Patient Demographics at My Coumadin Clinic

[ALCapshaw2]

The recent thread / poll asking how many Tissue Valvers were on Coumadin made me curious about the Patient Demographics at my Coumadin Clinic so I asked the Charge Nurse for their numbers.

MY Coumadin Clinic Patient Demographics are as follows:

328 Patients with Heart Valves - presumably mechanical? = 11.4%

2000 Patients with Atrial Fibrilation = 69.4%

552 Patients with other factors (DVT, Clotting Disorder, etc.) = 19.2%

2880 Total Patients served by 4 Certified Registered Nurse Practicioneers (CRNP) and several Technicians and other staff members in Huntsville, Alabama, "The Rocket City" (Home of NASA's 'Rocket Team', The Redstone Arsenal, and a lot of Low, Medium, and High Tech Industries).

'AL Capshaw'

(Yes, I realize this does NOT answer the question about what percentage of Tissue Valvers are on Coumadin, but it does point out that the vast majority of patients on Coumadin are on it because of Atrial Fibrilation and to a lesser degree, Deep Vein Thrombosis - DVT, and Clotting Disorders).

 

[Dina]

Interesting. Even though I have a tissue valve, and am 6 mos. post-op,
I have a pre-op history of a.flutter and my cardio says this makes me a
candidate to remain on the coumadin. He believes my need for it is 50-50,
and ,of course he would like for me to play it safe, atleast while my heart
is still in the healing phase(the lessening of my rt atrial dilation).
So I'm not too surprised that the majority is arrhythmia patients.Thanks
for the info--Dina

 

[Bina]

A-fib is obviously more common than Mech valves, but I'm surprised by the huge difference.
Very interesting, thanks Al.

 

[catwoman]

Al:

Interesting figures.

I assume these are grouped according to the main reason for being on warfarin. Wonder if any of these actually fall into two or more categories, i.e., a tissue valver who has a-fib who has had PE or DVT (or even a stroke)?

Some questions I have, which I doubt we can ever get answers:
How many are "lifelong" warfarin patients, i.e., mechanical valvers or have had repeat DVTs?
How many of the a-fib patients have had OSH and how many acquired a-fib due to the aging process?

Another interesting breakdown would be age ranges of the patients.

 

[Cooker]

Thanks Al.... interesting information.

 

[Susan BAV]

Interesting. I wonder how many of those with A-fib have no other heart history. Any idea? My uncle has been on ACT for 20+ years with chronic A-fib, has had two valves repaired following a massive heart attack, and may need valve replacement soon.

Also, do you know also what the optimum INRs are for each situation?

 

[Guest]

The INR range for every condition except heart valves is 2.0 to 3.0.

A bileaflet aortic valve is 2.0 to 3.0 except that it is easier to lump these together with other valves and just say 2.5 to 3.5 for all mechanical valves. On-X may be an exception but the jury is still out on that.

The medical journal Chest puts out the most comprehensive guidelines for anticoagulation therapy. The latest just came out in June 2008.

The newest Chest guideline for atrial flutter say that it should be considered using the same risk-based assessments as would be done for atrial fibrillaton. In other words, as far as warfarin is concerned a-flutter and a-fib are the same thing. This is a change from a few years ago when a-flutter was considered less likely to cause a stroke. The Chest guidelines rank the evidence on which the committees base their decisions with each decision. The best level of evidence is randomized, double-blinded (neither the person getting the medication nor the person giving it to them knows whether it is the active drug or the inactive placebo) placebo-controlled studied. The lowest level of evidence is an article detailing what happened to one individual. The level for the atrial flutter decision ranks right in the middle (third place out of six ranks).

I have had about 3,000 people at my seminars on warfarin management. I get the feeling that about 70% atrial fibrillation is about right for a clinic that is open to any person with any diagnosis.

 

[Marty]

About a year ago Alice had an episode of syncope later diagnosed as "sick sinus syndrome". They put in a pacemaker and she now has a nice normal pulse rate and rythym. However a few months ago they found that her atria were fluttering and fibrillating so they put her on warfarin ACT. It was news to me, but you can still fibrillate and throw thrombi even when you have a pacemaker.

 

[gijanet]

Hey, Al!

Hey, Al!

