what's you target INR ?

[extraordinary]

What's your target INR IS IT 2.0 - 3.0 OR IS IT 2.5-3.5 AND why it differs from one person to another ?

 

[pellicle]

Hi

What's your target INR IS IT 2.0 - 3.0 OR IS IT 2.5-3.5 AND why it differs from one person to another ?

basically it varies a bit depending on "what's wrong with you" and "which valve you had done". Mitral valve usually has higher target INR than Aortic by about 1 unit.

Table 20 from Guidelines on the management of valvular heart disease (version 2012)
The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)


it presents this table:

and this explanation

11.2.2.2 Target INR
In choosing an optimum target INR, one should consider patient
risk factors and the thrombogenicity of the prosthesis, as determined
by reported valve thrombosis rates for that prosthesis in relation
to specific INR levels (Table 20).

Currently available randomized trials comparing different INR values cannot be used
to determine target INR in all situations and varied methodologies
make them unsuitable for meta-analysis.

Certain caveats apply in selecting the optimum INR:

† Prostheses cannot be conveniently categorized by basic design
(e.g. bileaflet, tilting disc, etc.) or date of introduction for the
purpose of determining thrombogenicity.

† For many currently available prostheses—particularly newly
introduced designs—there is insufficient data on valve thrombosis
rates at different levels of INR, which would otherwise
allow for categorisation. Until further data become available,
they should be placed in the ‘medium thrombogenicity’
category.

The bit I blue bolded is to highlight what is frustrating even for medical professionals: there are tons of studies out there but noone seems to follow any sort of standards in analysis or reporting (either because they're incompetent data researchers but good surgeons OR because they want to twist things to suite their view before doing the research and choose skewed datasets to support their view: you pick)

my target is 2.5

Best Wishes

 

[Protimenow]

Three months ago, when my clinic realized that I only have ONE artificial valve, rather than an Aortic AND a Mitral, they changed my target of 2.5-3.5 to 2.0-3.0. I'm still more comfortable in the former. My main issue is for the self-tester, whose 2.0 on a meter may actually be 1.6 or higher in a lab. Even with the newer valves, there is increased risk of stroke at below 2.0 (and even if there wasn't, maintaining an INR between 2.0 and 3.0 doesn't really change a person's lifestyle).

On the meter that I've chosen as my 'trustworthy' meter, I know that a 2.0 is usually more like a lab's 2.3 or 2.4 - so I'm comfortable with it.

Perhaps an On-X actually DOES pose less risk with INRs of 1.5 - 2.0 than the other valves (or my 22 year old valve), but I agree with Pellicle's target of 2.5 for any valve.

To me, a 2.0 measured by some meters (and I've had a TIA partially due to my confidence in the accuracy of my meter's 2.1), can be dangerous - especially with older aortic valves. To me, trusting a meter that could vary by up to .3 or .4, trying to stay within a range that starts at 2.0 can be dangerous. (Of course, it MAY be possible that the meters report higher for some people than they do for others, meaning that a 2.0 on a meter may be an actual 1.7 for me, but a 2.0 on a meter for someone else may be closer to actually being 2.0 -- but I don't know how to verify that).

In summary -- I'm more comfortable with 2.5 and a minimal variance below that number - perhaps 2.5 -.3 + .5 or so)

 

[T in YVR]

My range is 2-3, and I try to stay right around 2.4-2.6. I have tested my Coaguchek XS vs. the lab on a few occasions and there seems to be 0.1 difference (with my Coaguchek reporting 0.1 higher than the lab on 3 of the 4 occasions that I have tested with both methods within a few hours of each other - I just got the XS and have just started home testing). On the other occasion both units reported the same INR.

Every doctor I have seen at the hospitals, my GP, etc, all thought the range for a person with a mech AV was 2.5-3.5, and I have had to correct them. I was told by my surgeon that with the On-X aortic valve 2-3 is the target range and that if you had both mitral and AV replaced then its 2.5-3.5.

