1.3 INR- AGAIN- lOVENOX?

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D

denobobeno

Ongoing saga of my INR..
I was at 2.7 on Monday, I went in at 3:30 on Thursday and I was down to 1.3. They checked it on two machines..
I don't know what to do.. about two weeks ago my INR was also at 1.3.:eek: My Cardiologist didn't order Lovenox...I just stayed on Coumadin..10 days later I had a TIA (as thought by my Primary Care Doctor) I hadn't felt like that since my stroke July 26..so I think that is probably correct. Anyway, my Primary Care had mentioned when I went in with the TIA that HE would have put me on Lovenox injections when my INR was 1.3 and was a little concerned.
When my INR was 1.3 again yesterday I had the Coumadin Clinic call my Primary Care and ask what I should do...he told them to have me come by and pick up a RX for Lovenox to begin immediately. I did. I started the injections last night and this morning I even gave my own..no problem..but, my Cardiologist is now upset because he feels like my Primary Care is not doing the right thing, he called my Primary and basically told him to butt out and now he wants me off the Lovenox.... my Cardiologist also wants me to go to the Coumadin Clinic and get my INR checked after being on the Lovenox and see how it has affected it.
I'm not sure how Lovenox works..will it show up immediately?? :confused: I don't kow what to do.. I really like my Primary and trust him. I'm not so sure about my Cardiologist. :confused:
WHAT SHOULD I DO??????? your thoughts are invaluable to me as I try to make these decisions.
Sorry it is so long and complicated.
Deana
 
If I had a previous stroke and a tia and was now at 1.3. I would continue with lovenox no matter who says what until i got to 2-2.5. I may also think about keeping inr at higher end of range.

i may be wrong, but dont think lovenox affects inr
 
Lovenox does not show up on an INR!! And this was your cardio that want to check your INR to see what the Lovenox was doing??????

Your Cardio is playing with your life. I would continue with your PC doc until you find a new cardio. If it were me, I would not stop the Lovenox until I was in range.

I don't understand how your INR can go from 2.7 to 1.3 in 3 days without missing doses. Have you been on antibiotics? Have you started a new medication or vitamins or other suppliments? Are you consuming prepackaged meals or drinks? (Soy protein is a huge content of many weight management products. Soy is rich in Vit K.) Protein bars? Meal replacement bars? Instant Breakfast, Slim Fast or other such drinks? Peppermint tea or other green teas? Ginsing? (A friend of mine gave me some lovely home grown peppermint for tea. It was so tasty. I didn't stop to think that I was basically giving myself a nice big infusion of Vit K! My INR went really low.) Lots of V8?
 
Deanna too many weird readings are coming out of this place your going to. As Karlynn points out, how could it drop that dramatically without a cause? You have been telling us everything, right?

Your PCP is correct in giving you the Lovenox, but Cardio is incorrect in checking INR unless your misunderstanding them and they mean continue your Coumadin and come in for another test to see where you are. Lovenox does not show up in an INR test.

You'd have to be self ingesting a ton of Vit K to get it to drop like that or miss doses completely. Something is certainly not right in Denmark here.
 
I hate to say it..but, I truly believe my Cardiologist doesn't understand Coumadin. I DID go in today like he asked to have it checked and I was still at 1.4. (of course).
He had called me first thing this morning and wanted my husband and I to come in to see him... I asked him if we could do this over the phone...he made a huge deal over he was afraid that I could bleed internally and he was very concerned, he said he was more worried about me bleeding from the brain. I had red flags go up..he doesn't know about me, valve replacement, or coumadin. I'm sorry but, I'm so frustrated with him. He has a huge ego and absolutely hated me going to my Primary for my TIA. I told him that is what my Neurologist asked me to do. He said I should have called him instead. I told him I had a TIA and he basically told me it was all my imagination. I explained to him it felt very similar to my stroke and I hadn't had that sensation since I've been home for four months.. I think he just doesn't want to admit that he possibly could have caused this by not starting me on Lovenox before it happened ( the last time I was at 1.3).
I probably don't make any sense but, I'm rambling because I'm so frustrated ( and a little mad, this is my life!)
I had eaten a salad every night for supper this week....I asked the guy at the Coumadin Clinic if I could eat more salads and he thought it was okay since my Coumadin was at 2.8 Monday. I have him baffled and myself baffled. I can't think of anything except greens that would have caused this.. Maybe that was enough. I kinda think it must be it. Maybe I was crazy to have eaten salad, but, I'm craving salad so bad. Is it better to not eat salads? Other than that I can't think of anything..
After all that drama.. my Cardiologist thought it was a good idea for me to be on Lovenox after he saw my INR was at 1.4. My husband said (laughingly) It's because now he thinks it was his idea instead of my Primary's.
I appreciate your help. I didn't realize that Lovenox wouldn't affect my INR. interesting I had to learn that from you guys isn't it.
Thanks and any more info you have is always appreciated
Deana
 