I don't want to put any more work on your poor charge nurse, but I would be interested in knowing an age breakdown for your patients on coumadin. Always looking for more coumadin kid moms................sigh! I know no one has probably done it, but I would really like to know any long term problems with bone and teeth development in kids due to coumadin interfering with calcium absorption on top of the vitamin K issue.................bigger sigh! Hugs. Janet

 

[Guest]

Charge nurse??? All I've got is a wife!!!

I think the best source is right here. I posted a poll a few years ago about osteoporosis with long-term use. It was not a problem among people who took warfarin for more than 30 years.

There will be other drugs before Katie gets to the 30 year mark.

Put osteoporosis about 10 notches below alien abduction on your list of worries for Katie.

 

[dick0236]

To AlCapshaw: Thanks for the survey. I used to go to a large PT Clinic and always wondered about the large number of people in the waiting room. I couldn't believe all of them were valve patients. Perhaps this explains why docs want me at -3 and I want to be a +3 INR. Even though I have been told that my range is 2.5 to 3.5, the docs always seem to prefer that I stay on the lower end. I assume that the Afib patients may have a lower PT range and that is what most docs/nurses are most comfortable with. My young PCP has no problem with my +3 INR even though he has told me that he would be more comfortable if it were closer to 2.5.

To Alldowick: I am sure it has been posted, but what are the general INR rules for the various conditions that require warfarin ? I am not trying to hijack Al's thread, but perhaps the docs, and especially nurses, are applying a "cookie cutter" approach to ACT.

 

[Ross]

Put osteoporosis about 10 notches below alien abduction on your list of worries for Katie.

With Katie, I think the aliens should worry about being abducted.

 

[ALCapshaw2]

MORE INFO from GOOGLE (INR, "Risk vs. INR")*

As AL Lodwick indicated, the recommended INR range for A-Fib and other conditions requiring anticoagulation is 2.0 to 3.0

I recall seeing curves of Stroke Risk vs. INR and Bleeding Risk vs. INR (I think it was on the St. Jude Medical website www.sjm.com) where the two curves intersected at an INR of 2.5 which resulted in the Lowest Combined Risk, hence the usual recommendation for INR between 2.0 and 3.0 barring other risk factors.

Glancing through some of the links on GOOGLE, I saw an article dealing with InterCranial Hemorrhage (ICH) vs. Age. Basically, I gathered that the risk of 'Brain Bleeds' begins to increase above age 60 and is more pronounced in the 80's. One interesting conclusion was the Bleeding Risk was NOT reduced significantly Below an INR of 2.0 and therefore the recommendation of 2.5 applied even for the more elderly.

The following was excerpted from the Medicare Memo outlining their decision to approve Home Testing for INR.

As noted earlier, warfarin has a narrow therapeutic index.7 Oral anticoagulant therapy has a minor bleeding complication rate of 10-20%, and major bleeding episodes in 1-5% of cases. Too much warfarin can have serious effects as demonstrated. Numerous studies in the literature demonstrate that INR > 3 results in higher risk of serious hemorrhage. An INR of 4 nearly doubles the risk, and an INR of 6 increases one's risk of developing a serious bleed nearly 7 times that of someone below an INR of 3.

Of comparable concern is underanticoagulation. Inadequate dosage can also lead to serious consequences. Numerous studies, including Hylek et al, demonstrated that INR below 2.0 results in a higher risk of strokes. This risk increases rapidly as INR drops below this threshold.

[End Quote]

Another article noted that for patients with Mechanical Heart Valves, especially in the Mitral Positon, higher INR's may be recommended, particularly if there are other Risk Factors (such as history of Stroke, etc.). Closer monitoring was recommended for such patients.

'AL Capshaw'

*One could spend Hours or Days reviewing all the Google Links under INR and "Risk vs. INR", some of which are to sites that require registration and/or 'fees' to review their material.

 

[ALCapshaw2]

Al:

Interesting figures.

SNIP

Another interesting breakdown would be age ranges of the patients.

The following is excerpted from the Medicare Memo outlining their decision to approve home testing of INR.