T

 

[Cooker]

First let me say that I'm not a doctor and this is just my opinion and the way I live life on warfarin. If I am between 2 and 5 I don't get concerned. If I'm a bit high I will skip a dose, if I'm a bit low I will double a dose. I test once a month. I really believe some people try too hard to manage the decimal points of INR, my PCP is one of them and that is why she does not manage or prescribe my warfarin. My cardiologist office does a great job and we are of the same mindset when it comes to INR and warfarin.

If you agree with me fine, if not fine ... this is a subject I do not debate ... everyone has to manage their anti-coagulation the way that is suitable to them...

 

[tom in MO]

If your only need for warfarin is your mechanical valve, the range is set by the manufacturer and the valve replacement industries based upon studies. Your doctor uses the range they believe is best. The range can be adjusted based upon more studies. Mine went from 2-3 to 2-2.5 based upon new info about my valve model, 2-3 is the consensus value for mechanical in the aortic osition.

 

[MarkU]

Mine's always been 2.5-3.5. No strokes or major bleeds in 14 years, so I guess it's working OK.

Mark

 

[Protimenow]

Mine has been 2.5-3.5, although for a while in the past, I wasn't too uncomfortable being closer to 2.0 or slightly above 3.5. My anticoagulation clinic now wants it to be 2.0-3.0, without taking into account the fact that this is an already older technology (circa 1991) valve, and the original recommendation was 2.5 - 3.5. The valve hasn't changed in the time since I got it -- just the technology of the newer valves may make 2.0-2.5 somewhat safer. It's kind of like saying that ALL cars can use unleaded gas -- without any regard to the fact that pre-1974 cars CAN'T.

What further concerns me with saying that 2.0 is okay is that self-testers may have meters that report higher than actual INRs. If the self-tester is comfortable with a 2.0 on the meter, but actually has an INR that's closer to 1.8 or so, the results could be disastrous. (I know -- I had a TIA when I trusted my meter's near-2.0 values. I'd hate to see anyone else having a TIA, or worse, because they trust the meter and the ACTUAL INR is sub-2.0)

 

[aussiemember]

I have a mitral mechanical valve and my target range is 2.5-3.5. I aim for 3 as I figure even if my meter reads high I will still be in a safe range. Have had no problems in 5 years so will continue to stay with this

 

[slipkid]

Every doctor I have seen at the hospitals, my GP, etc, all thought the range for a person with a mech AV was 2.5-3.5, and I have had to correct them. I was told by my surgeon that with the On-X aortic valve 2-3 is the target range and that if you had both mitral and AV replaced then its 2.5-3.5.

Interesting, I've had a similar experience. I swear one doctor in relation to another on my case has no idea what they are talking about, or what is going on with me specifically. Left hand not knowing what the right hand is doing. And some of this is even within the same doctor's office/staff.

My surgeon's staff originally told me 2.0 to 3.0 is my range and that is what they were looking for while monitoring me. I have an On-X aortic valve. My INR was anywhere between 1.1 and 3.3 during the first month or so, and my dose was changed up & down temporarily to get me "in range". I started on 5mg, went to 10mg for one day, then told to skip a dose, then back down to 5mg, then up to 7.5 for 4 days, then back down to 5mg.

After about 5-6 weeks the surgeon's office turned me over to the cardiologist's office for monitoring my INR. And the "assistant" in the cardiologist's office (who I have absolutely no faith in whatsoever after being told several strange things by him that even conflicted with what his own boss told me earlier) said my range is supposed to be 2.5 to 3.5.

I thought perhaps I was mistaken thinking it was supposed to be 2 to 3 so I asked the surgeon's office again since I had my last followup appt. there last week. The surgeon's assistant this time (a different assistant than who I had been working with previously in the surgeon's office) told me my range should be 1.5 to 2.5 (????). He said that for mitral valves it should be 2.5 to 3.5 and that the guy in the cardiologist's office must be confused & thinking I had a mitral replacement instead of aortic. I asked him to please speak with my cardiologist's office to "correct" them about this.

A few days later I decided to call On-X and ask them. Their answer was that for patient's in the USA the FDA approved range is currently 2.0 to 3.0, and that "1.5 to 2.5" is still not approved by the FDA (but is for Europe).