Deana

Deana

what type lettuce do you use in your salads ...and other veggies? and what type..dressing?.......I don't think that is what cause your INR to drop..but just curious? bonnie
 
Your PCP is giving you GOOD advice.

You TRUST your PCP.

ASK your PCP for a referal to ANOTHER Cardiologist ASAP.

What you are relaying about his recommendations for dealing with Low INR sounds DANGEROUS to me.

'AL Capshaw'
 
Did you have a hemorrhagic stroke? Or did you have a clotting stroke?

Joe had a hemorrhagic stroke while on IV Heparin. They are now keeping his INR lower than ordinary, but still in the 2.0 range. It's not ideal, since he has two mechanicals, but having another brain bleed is not ideal either. And Joe can never use Lovenox or Fragmin, and now, I guess Heparin, since it causes him to bleed.

And he is not a candidate for changing out his valves to tissue valves.

There was a great deal of discussion among the doctors treating him as to what the target range should be. No one knew what the right thing to do was, and they even told me that. They told me that it would have to be something that was done carefully, and that there were no good answers.
 
Deana dose the diet you eat, don't diet the dose of the drug. If you like salads that much, do it consistently and adjust for it, likewise with Greens and other vegetables. Stay as consistent as you possibly can. Once you find someone, even if it turns out to be yourself, that manages your Coumadin properly, this will all go away and it'll seem so simple.
 
Karlynn said:
Lovenox does not show up on an INR!! And this was your cardio that want to check your INR to see what the Lovenox was doing??????

Your Cardio is playing with your life. I would continue with your PC doc until you find a new cardio. If it were me, I would not stop the Lovenox until I was in range.

I don't understand how your INR can go from 2.7 to 1.3 in 3 days without missing doses. Have you been on antibiotics? Have you started a new medication or vitamins or other suppliments? Are you consuming prepackaged meals or drinks? (Soy protein is a huge content of many weight management products. Soy is rich in Vit K.) Protein bars? Meal replacement bars? Instant Breakfast, Slim Fast or other such drinks? Peppermint tea or other green teas? Ginsing? (A friend of mine gave me some lovely home grown peppermint for tea. It was so tasty. I didn't stop to think that I was basically giving myself a nice big infusion of Vit K! My INR went really low.) Lots of V8?
Click to expand...


Great Job Karilyn. What great advice, covered all the bases and then some.
 
I don't eat any lean cuisines or eat any specialy bars... or drink Slim Fast..can't think of anything on your list except..
One thing that I changed or my Dr changed was after my TIA a week ago I began taking 10 mg of Altace instead of 5mg. (my blood pressure had been running too high so we went up) Would that just now be catching up with me?
I had been on an antibiotic but, had stopped about a week ago too. Maybe it was all these together?
Another thing, my Cardiologist also told me he didn't believe in home testing,:mad: that none of his patients home test and that I would only run into more trouble. He said he would not write a RX for a home tester! I applied for one 3 weeks ago and so I hope he hasn't held me up this whole time! I need to get one before we go on a cruise the end of Dec. for a seven night cruise. I've never been on a Cruise before and I would just feel better having more control over my Coumadin while on board.. what if I threw up or something I think it would be to my advantage to be able to test if I see fit. I've already had the dreaded stroke..I'm not willing to take chances even if he is!
He said that I WOULD not need to test and I don't need it for the cruise.
He (I think) is very backward in his thinking.
My husband and I talked tonight and in light of everything..I am going to ask my PC to refer me to another Cardiologist. I want to self test and manage my own Coumadin with the help of my PC. I just know I can do a better job if I educate myself.
Thanks,
Deana

Granbonny, I eat iceberg, and romaine lettuce with Balsamic Vinegar and Olive Oil.. I eat all veggies but, If I'm having a salad then I just eat mostly protein with my salad, or of course..Tex-mex. It's my fav!
Nancy, I had a stroke because of a blood clot on my valve..from my INR being too low. Then a Lovenox injection released it and I had a stroke.
 
