On-x aortic valve initial INR range

[CazicT]

So I made it through surgery last week and am the proud owner of a new On-x mechanical valve.

very happy with it so far and I've been starting my Coumadin therapy this week for it with a goal INR of 1.5 - 2.0

looking at the cryolife web site though, I see a statement that says this is the goal after 3 months of standard therapy.

does anyone else have an on-x aortic valve? Did you go through standard therapy first before reducing INR?

I called my surgeons office who told me to ask the Coumadin clinic, they forwarded me there, but I left a voicemail, but it turns out that was the wrong number to call. Now it's off hours so I suppose I'll try again tomorrow.

i think most people in the area aren't too experienced with on-x, although I guess they at least know it is a lower INR valve... I just want to make sure I'm not risking anything based on someone's lack of knowledge, don't want to stroke out after such a successful ohs....

 

[pellicle]

Craig

firstly I think its very risky attempting to sit on a low INR in the first weeks / months after surgery because its well documented that your INR / Warfarin response will change in that time. Expect your dose to go up bu at least 50% in the coming months.

http://www.ajconline.org/article/S00...63-4/abstract#

..Thus, patients starting oral anticoagulation after HVR are significantly more sensitive to warfarin than nonsurgical patients...

[NB: the vast majority of data on warfarin management is NOT from Heart Valve Replacement patients ]


So this means that unless you are testing weekly you will err on the low side with known negative effects ... and for what? What possible benefit do you see?

The punishment for erring on the low side may be a TIA or stroke (in the short term) or the ongoing buildup of thrombosis on the valve leading to obstruction in the longer term. There was a post on that here just recently.

http://www.valvereplacement.org/foru...h-lowering-inr

I urge you to read that thread.

Myself I would target INR = 2.5 and not make adjustments if the INR falls to 2 or raises to 3 but hold.

I recommend my blog posts as a guide on that or PM me if you wish some assistance in the start of INR management.

http://cjeastwd.blogspot.com/2015/10...r-example.html

and

http://cjeastwd.blogspot.com/2014/09...ng-my-inr.html


If you attempt to sit on 1.5 (and for what benefit?) then a fall of just a few points will be outside the area that On-X themselves say is safe.

Don't tightrope walk without a net.

 

[DJM 18]

Craig,

First of all congratulations on your successful surgery.

You may want to read through this recent post regarding a member who lowered their INR as per the ON-X advertisement. Note, it was no failure with the valve but rather it seems with lowering the INR to such a level.

http://www.valvereplacement.org/foru...ring-inr/page2 Failure of Onx valve and problems with lowering INR

August 29th, 2017, 08:57 AM

 

[Agian]

On X recommends normal range for the first 3 months before dropping. Don't mess around. The advice you were given is misinformed. I have an On-X and aim for over 2.5 after 15 months. I haven't noticed any increased problems.

 

[CazicT]

Just to be clear, I'm not managing myself... yet. I figured I'd let things get settled first before getting my self tester and taking more control... but I'm thinking I might want to start looking into it closer...

so I didn't set that range myself.

I've started calling around to try to figure out who is responsible for setting this range and asking them to change. I think I may have the right phone number to call now, but the office is closed now for the weekend.

so what to do in the meantime? Stay the course till Monday and straighten it out then? Or go rogue and take more then they tell me until Monday when it can be sorted out.

don't really dont like going rogue, because then it will make it hard for them to dose me accurately later, but you guys got me scared.

Had a visiting nurse here today, measured 1.4. Same as yesterday.
haven't received instructions from clinic yet. Kinda hoping they double me tonight.

 

[Juli]

I ran into the same dilemma after my AVR in August 2016. There was also a lot of confusion about the INR range and I - as soon I was able to manage it myself - aimed for 2.0 and higher, However, I had an incident this August and are now set to a range of 2.5-3. There are at least two other forum members that also experienced incidents (see the link that DJM18 posted). I know that On-X is advertising the low INR range to compete with biological valves - based on my own experience I have my doubts.

JuLiOr

 

[Agian]

However, I had an incident this August and are now set to a range of 2.5-3.