So I've gotten 4 different answers (OK 2 answers were the same) - but 3 different ones in the span of just one week!!! Not very reassuring to me.

 

[tom in MO]

I had a similar thing, where I was told 2-3 by the warfarin clinic. In follow-up after surgery, I asked my surgeon and cardiologist and they said it was 2-3, but recently it was changed to 2-2.5 based on the completion of some long term studies. My cardiologist even said that going beneath 2 is no real danger, but it's prudent to be 2-3. I told the 2-2.5 range to the warfarin clinic, the nurse discussed it with the doctor and all three now say 2-2.5. That's a range specific to my St. Jude model.

 

[slipkid]

I got some progress on what my range is supposed to be today.

Had a conversation with the cardiologist's assistant - who didn't even know how to spell On-X and had never heard of it (not very reassuring there again, the folks managing my INR are not even familiar with the mechanical valve that I have or what the recommendations for it are), he only knew that for "all mechanical valves the range is 2.5 to 3.5". Not all of the various doctors etc are up on what the latest gear is, or recommendations are, and they don't all talk to each other either I guess.

On the one hand this is mind boggling to me. But on the other hand, I guess it makes sense. "In a perfect world" all the health care folks would know everything (by magic?), but no such place exists. Seems like we (the patients) really need to play the central role here and manage the caregivers instead of the other way around sometimes.

I was pretty frustrated with this (and some other things, like a voicemail he left me which sounded to me that he did not know what dosage of coumadin I'm on) and afraid I kind of pissed him off with my attitude (me saying: "Do you even know what meds I'm on???"). But, hopefully we cleared that up and are on the same page now. I don't mean to be a grouch but I can only take so much. Sigh. I need to try to curb my temper, afraid I am turning into Ralph Kramden. "I've got a BIIIGGG MOUTH. A BIIIIGGGGG MOUTH!" (Honeymooners reference).

I have had so many frustrating things happen to me healthcare related - dealing with an incompetent visiting nurse one week (long story), my original GP doc making a critical mistake (that almost killed me), numerous issues with medical billing problems, lab related snafus, you name it I've probably experienced it, my frustration boiled over today, I just have zero patience anymore for perceived incompetence with health care professionals. Add to that of course having a heart attack, getting cracked open, being in pain/sick, exhausted most of the time, tons of frustrations mounting (car problems, home a/c issues with the heat pump), financially stretched to the breaking point, it's amazing I haven't gone postal already.

Rant over...we (heart patients) are supposed to handle stress better and not let things get to us! Be something other than human, somehow. Thanks for letting me vent.

 

[pellicle]

Hi

Had a conversation with the cardiologist's assistant - who didn't even know how to spell On-X and had never heard of it (not very reassuring there again, the folks managing my INR are not even familiar with the mechanical valve that I have or what the recommendations for it are),

in their defence I would say that its more likely to be surgeons and perhaps cardiologists who know about valve details. The cardiologists assistant is ... well not the cardiologist. To expect them to be as across the business and remain as an assistant would be a bit of a high call.

Also, aside from the marketing calls from On-X I am uncertain that there is any Internationally recognised difference between accepted target INR for bi-leaflet pyrolytic carbon valve. To my knowledge its generally 2.5 target INR.

I can assume that a patient who was given a target of something lower (like 2) and then had a stroke , that said patient may indeed be unhappy and be perhaps inclined to take action against the people involved with managing their INR. So its a case of be cautious. There is very little data supporting anything lower than 2.5 anyway.

Personally I don't see what is to be gained by going "ultra low" in the range other than point scoring value. Can you suggest any benefits to be had by having an INR lower than 2.5 target?

 

[slipkid]

Thanks, my thoughts below....

Hi
in their defence I would say that its more likely to be surgeons and perhaps cardiologists who know about valve details. The cardiologists assistant is ... well not the cardiologist. To expect them to be as across the business and remain as an assistant would be a bit of a high call.

