Inr

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Paul Flannery

New member
Joined
Aug 12, 2023
Messages
1
What are yall's inr?
I had my aorta split open in a motorcycle accident blind sided by hit and run driver now prod owner of not a road king but an on-x valve
 
What are yall's inr?
I had my aorta split open in a motorcycle accident blind sided by hit and run driver now prod owner of not a road king but an on-x valve
Welcome Paul. INR depends on the valve you have. Mine is am old valve and my INR range is 2.5-3.5. Many of the new valves have a range of 2-3. On-X has a much lower range but many consider their range too low. There are lots of posts on this forum that address INR levels.
 
What are yall's inr?
I had my aorta split open in a motorcycle accident blind sided by hit and run driver now prod owner of not a road king but an on-x valve
sorry to hear that (from another motorcycle rider).

Not sure exactly what you're getting at but if you're asking "can I sit at INR < 2" the answer is not in my view.

Here are some perhaps helpful graphs and an article of mine

https://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
https://cjeastwd.blogspot.com/2015/10/managing-my-inr-example.html
2018 inr dose.png
2019 inr dose.png
2020 INR dose.png


reach out if you have more questions
 
What are yall's inr?
I had my aorta split open in a motorcycle accident blind sided by hit and run driver now prod owner of not a road king but an on-x valve
Welcome, Paul. This week my INR is 2.7, and the range for my valve/other conditions is 2.5 to 3.5.

If you haven't already done so, look for information about the CoaguChek devices, to be able to monitor your INR at home/wherever you are, with a finger-prick of blood. Ideally, then test weekly and you will greatly reduce the risks of any complications.
 
Welcome to the forum Paul!

Like you, I have a mechanical valve in the aortic position. My INR range is 2.0 to 3.0, which is pretty standard. I have a St Jude and one study found that St. Jude can be safely maintained at 2.0 to 2.5. Some target this range, and I will sometimes try to keep that tight range if I am actively doing jiu jitsu.

In that you have an On-x valve, some will push you towards an INR of 1.5 to 2.0. This was based on the outcomes from the PROACT Trial, which many experts believe is flawed. There have been lengthy discussions about this study on this forum. I will comment that I agree with @pellicle and @dick0236 and would personally avoid going below 2.0 in order to reduce the risk of stroke.
 
Hello Paul. Sorry about your misfortune, but know that you have the right heart valve. I also have an On-X valve, and I ride an Indian Challenger (I love motorcycles of all makes and own others). As far as I'm concerned, my INR range is 1.5 to 3, although it's usually 1.9-2.7.

Contrary to what you might read on this forum, no one will "push" you to be 1.5-2. The PROACT trial did show that it is indeed safe, but keeping it in that narrow range is very difficult. The take-home message is that the On-X valve has design nuances that probably make is less thrombogenic than older valves, and a less thrombogenic valve is an advantage at whatever INR you happen to be at. The only time my INR has been under 1.5 was when I did it intentionally for a colonoscopy.

Best wishes and don't worry about the ticking. You won't hear it over that Harley anyway! I always say that it's not the motorcycles that are dangerous. It's all those other fools barreling down the road and not paying attention.
 
The PROACT trial did show that it is indeed safe, but keeping it in that narrow range is very difficult.
That’s kind of the point though, isn’t it? Walking along the edge of a cliff on path may be safe, but the risk is a lot higher if you stumble vs walking on a path farther from the edge of the cliff.
 
Contrary to what you might read on this forum, no one will "push" you to be 1.5-2
You seem like a nice person and sorry to call you out on this, but this is not an accurate statement. We have several members who were given an initial INR range of 2.0 to 3.0. After the publication of the PROACT Trial, Cryolife sent a letter out to those who have received the On-x valve and told them that their INR target should be 1.5 to 2.0. This may have not been the case for Mexico patients, but this was the case for patients in the US. Also, some surgeons and cardiologists have instructed their patients with On-x to be at 1.5 to 2.0.

