. I have been on warfarin for 38 yrs and have had many procedures done where I have had to stop it. So far I have sailed through without any issues. Lately the Lovenox has been used less then yrs ago. Also depending on the procedure there is some concern of post op bleeding which may come into consideration when considering when to restart anticoagulation. I had a ruptured spinal disk and the surgeon didn't want any bleeding post op that might affect the spinal cord. So I did not start anticoagulation immediately. I did fine.

 

[Protimenow]

Years ago, I found a paper written by the Duke University Clinic that stated it takes about a week at low INR for stroke/TIA to occur. If I have time, I'll look for the paper.

A few days with an INR below 2.0 shouldn't be much of a concern.

 

[pellicle]

Hi

... My doctor wants me to stop taking Warfarin 3 days prior to the procedure, so my INR is 1.8 early Monday morning for the procedure. ...
So, here's my question (finally)....should I quit taking Warfarin 3 days prior to the procedure?

It depends, and basically unless you regularly take measurements and develop an understanding (from looking at the graphs and the numbers, not by osmosis) you won't really know. Which is why the regular guideline is "cease 5 days before, take heparin and cease heparin before procedure" because heparin is a known quantity for anticoagulation and resonds differently to Warfarin

Here's my take on the subject:
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html

My primary concern is my valve. I'm 54 yoa and am hoping to avoid another OHS.

your primary concern should be a stroke, the valves will tolerate quite an amount of abuse before approaching thombosis obstruction (based on what I see in the medical literature).

If you have a modern bi-leaflet valve of any type or maker and its in the aortic position then you really are in a low risk group for stroke (due to ceasing anticoagulation therapy - aka warfarin).

I spoke to the nurse and she advised the 3-4 day rule is "protocol".

and that would be about the limit of her knowledge, as nurses are by nature and training not really skilled in anything (although they'd like you to think they know more than the Doctors)

Read my post

 

[pellicle]

Hi

I don't think anyone knows exactly what the risks of a few days of lowish INR are for stroke or valve thrombosis. They seem to be very low however.

agreed and agreed

@VWalk, I'd suggest that Warfarin (in red) will drop off and restore about like this, while Heparin will drop off and restore like the blue line. So in practice you have a much tighter control over when AC is off and on again ...

what is unknown is the risk of being in that zone, and I would agree that unless you have other risk factors (previous stroke history, mitral valve, atrial fib ... that its less risky than answering your phone while driving.

 

[VWalk]

Thank you again for the information. Pellicle-I found your INR Management blog very informative.

 

[sue943]

Twice since starting on warfarin 14 years ago I have had to come off it in order to have kidney stone treatment. I was told to stop taking warfarin a week before and to start injecting Clexane once a day until the day before my procedure.

The first time I wasn't given advice or anything else after the procedure but due to the knowledge acquired on this forum I knew to start loading my system with warfarin. It was an anxious time for me and it took a while for my INR to come up to my range of 3.0 to 4.0, very scary.

Then several years later I had to have more stones zapped and this time asked the urologist to contact my cardiologist in regards to aftercare and my INR. This time they did the same for pre-procedure but this time they gave me more Clexane to inject for the following five or six days, and to load my wararin, it worked well.

So to me it is important to get cover until your INR is back up to range, I think the first time I had been dicing with having another stroke.

 

[Protimenow]

It takes about three days for warfarin's full effects on your INR to show up. I've had some minor procedures (balloon sinuplasty a few years ago was the most recent). I stopped taking warfarin three days before the procedure. I tested my INR at home an hour or two before the procedure- it was below 2.0 - a range that my surgeon was comfortable with - and had the procedure.
Afterward, I restarted my warfarin - and used Lovenox (low molecular weight heparin - probably the same thing that others used, but with different names), for a day or two (I don't recall how long) and on the third day, tested my INR and saw that it was back in range.

INR management is simple. Return to range in three or four days is typical for most, if not all, people.