Since this is the person in the cardiologist's office that is managing patient INRs I would expect that person would be informed (as well as the cardiologist himself) as to what the correct INR ranges should be for the patients/their type of heart valve/etc. Just the same as I would have wanted the mechanic who worked on my heat pump to know what a TXV valve is (long story)....:rolleyes2:

However - if the cardiologist's office had decided "well regardless of manufacturer recommendations, or AMA/FDA/whatever standards, or what the surgeon thinks, based on our office's experience, we feel the best/safest/whatever range is 2.5 to 3.5" then that is one thing. But that was not the case here, it was just "mechanical valves are 2.5 to 3.5" without knowing/considering anything else like different valves, or different "risk category patients", might have different recommendations for their INR. And now that they have become familiar with all of that, after consulting with the surgeon and On-x as well, they now feel that my range should be 2 to 3. Being informed is a good thing to help manage patients IMO.

Also, aside from the marketing calls from On-X I am uncertain that there is any Internationally recognised difference between accepted target INR for bi-leaflet pyrolytic carbon valve. To my knowledge its generally 2.5 target INR.

From what I understand, the range is 2.0 to 3.0 in the U.S., at least from what I've been reading lately, as approved by some kind of association like the FDA, for the On-X aortic valve, for "low risk" patient factors (sorry but I'm not up on all the details though).

I can assume that a patient who was given a target of something lower (like 2) and then had a stroke , that said patient may indeed be unhappy and be perhaps inclined to take action against the people involved with managing their INR. So its a case of be cautious. There is very little data supporting anything lower than 2.5 anyway.

Personally I don't see what is to be gained by going "ultra low" in the range other than point scoring value. Can you suggest any benefits to be had by having an INR lower than 2.5 target?

I am not a doctor but as I understand it the benefit is that the lower the effective/safe range for whatever valve it is, the better it is as far as keeping our bodies as close to "normal" as possible, thus reducing chances of bleeding issues, by not having our clotting times unnecessarily modified to be higher than is necessary, as well as the benefit of reducing other side effects from blood thinners (lower dosages). It's one of the reasons that some people chose biological valves over mechanicals (not having to deal with blood thinners at all).

If a mechanical valve could be invented that required no clotting time modification/no blood thinner med at all wouldn't that be a good thing? Or if not, then the lower the range the better, because this reduces the chances of clots forming (not having to worry about getting low)?

For example, if a valve is created that studies find cause no clot risk with INR in range of say as low as 1.5, then patients won't have to worry as much about an INR fluctuating down to 1.5 for whatever reason & resulting in a fatal stroke, even if for security/safety reasons their doctor tries to keep them up around 2.5 most of the time anyways.

Just how I understand things.

Right now I am down to 1.7 btw. And I should be higher IMO (I'd feel safer at 2 to 2.5). But they let me lapse 2 weeks between testing despite falling INRs over last 4 readings 2 weeks ago, despite my trying to tell the assistant this 2 weeks ago that I was steadily going down and had gone down below 2 before and felt I should be tested more often, like once per week (I had been tested 2x per week earlier). But I digress...this appears to be a learning process for them as well as me.

 

[Aggie85]

But I digress...this appears to be a learning process for them as well as me.

Yikes! But isn't this SUPPOSED to be the people who are supposed to already know what they're doing?!! Certainly you're not their only patient on AC monitoring!?

I know you've had lots of insurance issues, but is there an option near by for a dedicated AC clinic? Not just your Drs office monitoring it? Here in burbs of DC there are several clinics that are specifically for ONLY monitoring anti-coag patients. I'm in a military one but had looked into others since the base is a bit of a distance away. There were several options, just in my little suburb town. Many are associated with specific hospitals in the area and accept many forms of insurance.

From what I've seen, many of the dedicated clinics are run by pharmacist clinicians whose specific training is in managing Warfarin. As pharmacists they truly know the ins and outs of this! Not just guessing and learning from their patients. My Dr. managed mine directly until I got hooked up with the clinic and he didn't seem as up on protocols as I would've liked either, and he's a pretty good Dr. in my opinion. But he has only a few patients (partly because he's a pediatric cardio Doc) on Coumadin so really only "goes by the book" not VAST actual patient experiences as the AC clinic pharmacists who manage over 500 patients do.