As far as I'm concerned, my INR range is 1.5 to 3, although it's usually 1.9-2.7.
That is good to hear. Are you aware that although the range for the low end of the PROACT Trial was 1.5 to 2.0, that the average INR for this group during the study was 1.9- very close to the upper limit of 2.0. I think that if it were that close to the lower limit of 1.5 we would be looking at a totally different outcome. And, even with the 1.9 average INR, the rate of stroke was 3x as high as the slightly higher INR control group. So, glad that you are keeping your INR generally at or above 1.9.
As Superman indicated, better to not walk too close to the edge of the cliff. We will all fall above or below our target range from time to time. If your range is 1.5 to 2.0, the idea of sometimes falling below 1.5 is not good. This is especially true for those who do not self test and could potentially spend a month or more below 1.5 before they get their next lab. Always better to have a bit of margin from the danger zone.
 
The PROACT trial did show that it is indeed safe,
actually if you read the details it did not demonstrate that, but don't just take my word for that, read the actual analysis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6472691/
Comments of my own which are within textual quotes are in italics and encased in braces such as: {comment}

The authors make some good points and perhaps is one of the better critical assessments of PROACT. About halfway through, they say:

While the PROACT trial was generally well conducted, it raises several important points that warrant consideration. Firstly, the study sample size was calculated to demonstrate non-inferiority of a composite endpoint of bleeding, TE and thrombosis events, which was entirely driven by the reduction in bleeding events in the lower INR group as anticipated.
These findings require further analysis to ensure safety of aiming for lower INR targets.


The mean follow-up was 3.8 years and was 98% complete {so not very long}
The mean INR was 1.89 in the test group and 2.5 in the control group (p < 0.001).{so about what we target as the bottom end or }

Its worth remembering here that a much longer study of some 4000 patients found that for all valves the average duration of time needed to get a thrombosis event for INR around 1.8 was 4 years. How amusing they chose 3.8 years.

Means are given but not SD The mean INR was 1.89 in the test group and 2.5 in the control group (p < 0.001).

They say:

with no differences in the rates of TE and thrombosis events (2.96%/pt-yr in the test group versus 1.85%/pt-yr in the standard group, p = 0.178)

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So why then is nearly double suddenly no differences (and standard group and control group used loosely)? Strangely people seem to ignore that a TE thrombosis even is related to a stroke. New brain cells are presently hard to find.

Then:

.. This is consistent with recently published studies demonstrating the safety of a lower anticoagulation regimen in patients with mechanical AVR

Where they go on to cite a study which suggests this is actually the case for every other low risk patient with every other type of current bleaflet pyrolytic carbon valve. Sort of saying that “nothing except our marketing makes our valve stand out”

Then:
… Similar to findings from the PROACT trial, there were no differences in TE events (OR 0.33 [0.006–4.20], p = 0.6) while there was a significant decrease in bleeding events in the low-dose group (OR 0.36 [0.11–0.99], p = 0.04).

What is absent here in the actual PROACT study is any actual age related risk and a comparison to the age related risks of the general population.

Amusingly the claims by Cryolife that there is no difference in TE are supported by this reference:
https://www.jacc.org/doi/full/10.1016/j.jacc.2018.03.535

…which amusingly would actually suggest over the longer term there is a difference.

So my point is that when a study is sponsored by the valve maker who is after some point of differentiation of their product over another (St Jude for instance) they may actually not lie, but maybe they don't actually reflect the truth properly either.


Again, these are not my opinions, but actual citations from peer reviewed analysis undertaken medical researchers and published in a relevant medical practice journal
1692004674920.png


We are all entitled to our opinions but your phrase of "contrary to what you may hear here" is perhaps an attempt to dismiss what we say as like a fiction or hearsay. This is not the case.

...and don't worry about the ticking. You won't hear it over that Harley anyway!

fully agree ... I don't hear it on even my quiet bikes :)

Best Wishes
 
@BradP , to sum up the general take of many on this forum:

It’s a lot easier to replace blood cells than brain cells.

On-X had lower bleeding events and higher clotting events in the study that got them approved for a lower therapeutic range. Clotting events lead to pulmonary embolism, strokes, etc. I’ll take my chances with a bleed. Notice the Test group actually had a slightly (albeit statistically insignificant) higher mortality rate than the control group?

Just because nobody will “pressure” you if you want to maintain a higher therapeutic range, that doesn’t mean they aren’t using 1.5-2 as a status quo starting point for the uninformed. That, to me, is where the danger is. When the patient doesn’t know enough to push back against poor/dangerous guidance.
 