... the incidence of atrial fibrillation increases as
one gets older, from approximately 0.5% for ages 50-59,
to nearly 10% for ages 80-89.3 [End Quote]

 

[Guest]

The risk of stroke from atrial fibrillation (clotting stroke) rises so quickly at age 80+ that even with the increased risk of a bleeding stroke most people are better off on warfarin.

 

[cocoalab]

As noted earlier, warfarin has a narrow therapeutic index.7 Oral anticoagulant therapy has a minor bleeding complication rate of 10-20%, and major bleeding episodes in 1-5% of cases. Too much warfarin can have serious effects as demonstrated. Numerous studies in the literature demonstrate that INR > 3 results in higher risk of serious hemorrhage. An INR of 4 nearly doubles the risk, and an INR of 6 increases one's risk of developing a serious bleed nearly 7 times that of someone below an INR of 3.

Of comparable concern is underanticoagulation. Inadequate dosage can also lead to serious consequences. Numerous studies, including Hylek et al, demonstrated that INR below 2.0 results in a higher risk of strokes. This risk increases rapidly as INR drops below this threshold.

[End Quote]

This is really comforting right now as Andrew is today or at least as of last night at 6.1. Talk about a yo-yo!

 

[ALCapshaw2]

As noted earlier, warfarin has a narrow therapeutic index.7 Oral anticoagulant therapy has a minor bleeding complication rate of 10-20%, and major bleeding episodes in 1-5% of cases. Too much warfarin can have serious effects as demonstrated. Numerous studies in the literature demonstrate that INR > 3 results in higher risk of serious hemorrhage. An INR of 4 nearly doubles the risk, and an INR of 6 increases one's risk of developing a serious bleed nearly 7 times that of someone below an INR of 3.

Of comparable concern is underanticoagulation. Inadequate dosage can also lead to serious consequences. Numerous studies, including Hylek et al, demonstrated that INR below 2.0 results in a higher risk of strokes. This risk increases rapidly as INR drops below this threshold.

[End Quote]

This is really comforting right now as Andrew is today or at least as of last night at 6.1. Talk about a yo-yo!

NOW you know why everyone who has responded to your posts is so concerned about Andrew's MIS-MANAGEMENT of his Coumadin / INR. Get his Cardiologist involved. Those Nurses (and late test results) are only going to keep him in "Yo-Yo" mode.

 

[ALCapshaw2]

Al:

Interesting figures.

I assume these are grouped according to the main reason for being on warfarin. Wonder if any of these actually fall into two or more categories, i.e., a tissue valver who has a-fib who has had PE or DVT (or even a stroke)?

Some questions I have, which I doubt we can ever get answers:
How many are "lifelong" warfarin patients, i.e., mechanical valvers or have had repeat DVTs?
How many of the a-fib patients have had OSH and how many acquired a-fib due to the aging process?

Another interesting breakdown would be age ranges of the patients.

I spoke with the Charge Nurse again about the clinic's demographics.

She said that they are sorted by Primary Diagnosis, Secondary Diagnosis, etc. and clarified that for a Tissue Valver with A-Fib, the A-Fib would be the Primary Diagnosis. She then concluded that the 328 (or was it 324?) Valve Patients would 'most likely' all have Mechanical Valves.

They Do Not break down by types of valves per se and they Do Not break down by AGE.

I asked her if she was aware of our Anti-Coagulation Forum. She said "Yes, and FYI, 3 of their staffers would be taking the Examination to become Certified AntiCoagulation Care Providers".

From MY perspective, their CRNP's do an Excellent Job.
I can only hope that more AntiCoagulation Clinics follow their example.

'AL Capshaw'

 

[gijanet]

Well, poop!

Well, poop!

They Do Not break down by types of valves per se and they Do Not break down by AGE.
'AL Capshaw'

And again, well, poop! Thanks for sharing anyway, Al!

 

[gijanet]

Haha!

Haha!

Charge nurse??? All I've got is a wife!!!

Put osteoporosis about 10 notches below alien abduction on your list of worries for Katie.

Should have clarified my Al's, Al. Sorry! That was directed to Al Capshaw (guess I shouldn't have been lazy and said, "your clinic's charge nurse," but I was). Thanks for chiming in, though, as you reallly have my hopes up that there is something new on the horizon. As for alien abduction, with Katie, I don't rule anything out. Haha! Hugs. J.