Discharge INR

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Deidra

Deidra

VR.org Supporter
Supporting Member
Joined
Jan 24, 2024
Messages
51
Location
Portland, OR
Hey all!

I just had my aortic valve and root replaced with an On-X mechanical prosthesis on May 8th.

My INR was hanging around 1.3 while I was on a 2.5mg dose for 3 days after I got out of the ICU. (Obviously they've had me on heparin shots since the surgery.) They finally bumped the Warfarin dose to 5mg last night and today my INR is 1.59.

They said this is good enough to discharge, which don't get me wrong I definitely want to do, I'm kinda sick of being here and I'd be sleeping a lot better at home. But I am worried about my INR being kind of low. I know it's an On-X valve and so technically speaking its in range, but I know that info isnt as reliable as its claimed to be and I'd prefer to be at a range of 2-3. My cardiologist and I spoke before the surgery and she said she agrees and also wants me in that range as the target. This was a while ago, and shes not the one managing my discharge though.

Do you have any advice here? Im sure it'll be ok but just wanted to gather any thoughts/wisdom from y'all.

Edit: And of course they will be seeing me back tomorrow or Thursday to check my INR again.

Edit edit: The cardiologist thats been working with my discharge came in and said the heparin shots i've been getting aren't at a therapeutic level for the valve actually (?), and they do want me at 2-3 INR for the first few months anyway, but the surgeon feels that its safe for me to go home right now. Fascinating.
 
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Deidra said:
Fascinating
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Indeed
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Deidra said:
No I do have them, warfarin and other stuff. Doesn't include aspirin.
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the system over there clearly deems aspirin as unnecessary ... given your low INR (just shaking my head at that still) I would say yes!
I personally go for whatever size the supermarket sells (its all the same) and take half a tablet. For you I'd take that half a tablet daily until you're in range. Then I'd perhaps make that half every two days (I can explain why if you you want).

but really, you want INR to be over 2 as a priority. Lets see if they bumble along like they did for poor Seaton.

please do keep following up on this situation; but Keith the Moravian Swearing bear just says
1715718538463.png


I'm still in some sort of shock at the perpetual problem that doesn't ever get addressed (at least in the last 12 years of me being on this forum).
 
In more detail now that I'm before a PC and with a coffee

Deidra said:
My INR was hanging around 1.3 while I was on a 2.5mg dose for 3 days after I got out of the ICU. (Obviously they've had me on heparin shots since the surgery.)
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well there should have been a time when you were not on heparin in the ICU because we need coagulation at those times...

Deidra said:
They finally bumped the Warfarin dose to 5mg last night and today my INR is 1.59.
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dopes, 5 should have been the starting dose ...

Deidra said:
They said this is good enough to discharge, which don't get me wrong I definitely want to do,
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I see your reasons, but that "good enough" is not my understanding of "proper protocols" but then who cares about the patient? Certainly not them.
Deidra said:
But I am worried about my INR being kind of low.
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concerned is the more appropriate level IMO

Deidra said:
I know it's an On-X valve and so technically speaking its in range,
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frankly bullshit and not its not even technically speaking "in range"

Deidra said:
My cardiologist and I spoke before the surgery and she said she agrees and also wants me in that range [2~3]as the range [the target is 2.5]
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I ammended a few points and I agree with your Cardio (hospital needs a solid spanking ...


Deidra said:
This was a while ago, and shes not the one managing my discharge though.
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they never are
Deidra said:
Do you have any advice here?
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increase your INR to 2.5 as a priority.

Deidra said:
Edit edit: The cardiologist thats been working with my discharge came in and said the heparin shots i've been getting aren't at a therapeutic level for the valve actually (?), and they do want me at 2-3 INR for the first few months anyway, but the surgeon feels that its safe for me to go home right now. Fascinating.
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safe in that there is no imminent threat, but "safe" is a bad word for them to have used without proper clarity. Its ok because you're here with other valvers, but imagine some poor sap getting released into the wild?