What are yall's inr?
I had my aorta split open in a motorcycle accident blind sided by hit and run driver now prod owner of not a road king but an on-x valve
Are you asking what our INR was as of our most recent test? Or our standard therapeutic range that we aim for?

I try to stay within 2.5-3.5. My last test showed 2.9. St. Jude mechanical valve.
 
It’s a lot easier to replace blood cells than brain cells.
Thanks, Superman, for posting this. In two days I will celebrate the 56th anniversary (8/16/1967-8/16/2023) of my mechanical valve. My ONLY issue with my valve over all these years was a serious TIA seven years after my surgery. The stroke was caused by a clot due, almost certainly, to a low INR (PT in those days). I maintain an INR of 2.5-3.5 and have a little concern if I drop to 2 or go above 4.......which almost never happens......I adjust my warfarin dose to get away from those extremes.

Serious bleeds have never been a problem altho I've had my share of cuts (a few that have required stitches). Recently I had an "old mans fall".......broke 3 ribs but never bruised.....go figure!

An INR of under 2 for an extended period of time is walking too close to the edge of the cliff.
 
That, to me, is where the danger is. When the patient doesn’t know enough to push back against poor/dangerous guidance.
or when the patient has a (verging on hysterical) pathalogical fear of any warfarin at all it seems somehow a little less is a less bitter pill to gag on.
 
I'm new to this (surgery 09/14/2023), so I am targeting INR in the range of 2 to 3 for these first 3 months. I have an On-X aortic valve, and my Coagulation clinic said we'll lower my target range to (I think) 1.5 to 2.5 after 3 months. Since this is still a couple months away, I have not yet discussed it with them.

What benefit might I get from an INR range of 1.5 to 2 rather than a range of 2 to 3? I still need to test INR weekly, and I still need to take warfaren every day. Would the lower range cause less bruising when I am struck while training martial arts? Will it mean I don't need to worry about the buffalo grass cutting my legs when I work in my yard? Are there some other examples someone can give of a life style benefit of the lower INR range? Currently I'm thinking I'd rather stay at a target range of 2 to 3 and just and just consider the 1.5 value as an extra safety margin.

In any case, since I had an episode of afib during cardiac rehab last week, my cardiologist recommends that I stay at an INR target of 2 to 3. Which sound very sensible to me.

Also, I greatly appreciate threads like this. I am learning a lot, which will help me when I have discussions with the nurse at the Coagulation clinic, my cardiologist, etc. Thank you!
 
Welcome, Mark. I've had my (St Jude) valve 9 years, and am still learning lots thanks to this site, which has some very knowledgeable contributors. They are generous with their time.

If you search "On-X" on this site, you will find lots of posts about it, such as this one. A fair few people will agree with you about maintaining a higher range. From my own experience, I have seen a drop of 0.7 in my INR between one week and the next, caused by going down with a cold. The INR drop was before the cold gave symptoms, so if you're maintaining a lower range there's not much room for such a drop and you're more at risk of an adverse event.
 
What benefit might I get from an INR range of 1.5 to 2 rather than a range of 2 to 3?

Fewer bleeds with the lower INR. That counts minor and major bleeds.

But, 3x as many strokes, with the lower INR range.

There are some threads here criticizing the Proact Trial, which was the trial which was used to gain approval for the lower INR range for On-x. Personally, I'd rather have a bleed than a stroke, and most here on warfarin seem to share that sentiment. My surgeon was of the opinion that the lower INR is a marketing gimmick and was very familiar with and highly critical of the Proact Trial. I was weighing St Jude or On-x. He indicated that if I decided to go with On-x, they would have me at 2.0-3.0 INR.

I would strongly suggest reading the threads which discuss the lower INR for the On-x. We have had members have some serious clotting issues with On-x at the low range of 1.5 to 2.0. Even though the low INR arm of the trial had 3x as many strokes, because the study was small, they were able to claim "no significant difference". From there, it often gets modified to "no difference" when discussed. You may have heard the term, "“There are three kinds of lies: Lies, Damned Lies, and Statistics” The point being that many feel that there was some statistical slight of hand with the claim that there was no statistical difference in clotting. It was a small trial. Somehow 1 is not statistically significant from 3. But, if the ratios held with a larger trial, and it was 100 strokes vs 300, that, of course would be statistically significant.
 
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