Two words to this Cardio, "Your Fired". He's not looking out for your best interests, he's looking out for his own.
 
After reading your last post, I agree, fire the SOB and find someone who knows what they are doing. There are too many good cardiologists to put up with this kind of incompetence.
 
Cardiologist does not equal warfarin expert.

There is about a 99% chance that what is causing your fluctuating INRs is going in your mouth.

You need to keep close track. You said "antibiotic" for example. You need to know which antibiotic and what days you took it in relationship to your warfarin dosage changes. You just got a big lesson in being proactive.
 
Blood Studies

Blood Studies

You might want to request hypercoagualability studies to see if there are any abnormalities with your blood clotting.

My husband has had these studies, and I wanted to mention that if suppression of proteins C and S are mentioned in the report, that is an expected affect of coumadin (some physicians may not be aware and think it is the patient's problem!). I looked for a link that mentions this and found the following - no doubt there are others.

http://www.emedicine.com/emerg/topic872.htm

As we all know, stroke and TIA are to be avoided at all costs. Be agressive in finding the help you need.

Best wishes as you search for help,
Arlyss
 
Hypercoagulability hardly ever causes fluctuations in the INR. The things that usually cause fluctuations in the INR are:
1. Variations of what you put in your mouth
2. Variations in the amount of exercise you get
3. Antiphospholipid antibody syndrome including lupus anticoagulant
4. Budd-Chiari Syndrome - a blood clot that is in the blood vessel leading away from the liver

Probably 95% are related to #1, 4% related to #2, so that leaves 1% to #3 & 4.

Anything else would really be a long shot.

Read every label of everything that goes in your mouth. You will be very surprised at what contains vitamin K.

Rather than getting expensive tests done, that are most likely to turn up negative, keeping a month-long diary of EVERYTHING that you put in your mouth is usually the fastest and cheapest as well as the most definitive way to solve the problem.
 
I want to thank Al Lodwick for adding so many helpful details regarding what impacts the INR. The blood is so complex, including various factors and drugs that are not reflected in the INR.

I looked at Deana's profile, and she does not mention the reason for her AVR, but at the age of 45, I am wondering if she had a bicuspid aortic valve? Some bicuspid individuals can be very complex - I know two bicuspid women with rather rare blood disorders that were not easily diagnosed, so I am always a little suspicious of BAVs.

In reading Deana's profile, she had a stroke two weeks post op, so her problems began very early, and they are continuing. The difficulties she is having seem beyond what is typical/normal after AVR.

In over 16 years on coumadin, it has generally not been this difficult for my husband. He did fluctuate more the first months following his surgeries, then his readings became very stable. The fluctuation in his anticoagulation primarily correlated with the healing process following his surgeries. A reasonable diet, antibiotics, blood pressure medications have not been problematic. Although he has a tissue valve now, he continues on both low-dose coumadin and plavix at this time, in an abundance of caution to avoid any more embolic material reaching his brain. It also may be that the blood makes its way to some constricted areas of his brain more easily with "thinner", more "slippery" blood - actually Plavix and coumadin work differently - but with both drugs trying to prevent even tiny clots or "micro emboli" from forming, which is important for him. Following what he experienced in the last year, he cannot afford any more brain injury at all.

I do wish you all the best, Deanna, in finding help,
Arlyss
 
I should add that the major stroke my husband had almost a year ago now did impact his anticoagulation signficantly. He had been very stable until that happened, and I can only think that his entire body experienced tremendous change at that time. I remember one day in the hospital, he was checked 3 times - one of the readings was very different, and I suspect that may have been an error, so there was a need to check it once more. His INR was checked every day for many weeks. (It was run higher, trying to protect him until the valve could be removed.) Again, I can only correlate it with the tremendous changes his body went though then.

