My first glitch post surgery is with ACT

[Fast Eddie]

Of course, everything SEEMED to be going swell (and it probably is), but there's a glitch.

They gave me te On-X valve during surgery. Leading up to discharge, I was on Heparin until the day of discharge. At that point I believe my INR was 1.8. Which is I think low for the On-X in aortic position. I think it's range is 2.0 - 3.0 in aortic position. I HAVE to believe, though, that they wold not have discharged me if they were uncomfortable with my INR that low.

But now my primary care doc is managaing the Coumadin, and he called and HE'S not comfortable with me going into the long weekend with that low an INR. He is suggesting bridging with Lovenox until the INR is higher.

But of course the surgeon's office doesn't want to hear about Lovenox with a mechanical valve.

So right now I'm stuck in the middle. I had the surgeon's office contact my PCP to try and sort this out.

I expected to eventually have to deal with the whole Lovenox issue eventually, I just wasn't anticipating it this soon!

This should all be sorted out by tomorrow or the next day as the Coumadin level builds.

Fast Eddie

 

[WayneGM]

Sorry to hear about the glitch, although hopefully it's not a big glitch. I'm sure the Surgeon and PCP will work it out. As I understand it, I think the Surgeon usually prevails on post-op care matters. Good luck.

 

[briansmom]

FWIW, my son's docs are also not concerned with an INR that low. In fact they are saying to keep his INR between 1.8-2.5. I am striving to keep it on the high side. My son also has an On-X valve.

 

[Ross]

1.8 isn't anything to get ragged about. The next test could prove to be higher, even if tested the same day. In any event, how many mg's are you taking per day? Any other meds? Increasing the dose by 10% over the week should put right where you need to be, but bare in mind, as your activity level increases, your INR will drop, needing more adjustment.

 

[ALCapshaw2]

You said your surgeon is uncomfortable using Lovenox with a Mechanical Valve??? HUH? Bridging (with either Lovenox or IV Heparin) IS the usual protocol. