Virtual Colonoscopy Anyone?

[Karlynn]

Confessions of a warfarin user.

Confessions of a warfarin user.

Hi Rain (not to be confused with Lo rain).

I know you hate being on "the rat poison" but I don't recall you every saying why. If you don't mind sharing, I'd be interested in knowing. I'm really sorry that you do hate it so much, since it's a fact of life for you now and I sure hope you haven't had any bad complications.

I think the rocking chair comment is a tinsy misleading. I've been on rat poison for 12+ years. I'm active, in that I travel (Europe for 2 weeks 3 summers ago and maybe Paris this summer), I walk, I work out and lift weights, I play with my 100 pound puppy and chase him around the yard and I don't find the poison to be an issue. I have a regular glass of wine or a beer and an occasional margarita. I don't do "extreme" sports, or ski (I was bad before the valve replacement -flat Illinois you know- so figured I'd be just as bad after and didn't want to risk it.)

I had the replacement when I was 32. My kids have now just entered college. I figure that if I had a tissue valve put in, during the last part of their high school years where I was running around to swim meets, water polo games and that trip to Europe I mentioned, I would have either been slowed do to a heart in need of another valve, or recuperating from another OHS instead. I was slowed so badly when they were babies (pre-replacement) I'm so glad I didn't have to put them through that again.

I should also mention that my husband broke my hand 3 weeks ago while we were goofing around in the family room (not the best thing for someone who earns a salary playing piano) and I had no bleeding issues, other than the expected bruising anyone would get.

I DO get annoyed from time to time with the INR testing. I've never been all that stable, so test every 2 weeks and try to stay on the high side of the range as opposed to the low. I started this little trip when the pro-time numbers were the only ones used, INR wasn't standard yet. Talk about a guessing game. It's not a joy and a pleasure to keep it all monitored, but I don't get overly worried about it. But I don't kid myself that it's like taking my Lipitor. I miss a Lipitor, no big deal, I miss my rat poison and it's not so care-free, so being vigilant is necessary. I don't look forward to having to go off warfarin for a procedure that requires me to, but I don't worry about that now, that bridge will be crossed if/when it happens. I get annoyed with warfarin from time to time simply because I can get a bit ticked over having this heart issue to begin with. Who doesn't want to be the picture of health?

I guess my view is that the last 12 years have been great. The fact that my heart was damaged permantly slowed me some, but the warfarin hasn't. I'm glad that with all the hecticness that has been my life in the last 12 years, I didn't have to worry about or anticipate another major heart surgery. The last 12 years of my life would't have had time for that.

I just think that there is so much talk here lately about how horrible warfarin is and how that is the main reason some younger people are going for the tissue valve and figuring the risk of repeat surgeries is the better risk. And that's their choice, so that's cool. But I worry about those who do make it for that reason and then end up having to take warfarin because of chronic a-fib (a not so uncommon "guest" after heart surgery) or other clotting issues unrelated to the heart. Do they then feel like they are living on borrowed time because of the dangers of being on warfarin? I would't want them to despair over something that will more likely save their life, than take it.

If I were getting a valve job now, at 45, would I consider a tissue valve? Most definately. Would it be my choice? Gosh, I couldn't really say.

 

[Bryan B]

Well as most of you know I had a Ross Procedure, and if I had it to do over again I would choose to have it done again. My backup plan was the pericardial bovine valve. Having gone through the surgery I would now have 2nd thoughts going with the tissue valve. Not so much because I would be mentally afraid of having another surgery (it was not nearly as bad as I thought it would be), but I would worry more about complications with any additional surgeries. If my Ross lasts a lifetime or gets me to my late 60's I might consider a tissue valve to hopefully get me to the distance. If something were to happen that would cause me to need another aortic valve 10-20 years down the road I would seriously consider going with a mechanical valve this time. Who knows what will be available 10-20 years down the road, but if I ever need another aortic replacement it WILL be one that will get me the distance (unless I live to be 100 ).

I feel fortunate that I was healthy enough to have a choice, and that choice was a difficult one to make. I ended up going with a "gut feeling" I had early on in my research. After reading all the posts, I can see both sides of the arguement about Coumadin. If I was to end up on Coumadin, I would want as much control over my testing and dosing as possible whether I had to eat the costs or not. After what I've been through the last 10 months, about the only physician I still have full trust in is my surgeon.

 

[Rain]

Stressing over INR is a waste of time... take your rat poison, and hope for the best!

Stressing over INR is a waste of time... take your rat poison, and hope for the best!

Karlyn,

So sorry to hear about your broken hand!! Ouchie! My hand would have bruised. If you touch me I bruise.... one of the many reasons I hate coumadin. Not only do I bruise... but then it takes a month for it to heal!! I was ?goofing around? with my son last summer... all he did was grab my wrists... I tried to free them by twisting them to the outside quickly, the way wrestlers do... the next day I had bruises on both my wrists! Gee whiz!! I hate being a pansey!

I don?t spend much time stressing out over my health problems or the fact that I?d be dead if I stopped taking the rat poison.... or if I ate to much of it for that matter. For the most part, I drink what I want to drink, eat what I want to eat and play the way I want to play, exercise the way I don?t want to exercise, lift weights, travel, play with my 100 lb puppy, etc, etc, etc.. Well, no... I have not been snow or water skiing since my surgery... nor have I jumped on a car hood or inner tube and flew down the mountain after a nice snow storm.... a few of the things I LOVE to do. Coumadin has an iron fist around my life.... I guess that?s what I hate more than anything. Wait... no... I think what I hate the very most is that ?CONSISTENCY? part! Really... who eats the same amount of K daily? Who gets the same amount of sleep every night? Who has the same amount of stress in their lives daily?? Who gets the same amount of exercise daily? Who knows when their crazy, darn dog is gonna get in the flower bed??!! I don?t!!!! Who knows whether the oncologist, gynecologist, internist, dentist, PCP, ER, etc, etc knows about Protime and all that it involves? I could write a book on all the reasons I hate taking coumadin. And I?m not real happy about having to wear a ?tag? around my wrist stating that I have a health problem either. Or monitor it! I have to actually slice my finger and make myself BLEED... just because of this rotten drug. And THEN I have a freakin bruise on the end of my finger and I have a hard time coming here and whining about it. Okay... that?s enough.

It may sound to you guys like I spend a lot of time worrying about it... especially after that little outburst... but I don?t. lol I just happen to believe that taking coumadin IS a ?big deal?. BUT.... anyone with a mechanical valve CAN learn to live with it.... otherwise... you?ll die! lol


The ?younger? people deserve a lot more credit than you are giving them. Most of them are researching the alternatives and making wise choices that suit their lives. I wouldn?t encourage anyone to go one way or the other. If my 20 year old child needed his aorta replaced we?d be looking at alternatives.... And in the end we may go with a mechanical!! .... but we wouldn?t do it with a sugar coating that it wouldn?t impact his life.

 

[Guest]

Rain,

I think a lot of my patients are just like you. They hate it but they manage to live with it.

 

[Karlynn]

Rain,
I knew you are a "live life to the fullest" kind of gal, which is why I was curious about your reasons for hating the rat poison. You are right, it is a BIG DEAL and I wouldn't want to give anyone the idea it wasn't. But, as you said, it's a big deal that can be lived with -- and still live well. And you know what, a lot of your complaints are ones I share.

I was just getting concerned because there have been a few posts lately (not yours darlin') that made ME feel like I should be preparing to die from the stuff and anyone choosing a mechanical wasn't really making a wise choice. I was concerned that others going into their time of valve choice, might have an over-inflated view of the danger. I want them to know that life can go on normally. Most of us here have lived lives that were seriously affected by our messed up valves. I wanted others to know that I'll take my life on Coumadin with my mechanical valve any day, over the way I was prior to my surgery.

By the way, I meant to mention in my other post on your thread, that I'm so glad to hear that your Ryan was given the okay to wait on the surgery.

 

[catwoman]

Rain:

I've accepted taking coumadin. HOWEVER, I still have bouts of anger at my body failing me. How dare my mitral valve to give way? Darn it! Why wasn't I in the 95-98% of people with MVP who have absolutely no problems throughout their lives? Or even in the percentage who never have valve problems?
I give myself permission to vent that every so often, to my husband or a very close friend, then I go back to acceptance of the situation.
I'm alive, and very grateful. I intend to live, not just sit around for the rest of my life, despite taking coumadin.

My 1st heart valve anniversary is coming up 6/24. I'll be at a convention (Cat Fanciers Association) at one of the Disney resorts outside Orlando FL. My roommates & I are going to celebrate that night -- maybe have martinis at the hospitality suite with Mickey and Minnie!

 

[Ross]

This thread is starting to take turn into a new subject. Out of respect for the thread starter, lets try to stay on the subject of bridge therapy and colonscopy please.

 

[Marty]

OK, Ross!

OK, Ross!

OK, Ross you asked for it. I checked with my cardiologist who is generally thought to be tops in Northern Virginia and asked him point blank what he would order in the way of bridge therapy if I decided on colonoscopy. He said he would rrecommend a three day hold and then start up regular dose day after. He said he has done this for years and never had a problem. I didn't tell him I would not follow his advice. He's a nice guy and I didn't want to hurt his feelings. I also wouldn't want to be his first "complication".

 

[Karlynn]

I have an appointment next week with my cardio. I'll aske her and see what she has to say....and report back of course.

 

[Rich]

Right on Marty

Right on Marty

I have received exactly the same story from my cardiologist as Marty.
I have done this three times so far for invasive procedures.
Fortunately I have survived BUT next time (if there is a next time) we are going to have a serious talk.
This doctor is chief of cardiology at two sister hospitals here, they are the top rated hospitals in Michigan.
They are also some of the best in this country.
So when your'e up against all that what do you do ??

 

[Guest]

Tell them, "The thing I fear most is having a stroke. I'd like to do everything that I can to prevent one. I know of several people who had them going off warfarin for procedures. I realize that bridge therapy does not offer 100% assurance but there are quite a few hours less when my anticoagualtion needs are not met. Would you please work with me to get bridge coverage?"

I tell my patients that the last thing I want to see is them laying in a hospital bed looking up at me saying, "I told you I needed..." Or worse yet, them laying in a hospital bed looking up at me and not being able to say, "I told you..."

I had a 32 year old man who had two valves put in when he was 18. He thought that all he had to do was keep taking warfarin the way that he was told when he left the hospital. He was one of my first patients. For the entire first year I kept testing him and telling him that he needed more warfarin. We got along OK but I knew that he was blowing me off. On Labor Day Weekend he took his family fishing up in the mountains. They were way out in the back country on 4-wheel drive narrow mountain roads. They arrived at their destination and he stepped out of the truck and collapsed with a stroke. His wife and little daughter struggled to get him back in the truck. Then his wife had to drive hours over this road that terrified her to get him to a hospital. The little hospital did not have the expertise to care for him, so an air ambulance had to be arranged. By the time he got to our hospital he had lost so much brain that he was paralyzed on the left side. I am still haunted by the sight of the therapist having him sit up in bed and then when she thought he had his balance letting go of him for a second and he fell over on his side on the bed with no more reaction than a big teddy bear falling over would have had. He went from being one of those people who draws the concept picture of what a building will look like to struggling to wash dishes in a restaurant. He not only couldn't move his left hand but he could no longer concentrate enough to stay on a project more than a few minutes. My original grant was for one year from Sept 1 to August 31. I had no major strokes during my first year which made the grant look very good. His stroke happened on day 367 of my clinic. While it did not show up on the paper, I've always known in my heart that he was my first failure. Fear of another one of those is one of the things that drives me to keep helping others.

 

[bvdr]

That's a great answer, Al. I've told my doctors that I would much rather risk a major bleed than a mild stroke and that is exactly how I feel.

 

[RCB]

Marty- you have me scared now!

Marty- you have me scared now!

I have had bridge therapy( what it is called here ) 3 times. Once in '91 for gall bladder surgery at Toledo Hospital, twice in '96 for an EP study and mitral valvoplasty
at Medical College of Ohio by two different cardiologist.
They called it "blood conditioning". I entered the hospital
three days before the procedure having stopped my warfarin the day before. I was put on a heparin drip and had
a PT draw within minutes of being in my room. As time went on they took my PT every at least 12 hrs and adjusted my heparin drip, based on the test. The day of the procedure, the heparin was stopped a couple of hours before
the procedure. I remember the dr's warning to me, he said
"If they don't have you on the way down to surgery by
30 minutes before the procedure- START SCREAMING AT THEM TO GET YOU DOWN TO SURGERY"! After the procedure they started the heparin drip again ( I had an
IV all the time I was there) took a PT again and started my warfarin- weaning me off of heparin.

Now you tell me this protocol is NOT SOP!

In the matter of weeks, I have to have a pre-op cath.,
followed by OHS surgery in a couple of days. They have already told me to report a couple of days early, to "get my
blood ready". So it seems me my new drs. are following the same protocol. Although this is my third redo, many others have had to replace their mech. valves and I'm sure
that I as well as others were not on warfain while we had
OHS.

If this is not a matter of standard medical protocol- How can
all these guys be shooting from the hip!

Marty- say it ain't so!

 

[Marty]

As far as I know the protocol for for OHS is standard and works very well. The problem as I see it is after surgery and the first days at home..getting back to a stable therapeutic INR . The next problem is if you need a procedure like colonoscopy. Do you "hold" as many good cardiologists recommend or do you "bridge" with Lovenox or heparin? I favor bridge and I believe if you ask your doctors to work with you on this they will.

 

[Nancy]

This is my own opinion, but is based on what Joe has gone through.

The docs in the cardio field or those that monitor Coumadin on a regular basis understand about bridge therapy. But once you wander out of that area of expertise, you are in very muddy waters, and at the mercy of doctors who don't fully understand about bridging patients with mechanical valves. They think it's extremely complicated, so decide that holding Coumadin for a couple of days is easier. No muss, no fuss, no trying to massage the dose with Lovenox or Heparin. They do not fully understand that this can be dangerous for many mechanical valve patients. And--the worst thing is that they will not communicate with the doctor who knows about that patient's Coumadin management. So the patient then has to make sure they are being treated in a safe manner. It's tough and it's nasty for patients. Puts them in an adversarial situation.

I feel that's where the very gray area is located.

 

[warrenr]

Recommendations for anticoagulants use during surgery and invasive procedures

Recommendations for anticoagulants use during surgery and invasive procedures

The information i am finding through my research concerning the use of coumadin/warfarin management, especially for those of you with prosthetic heart valves continues to amaze me. I am going to start attaching articles that i come across to this thread. Here is the first one and it's from "bestpracticeofmedicine.com" MDALERT.


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...Alert

Monday, May 12, 2003

Recommendations for anticoagulants use during surgery and invasive procedures
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WHAT YOU NEED TO KNOW
NEW YORK May 12, 2003 Anticoagulant therapy in the perioperative period should be managed based on the procedure involved and the patient's risk of thromboembolic stroke without anticoagulation, according to a review in the Archives of Internal Medicine.
The perioperative management of patients receiving long-term oral anticoagulant (OAC) therapy requires balancing the risk of bleeding vs the risk of thromboembolism. The need for standard recommendations is high, as about 40% of the 2.3 million patients with atrial fibrillation receive OAC therapy.
Researchers reviewed 31 reports on the perioperative management and outcomes of patients on long-term OAC therapy. Overall, they found poor quality across studies because of small sample sizes, lack of no-treatment control groups, and lack of information on administration and discontinuation timing and follow-up duration.
Among the studies, 29 thromboembolic events, including 7 strokes, were reported during or after surgery or invasive procedures in 1868 patients who were on long-term OAC, with various perioperative anticoagulation-management strategies. In 3 studies in which OAC was discontinued and low-molecular-weight heparin was administered, the rates of thromboembolic events and major bleeding were very low.
The authors concluded that patients can continue their usual OAC therapy when undergoing dental procedures, arthrocentesis, cataract surgery, and upper endoscopy or colonoscopy, as major bleeding was rare in those cases.
For other invasive and surgical procedures, they recommended discontinuing oral anticoagulation and individualizing intravenous or subcutaneus heparin therapy based on the patient's annual risk of thromboembolic stroke without anticoagulation: none for low risk (less than 4%); optional for a moderate risk (4% to 7%); and recommended for high risk (more than 7%).