JuLiOr

.... even at an inr over 2. Are you ok?

 

[pellicle]

Hi

I actually responded to this, but it was removed subject to moderation...

Just to be clear, I'm not managing myself... yet. I figured I'd let things get settled first before getting my self tester and taking more control... but I'm thinking I might want to start looking into it closer...

(nods) ... ok, I suspected you may have been wanting to steer this lower yourself, but I understand it now that you'd rather not.

I've started calling around to try to figure out who is responsible for setting this range and asking them to change. I think I may have the right phone number to call now, but the office is closed now for the weekend.

so what to do in the meantime? Stay the course till Monday and straighten it out then?

that's the course I'd recommend. Having a low INR isn't going to be too risky in a few days, but you'll definitely want them to steer it higher (as Agian and Juli have said)

Had a visiting nurse here today, measured 1.4. Same as yesterday.
haven't received instructions from clinic yet. Kinda hoping they double me tonight.

its classic stuff isn't it. Dopes.

I would still advocate towards you documenting things yourself, a spreadsheet with the columns:
date : dose : INR
would be a great start and have that daily for a while (few months at least) before you move over to a yearly sheet with weekly entries of the above.

Let me know if you want some help, you can PM me if you want to.

Best Wishes

 

[Juli]

.... even at an inr over 2. Are you ok?

Yes - came out of it without permanent damage. Was scary beyond believe - had no idea what was happening to me.

 

[CazicT]

I would still advocate towards you documenting things yourself, a spreadsheet with the columns:
date : dose : INR
would be a great start and have that daily for a while (few months at least) before you move over to a yearly sheet with weekly entries of the above.

Let me know if you want some help, you can PM me if you want to.

Best Wishes

Thanks Pell, I'll be compiling this data into a spreadsheet and will take you up on the offer for help soon. Thanks by the way for all your contributions to this forum. Your posts are always very informative and well thought out. I definitely see your point about there being no real benefit to keeping it lower and some possible catastrophic downsides to being too low. I like the idea of the lower i.n.r. being more of a buffer if things get screwed up rather than a goal into itself.

Amway, I'll try to get my range raised Monday and will call insurance company to see what they'll cover as far as self testing.

 

[pellicle]

Hi

I'll be compiling this data into a spreadsheet and will take you up on the offer for help soon.

you're welcome ... in your own time.

I definitely see your point about there being no real benefit to keeping it lower and some possible catastrophic downsides to being too low. I like the idea of the lower i.n.r. being more of a buffer if things get screwed up rather than a goal into itself.

totally with you on that point. Its nice to know that if you forget your pills now and then it does not have dire consequences ...

I'll try to get my range raised Monday and will call insurance company to see what they'll cover as far as self testing.

well even if you don't do self management keeping your own records (my spreadsheet is on dropbox dates to 2012) is a valuable learning resource and a valuable tool in persuading INR managers (AKA dopes and nongs) that you do not need to do "<insertStupidDirections>". Its also handy to refer back to and see long term things too. My motto with INR is : "Know Thyself"

All the studies on INR management point to the single most significant factor in avoiding any problems and having event free life as being patient involvement and keeping INR in range > 80% of the time.

Best Wishes

 

[Agian]

Yes - came out of it without permanent damage. Was scary beyond believe - had no idea what was happening to me.

I'm pleased you're ok.

 

[Agian]

That chart Pel keeps digging up, shows the goldilocks range starting at 2.5. My gut feeling is that we should aim higher than 2.5.

 

[CazicT]

Well I think someone finally listened to me, the clinic called back after initially giving me A 2.5MG DOSE to switch it to 5mg... after a 1.8 i.n.r. this seems like they want to push me above 2.

it was a lot harder than I would have thought to get this worked out, but at my follow up with the surgeon, I think I got the nurse practitioner to look into it. (Didn't see the surgeon that day) .

anyway, hopefully by the time the 3 months are up I'll be self managing. But we shall see... I'll be advocating for keeping it at 2-3. Thanks everyone for the help.