Living in paradise (Pensacola Florida) has its drawbacks for some of us as I have found out. My sinuses have been giving me fits the last couple of years and now per CT scan and MRI they are badly inflamed with large polyps in the left side. ENT doctor had me try prednisone and levequine last year and it only helped the inflammation mildly. This year polyps formed and are really tuff to deal with.
Now this is where the confusion for me comes. Conventional wisdom is to cut out the polyps and hope they don’t return at least for a few years. My ENT doc nixed that because of the On-X aortic valve. He said my cardiologist with have to sign off on stopping the coumadin for 2 weeks! I said what about louvenox as a bridge till the bleeding stops? Now this is where I get confused. He claimed that lovenox is just another bold thinner and would produce the same results as Coumadin for bleeding risk. My healthcare is at the local military base and they are active duty doctors. I am not prepared financially to seek outside doctors at this time, but is this ENT doc up for antiplatelet people or just too cautious to try it? I thought louvenox was commonly used by the medical community for these types of operations. I’m on 2 steroids (prednisone and budesonide) for 2 weeks. My INR is finally stable at 2.2 – 2.5 but today it was 2.7 after one day 60mg of prednisone, two shots of fluticasone nasal spray, and 6 ml of budesonide. I will be testing every 3 days till it’s done. I’m really concerned about finding doctors to operate if something serious happens. Can bridging be that rare or is it just my location?
Sorry you have to deal with this, it sounds miserable. First I am NOT an expert or even pretending to be, and i havent really looked into things like bridging the past couple years, so may be out dated BUT... I would call your cardiologist and who ever is in charge of your Coum management. I also would ask the surgeon what the risk of bleeding are with sinus surgery, or with where your polyps are. I do NOT know, but considering we have a member who has been currently having bleeding problems in his sinuses from a fall, I guess blood vessels in the sinuses can bleed quite a bit,
When you say the doctor wants you off coumadin for 2 weeks, do you mean total? Like a week before and a week after or 2 weeks prior to surgery? As for the surgery and bridge or not to bridge, ...its a little tuff, since as far as I know there still arent firm guidelines, and many different opinions and things seem to change every year.
Also what is "safest' ( lower risk of bleed but not increase the chances of a clot) depends on a lot of different things, like Why are you on Coumadin, since the chances of clotting are higher for someone with a mech valves than on it for Afib (If I remember right) or even which valve is your mechanical valve (aorta, mitral etc)also it depends on what procedure is being done and the risks of bleeds for that..like already they are saying it is fine to do some low risk of bleed things either on your normal level of Coumadin or try to lower the INR before the procedure.
But surgeries with higher risk of bleeding -mainly inside where it can be hard to see your still bleeding , but also where the wound is closed, need to be done w/ out Anticoagulants in you. . Where you have to stop Coumadin, some people say before the surgery after stopping the Coumadin test your INR and when the INR gets low (maybe 1.5?) start either Lovenox shots or IV heparin, (as far as i know that is still IV so have to go inpatient for a couple days) since they have a shorter half life than Coum, so clear from the system when you stop them shortly before the procedure.
Then there are also different opinions about what to do after the surgery, again it depends on all the same things, but for lower risk of bleed/clot they just might start Coumadin and other recomend after the first 24 hours or so, when the bleeding is stopped start Lovenox 2 times a day while starting the coumadin back up and stop it once your INR is back above 2. Altho some of the members here over the year, think adding Lovenox after surgery made their bleeding problems worse than if they just took their normal dose of coumadin post procedure
It sounds as if your ENT is pretty out of step with anticoagulation. Stop warfarin for TWO WEEKS? Bridging DOES have an effect on clotting (otherwise they wouldn't use it if your INR is too low), but it works differently from the way that Warfarin works. It seems as if temporarily lowering your INR by stopping warfarin for a day or two (or three) is the way they do it -- once surgery is done, Lovenox will quickly raise your INR (reducing your stroke risk) while you stabilize again on Warfarin.
At least, this is the way it seems that others on this form have had it done.
Lovenox does NOT raise your INR, The test for Lovenox is factor Xa It just protects you from clotting while the coumadin is getting into range.(but hopefully with out raising to chance of a bleed too much.
Sorry this wasnt really helpful, but here is link to the abstract for "Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." from 2012
http://www.ncbi.nlm.nih.gov/pubmed/22315266
and here are the full guidelines
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278059/ all 37 pages of it, that toward the beginning state "
"Our recommendations relating to the need for bridging anticoagulation (section 2.4) will not refer to a specific bridging dose regimen and will deal with the issue of whether bridging is needed in a more generic sense.
there are currently doing studies on bridging, for Afib (non valvular)
http://circ.ahajournals.org/content/125/12/e496.full#sec-10 tells about it and this site even tho it is Afib patients and not mech valvers, might have good info to discuss w/ your doctors.
https://bridge.dcri.duke.edu/websit...To Bridge or Not to Bridge_ JTO 24APR2012.pdf
here is a link to a few of the bridge study articles, again this is for AFIB but might be helpful
https://bridge.dcri.duke.edu/bridge-publications