What are these clowns you're with now, going to do when you have a cold or need antibiotics???? Do they even know which drugs are ok to give you in different circumstances? Not just looking it up and seeing, but truly KNOW. Do they KNOW how to bridge you with Heparine if for some reason you need to go off Coumadin for a procedure or something? They can't be guessing and learning from you what to do.

Slipkid, I'm not trying to add more stress and I'm sorry if this post does. But from what you're saying, I'm really worried about how well these guys are "managing" you. I found the AC clinics in my area just by Google searching Anti-Coagulation clinics in Woodbridge (insert your town or region, etc...) See if anything comes up. Call any and ask if they take your insurance and what they need for you to be added as a patient. Many only need a script from your Dr. to enroll you. You might also ask the insurance company if they have any AC dedicated clinics on roster or in your area.

Best of luck with this! And RANT all you want if it helps! We don't want you having another heart attack!

Linda

PS did I actually manage to figure out how to add a quote!?!?!? Is there an easier way than having to hand delete all the rest of quoted post first? But at least I think I've learned something today.

 

[pellicle]

Hi

Since this is the person in the cardiologist's office that is managing patient INRs I would expect that person would be informed (as well as the cardiologist himself) as to what the correct INR ranges should be for the patients/their type of heart valve/etc.

it has not been my experience that anyone who is responsible for managing the INR is aware of this. In reality as long as the person who sets the target knows about it then all is fine I would think.

Just the same as I would have wanted the mechanic who worked on my heat pump to know what a TXV valve is (long story).

as an electronics tech years ago I can assure you that many technicans (including car technicians) know bugger all about the physics underlying it. What really matters is that they do their allotted job well.

But that was not the case here, it was just "mechanical valves are 2.5 to 3.5" without knowing/considering anything else like different valves, or different "risk category patients",

sorry, clearly I misunderstood. Also I was simply providing opinion on the requirement that the assistant knows valves from valves ...

And now that they have become familiar with all of that, after consulting with the surgeon and On-x as well, they now feel that my range should be 2 to 3. Being informed is a good thing to help manage patients IMO.

which btw is a target of 2.5 and its good that they sorted it out ... but there would be hardly any significant risk on being on a target of 3

From what I understand, the range is 2.0 to 3.0 in the U.S.

that is my understanding too ... for all pyrolytic valves

from what I've been reading lately, as approved by some kind of association like the FDA, for the On-X aortic valve, for "low risk" patient factors (sorry but I'm not up on all the details though).

I understood there was a trial, I understood that trial was not complete and that from that there may be new recommendations come out to lower the INR.

I am not a doctor but as I understand it the benefit is that the lower the effective/safe range for whatever valve it is, the better it is as far as keeping our bodies as close to "normal" as possible,

from what I read that is not correct, much evidence exists to suggest that having (in later years) an INR that is higher than "normal" has significant benefits.

I had been trying to get this article before I posted the above but I think you'll find it interesting to read (now that I've got a hold of it)

http://archinte.jamanetwork.com/article.aspx?articleid=415179

For instance this curve (while not being specific to your valve) I think makes the risk / INR relationship clear

thus reducing chances of bleeding issues, by not having our clotting times unnecessarily modified to be higher than is necessary, as well as the benefit of reducing other side effects from blood thinners (lower dosages). It's one of the reasons that some people chose biological valves over mechanicals (not having to deal with blood thinners at all).

some evidence exists that anticoagulation actually provides benefits ... but I do not wish to get into a why people choose a valve discussion.

If a mechanical valve could be invented that required no clotting time modification/no blood thinner med at all wouldn't that be a good thing?

it would ... as yet we have not seen one, and I'm only aware of the ATS ForceField technology being close to that. As it is your On-X valve is not such a valve and in many ways is not significantly better at thrombogenicity than my ATS valve is.

Or if not, then the lower the range the better, because this reduces the chances of clots forming (not having to worry about getting low)?

at 1.5 I'd say you would be running risks of TIA because its unlikely you'll not dip lower.

For example, if a valve is created that studies find cause no clot risk with INR in range of say as low as 1.5, then patients won't have to worry as much about an INR fluctuating down to 1.5 for

are you aware of such studies?

Well I think that your level of 1.7 is a bit 'dicey' but ultimately it is only you who makes the informed choice on what you feel comfortable with. An old phrase is that its easier to replace blood cells than brain cells (meaning that a small bleed may be less problematic than a small clot and a stroke)

Fatal doesn't bother me in the least, living impaired is quite a serious matter for you and your carers.

 

[pellicle]

Hi

PS did I actually manage to figure out how to add a quote!?!?!? Is there an easier way than having to hand delete all the rest of quoted post first? But at least I think I've learned something today.

deleting on a tablet sucks big time. I only do it when on the PC ... where I insert a quote by selecting what I want and hitting the quote button.

but on the tablet I don't bother ...

 

[slipkid]

Yikes! But isn't this SUPPOSED to be the people who are supposed to already know what they're doing?!! Certainly you're not their only patient on AC monitoring!?

I would think not but my recent experience leads me to believe they are not that experienced with this. The guy today even said something like "this is a learning process for us", at least that is what I remember.

I'm too tired to go through the whole story now, but there is some background in all this that had led to lose faith in him/them already; several things have happened.

My numbers are too low now btw (1.7). Yet he let me go 2 weeks without being tested despite my trying to express that my dosage had previously been upped then dropped, and my numbers were consistently dropping when he took over my "monitoring", and I should be tested more often since I felt I would get too low in 2 weeks. I knew I was going to drop below 2, and keep dropping, and I was right. Sigh. And originally today he told me to wait until Sunday before upping it another 2.5mg (?that made no sense to me, why not up it right away/tonight?). But he called back and told me to up it tonight, then go back to normal dose. I suggested I get retested next week, which I will do. Again though, I am not very comfortable with what is going on....seemed a lot better when I had a visiting nurse testing me 2x a week & surgeon's adjusting it as we go, almost every day. I understand it is not an exact science but I don't think I am getting the best care....as you say....I don't want to keep causing "trouble" though...I feel too beat down as it is.

I will google/investigate Anti-Coagulation clinics as you say though, thanks.

 

[pellicle]

My numbers are too low now btw (1.7). Yet he let me go 2 weeks without being tested despite my trying to express that my dosage had previously been upped then dropped, and my numbers were consistently dropping when he took over my "monitoring", and I should be tested more often since I felt I would get too low in 2 weeks. I knew I was going to drop below 2, and keep dropping, and I was right. Sigh.

based on that I agree, and think you need to change clinics or take charge of your dosing yourself. I guess though you being in the USA makes that harder.

 

[slipkid]

Well I think that your level of 1.7 is a bit 'dicey' but ultimately it is only you who makes the informed choice on what you feel comfortable with. An old phrase is that its easier to replace blood cells than brain cells (meaning that a small bleed may be less problematic than a small clot and a stroke)

Fatal doesn't bother me in the least, living impaired is quite a serious matter for you and your carers.

Well, You get no argument from me, I did not want to drop below 2, but the guy in charge of monitoring me doesn't seem concerned about it (1.7 now and probably heading south). He was going to have me wait another 4 days before even upping my dose! Luckily he called me back and told me I could up my dosage tonight "if I wanted to". As it is I doubt that just upping it 2.5mg tonight to 7.5mg, then going back to 5 tomorrow night, is going to make much of a diff but I will follow what the "doctor" is telling me to do. If I have a stroke hopefully they will learn from the experience and other patients will benefit. If I get lucky and remain healthy regardless of the INR # (1.7 or lower) then no one will benefit & learn from how not to manage a patient's INR (assuming they are doing this wrong and I think they are), but maybe I should then celebrate my good fortune in surviving in spite of possibly lax management.

And I have no carers btw. If I have a stroke and suffer any kind of damage - then I am better off dead. Not to be morbid or anything.

Wish me luck.