TIA's and coumaden

[Mb]

Hello everyone!

Just a quick question.................my husband seems to be having a series of TIA's. Left leg ...cannot bear weight, intermittently....then on Saturday, right leg, facial numbness etc. Had his INR checked and it was 1.9
(I know, too low, but we CANNOT figure out what is going on....he has been therapuetic for three years!!) Having an MRI and an MRA next Monday, earliest they could get him in.
Question: Could these TIA's be caused by an INR of 1.9?
He is a dual valver, aortic/mitral St. Jude, needs a tricuspid repair, and is in chronic a-fib.
ANY input would be appreciated. This is a bit scarey. - Marybeth

 

[geebee]

Marybeth,
Yes, an INR of 1.9, especially with a mechanical mitral, can cause TIAs. The mitral valve is very prone to clotting which is why the usual INR for mitrals is 2.5-3.5 (preferably around 3.0). Once you get below 2.2, you are prone to clotting and TIAs.
I have had TIAs in the past even while in a theraputic INR range. I take low dose aspirin, in addition to the coumadin, to prevent those and it has worked. Your husband might want to check with his cardio about that possibility.
You and your husband should talk to your cardio about some meds to bring the INR up faster than coumadin increases will do. If I had an INR of 1.9 and was NOT symptomatic, I would simply increase my coumadin. However, with your husband being symptomatic, I would insist on some fast changes.
There is always, of course, the possibility that something else is going on not connected to the mechanical valves but I would not want to take any chances.

 

[Nancy]

Yes, 1.9 can be TIA territory. Joe is living proof. He's had many, many over the years with low INRs. He hasn't had many in the last several years because his INR is managed well. But even so, there have been times when he's dipped for a short period of time, and I'm always scared for him.

They happened with frequency when his valves were in trouble too.

And the combination of troublesome valves, afib plus low INR would be cause for concern with TIAs. Not a good combo.

He was on Plavix for a while, not anymore.

 

[Guest]

Has somebody increased his warfarin dose. It absolutely must be done and ASAP. It cannot wait for the results for the MRI/MRA.

 

[John & Joann]

You are hearing from all of the patients with a long history of Coumadin. YOU NEED TO ACT NOW! I would increase the coumadin on my own --without directions from the doctor. I would also suggest that you IMMEDIATELY locate a Coumadin Clinic. Al can give you some direction. Your problem is very serious and may/may not be related to your 1.9 reading, but you can not take any more chances.

 

[ALCapshaw2]

Upping his dose is a good idea,
but it would help to provide a
guideline as to HOW MUCH
of an increase to make,
just for safety's sake.

I 'think' I know but will
defer to our expert, Al Lodwick.

'AL Capshaw'

 

[Guest]

If it were my patient, I'd double the dose today and then increase by the equivalent of one day's dose over the next week.

 

[Mb]

Thank you all for your replies.

Wayne has been taking coumaden for almost four years now. He also takes that baby aspirin you spoke of. He went straight from the nuerologists office to the coumaden clinic, which is why we know what his INR was on Monday. The nurse there said these issues could not be related to the INR as it wasn't "too low",even though she knows what his range is supposed to be, and that we like to keep him on the higher end. They increased his dosage, and as soon as he got home, he took the extra pills. Yesterday he had no events. The event on Saturday was the worst he has had, and I think made us more nervous as it was his right leg that time. Sunday evening, it was the usual left leg. (He had already seen the neurologist about the left leg, who said it might be a pinched nerve, but given Saturday's event, he is more concerned about it.)

He did have at least -2- TIA's prior to his surgery, and prior to going on the coumaden. He really is closely monitored. He did get his teeth cleaned last week, and did the normal antibiotic dosing, but we both thought that the meds up the INR, not lower it. Is this true?

Marybeth

 

[Mb]

Nancy:

I read your post again, and took note. At the last cardio visit on 2/1 he mentioned that his most recent echo (August of 2004), the pressure gradients had increased, meaning that perhaps scar tissue had formed around the valves, and that they might not be opening as well as before...perhaps slightly stenotic? Plus, of course, the issues with the severely leaking tricuspid valve. Oh, my, - Marybeth

 

[Nancy]

Marybeth-

I know how you and Wayne must be feeling at this point in time. This is very rocky territory, and even with good medical care, sometimes you feel out there on a long branch without a safety net. Unfortunately, we never have access to a live-in doctor who will be there when these things happen.

It's tough when you aren't a medical professional and have to make sudden decisions, and hope they are the right ones.

I guess that's why I always err on the side of caution, and try to call sooner than later. I really don't care if his doctors think I am haunting them. Joe does have doctors now who understand our position, thank God, and they are excellent with responses.

These guys are complicated patients.

 

[Guest]

It can never be said that something like this is not related to the INR. It is only less likely that it would happen. To believe otherwise would be the same as thinking, "I can't possible be in a wreck because I and not speeding."

My guess is that there is a relationship between the malfunctioning valve, the low INR and the TIAs.

 

[Mb]

Dear Al:

I agree with you. Add the chronic a-fib to that as well....another risk factor. He has also had two episodes of purple toe syndrome in the past twelve months or so, which I understand are microemboli ending at the extremities. I think what I am most concerned about is........are there more? Is there a larger clot in his heart and just pieces are breaking off? I can tell you this....one more episode and I am going to be screaming for an echo.....and believe me, I can scream pretty loud.

Thank you for all of your input. I cannot tell you how much I appreciate it. By the way....so far today, he is ok, and has not had another episode....but frankly, the left leg episodes have been at night. - Marybeth