Nancy, you and Joe are facing many challenges dealing with maintaining this delicate balance - too much anticoagulant or too little can both be problems regarding injury to the brain. I do feel for you both.

In thinking about an approach when there are problems, and having various laboratory tests versus the practical side of keeping strict notes about diet, etc., if it were my own body, I would do both. If I am like a majority of the population, it is very possible that just staying on top of my diet and medications might resolve the issue. But, I may be one of the few who is different, and finding a specialist to put me through various tests might be extremely important.

Today, I live with the realization that there was one test that could have discovered the strands on my husband's valve and prevented his stroke, but its value was just not understood at that time. (This past week another man, advised to have that test based on what happened to my husband, has had his valve removed. Multiple major centers that were consulted agreed with that decision - so, knowledge is beginning to emerge and prevent this from happening to others.)

Aortic aneurysm vicitms might have been saved if a CT scan and accurate interpretation of the images had been done. No one realized how important it was in these people, who often are tested for heart disease/heart attack, and then told it is anxiety.

And so I have become an advocate of looking into things thoroughly via testing, especially when the circumstances do not seem to fit the "norm" and the testing does no harm.


Best wishes,
Arlyss
 
There is no doubt that a major stroke places major stresses on the body and that those stresses cause changes in the INR.

Consider:
Probably not eating well - being given a (different) vitamin
Possibly not being able to swallow - tube feeds have fiber that binds warfarin and keeps it from being absorbed, and are loaded with vitamin K.
Not being able to carry on daily activities due to paralysis - leads to high INR.
The INR being checked often and possibly getting a false reading causing uncertainty about what warfarin dose to give. Possibly an inexperienced warfarin-dosing person basing changes on yesterday's dose rather than looking at what he got over the past week.

All of these things fit Arlyss' idea that there was stress on her husband. However, they also fit perfectly into my theory that it is almost always what goes into the mouth or affects the activity level.

The blood is not flowing better because it is thinner or more slippery - it is flowing better because it is less likely to clot.

As for testing, it can do harm. If someone was tested for protein C or S deficiency they should have either been off warfarin or not had the test done. If you are off warfarin then there is the risk of stroke. If you have an unnecessary test done then it reflects it next year's insurance or Medicare payment. Condiser that if everyone had $1000 worth of unnecessary tests done, then next year everyone would pay $1000 more for health insurance to make up for the loss.
 
Al's helpful comments give rise to further thoughts/questions about the experience of patients on coumdain after valve replacement surgery, when their activity levels, appetite/diet, medications, etc. also are all very impacted. I am wondering how many of them have the types of complications that Deana has experienced, and if there is sufficient understanding to help them avoid it. It would be so much better to anticipate and possibly prevent in those who are vulnerable.

I was just reading Sherrin's thread, and it is clear that she is at high risk of stroke - because of her history. It would be so much better if Sherrin didn't have to experience that history in order to establish that she is at risk, apparently more than some others.

Just to clarify, my husband's stroke was not caused by the typcial blood clot forming and reaching the brain. Fortunately, at the time of his stroke, his INR had been measured the day before and was in proper range, and remained so when checked in the ER. Otherwise, improper anticoagulation would have been considered the most likely suspect in someone with a mechanical aortic valve. (There is so little understanding about valvular strands that anything that is postulated about these strands is highly speculative at best. It took evaluation at a major center to find the cause of his stroke - initially there was no explanation.) Being on coumadin added complexity to his post-stroke experience, however.

From an economic stand point, unnecessary testing does inflate costs. But the cost of not doing a test that is needed (and properly interpreting the results) can be tremendous both in economic terms and in human suffering. I have learned to question whether it is always known what test is needed or could be helpful. Whether or not expertise in hematology or another specialty can help some of these situations involving heart valve patients, I do not know. But asking the question is important.

Stroke is the leading cause of disability in this country. I have learned some lessons about economics once a stroke has occured. I hope for their sake that those dealing with heart valve issues can proactively be protected from experiencing injury to their brain.

Best wishes,
Arlyss
 
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