The post hospital release scene from The Wrestler has always made me cringe.
 
Deidra said:
Hey all!

I just had my aortic valve and root replaced with an On-X mechanical prosthesis on May 8th.

My INR was hanging around 1.3 while I was on a 2.5mg dose for 3 days after I got out of the ICU. (Obviously they've had me on heparin shots since the surgery.) They finally bumped the Warfarin dose to 5mg last night and today my INR is 1.59.
Click to expand...


Deidra said:
Your INR is going in the right direction, 1.3 to 1.59. Doubling your dose from 2.5mg to 5mg last nite should show up in your INR in another couple of days. So long as your INR keeps increasing and by testing every few days you should be OK. Testing INR every day is kinda a waste of time and money.......it takes warfarin a couple days to metabolize.
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I also recall being discharged after surgery my INR being under 2.0, think it was like 1.6 or 1.8 and it took a few days to a week or so to get it in range.
Be aware also over the coming weeks/months generally your dose will need to increase as your body seems to ‘get used to’ warfarin. I left hospital on 5mg daily and have been anywhere from 8mg to 12 mg daily over the last 9 years.
I have a coaguchek and manage my dosing 100% myself and wouldn’t have it any other way.
I also was discharged on 100mg daily aspirin which iv stuck with, with no issues.
 
Warrick said:
I also recall being discharged after surgery my INR being under 2.0, think it was like 1.6 or 1.8 and it took a few days to a week or so to get it in range
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Its a good time to mention others

https://www.valvereplacement.org/threads/how-scared-should-i-be.888016/

PS: since we're talking about this, and keeping in mind that I'm not a doctor, I have occasionally wondered about the "protocol" of not discharging a patient until they are over INR = 2

Some points that come to mind (these are not answers, but questions and perhaps I'll research these in the morning)
  • why the rush? I mean is it evidence based or just done because at least we can let them go knowing they're on the right path
  • should not the INR clinic be able to manage that (cites a recent thread showing how long it takes sometimes)
  • is it to send a message to the patient (psychology)
  • I expect starting ACT is all a juggling act with trade-offs; too soon and you may set the grounds for para-valvular leaks (or other issues) too late and you may get greater thrombosis formation on the scar?
There are a few other possibilities, but at the end of the day it would seem to me a few more days (meaning for you @Deidra ) probably won't make any significant difference.
 
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Thanks for the update Deidra.

I'm glad to see that they were agressive in adjusting you from 2.5mg to 5mg. Too often, it seems, they don't increase sufficiently and patients often end up spending much more time below range than they should following surgery.

If I am understanding the dosing that they have given you, you were at 2.5mg on Friday, Saturday and Sunday. Tested Sunday at 1.3. Monday they moved you to 5mg and Tuesday you tested at INR of 1.59. That is a decent bump after just one day following the increased dosage. By Thursday's INR draw, you will have been at 5mg for Monday, Tues and Wednesday, and I would expect you'll see a decent increase from 1.59 by then.

I'm not sure how I feel about releasing patients when they are not yet in range. It certainly seems questionable when the patient is at 1.1 to 1.3, which we have seen several times with some of our members. Yours was 1.59 and climbing, so I think that your situation was not too bad. Maybe testing where your INR was at after 2 days at 5mg dosing before release would have been a little more conservative. My target INR after surgery was 3.0. My INR was checked daily in the hospital, which I believe is standard, and I was right on target for 3 consecutive days before release with an INR between 2.9 to 3.1 on each of those days. Whether they would have released me if I was below range, I really don't know. I imagine that the thinking is that the clinic can manage you just as well at home as they can in the hosptital. However, one advantage of being in the hospital is the ease of completing daily testing.

I'm also glad that they're testing you just a couple of days after release. Often times we are loaded up with several new medications upon release and that can affect INR in either direction, so I'm in the camp of frequent testing after surgery and upon release, until things stabilize.

Please let us know what Thursday's INR results show.
 
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