WHAT YOU SHOULD DO
Recommended by Barry D. Weiss, MD, Professor of Clinical Family and Community Medicine, Department of Family and Community Medicine, University of Arizona College of Medicine, Deputy Editor of Best Practice of Medicine.
Do not stop chronic coumadin therapy when patients undergo dental procedures, arthrocentesis, or cataract surgery. Assuming a patient's International Normalized Ratio (INR) is in, and not above, the therapeutic range, the rate of hemorrhagic complications from these procedures is low - 0.2 percent for dental procedures, close to zero for arthrocentesis, and only minor bleeding (mild hyphema and subconjunctival hemorrhage) for cataract surgery. The risk of thromboembolic events from stopping coumadin when patients undergo these procedures is substantially higher than the risk of bleeding with continued coumadin therapy.
Do not stop chronic coumadin therapy before a patient undergoes upper or lower gastrointestinal endoscopy, even if the patient will have a biopsy. With an INR in the therapeutic range, the rate of bleeding in such patients is very low. Coumadin should be stopped temporarily, however, if the patient will have a polypectomy. If a patient having a polypectomy is at high risk of thromboembolism (eg, mechanical mitral valve, atrial fibrillation with a history of stroke), intravenous heparin can be administered while coumadin is being stopped. Heparin should be discontinued 4 to 6 hours before the scheduled endoscopy and may be resumed 2 to 6 hours after the procedure. Coumadin can also be restarted after the procedure, and heparin continued until the INR is in the therapeutic range.
Stop coumadin therapy before most other invasive procedures and surgeries. Patients at high risk for thromboembolism (eg, mechanical mitral valve, atrial fibrillation with a history of stroke) should receive heparin temporarily in a protocol similar to that outlined in the previous paragraph. Heparin should also be considered for patients with a moderate risk of thromboembolism (eg, mechanical aortic valve). Heparin is not needed, however, for patients with a low risk of thromboembolic complications (eg, atrial fibrillation without history of stroke).
Be aware that the above recommendation are derived from a systematic review of 31 studies of bleeding complications in patients undergoing procedures while on chronic anticoagulation therapy. Although the individual studies represent the best knowledge available, the quality of the studies was variable. Note that the recommendations for continuing coumadin therapy only apply to patients with therapeutic INR levels.

REFERENCES AND LINKS
Dunn AS, Turpie AGG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med. 2003;163:901-8. [Pubmed abstract][Related articles]
Douketis JD. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002;108(1):3-13. [Pubmed abstract][Related articles]
Hewitt RL, Chun KL, Flint LM. Current clinical concepts in perioperative anticoagulation. Am Surg. 1999;65(3):270-3. Review. [Pubmed abstract][Related articles]

TOP

 

[Shirley]

Warren,

I am very sorry to hear about your Dad's stroke. We will keep him and your family in our prayers.

Last year my husband, Jim L. needed a minor outpatient surgery performed. It took him 3 months to find a Dr. that would perform the surgery without taking him off his coumadin. The day of the surgery the Dr. and the anesthesiologist talked with us about Jim's INR,etc. They were well-informed and did the procedure with no problems with bleeding or anything else.

Even scarier to me than the colonoscopy is that some MDs and dentists still tell heart patients to go off their coumadin for 3 days prior to regular dental cleanings. I have had some good discussions with some of my patients and asked them to talk more with their PCPs. I too think that the DRs and dentists need to learn much more about this type of therapy.

God bless you,
Shirley

 

[warrenr]

University of North Carolina GI Prodedure Request Form

University of North Carolina GI Prodedure Request Form

Check out this link http://www.med.unc.edu/medicine/web/GIProcedureform.pdf

Look at Pertinent patient conditions (mechanical heart valve) and read note 2. Looks like there SOP is Bridge Therapy.

I will continue to post links such as this in hope that the message gets out to everyone with mechanical heart valves. This is what my father would want plus its the right thing to do.

warren r mead

 

[warrenr]

American Society for Gastrointestinal Endoscopy

American Society for Gastrointestinal Endoscopy

I keep hearing that there are no Standard Operating Procedures or Standard Guidlines for Anticoagulation Therapy for Colonoscopy, then what the H... do you call this

Read the information linked below and it seems that the ASGE understands but there members don't listen to them

http://www.asge.org/gui/resources/manual/pe_maatep.asp

Now I am more confused about this than before.....

sure would like everybodies input on this

warren r mead

 

[warrenr]

How the Cleveland Clinic does it

How the Cleveland Clinic does it

Here is another great link

http://www.ccjm.org/pdffiles/Jaffer1103.pdf

If the American Society for Gastrointestinal Endoscopy has guidlines and The Cleveland Clinic, The University of North Carolina, etc. follow these guidlines why is this not considered Standard Operating Procedure

P.S. If you want me to stop posting these links let me know and i wll discontinue. Otherwise I will keep them comming.

Warren R mead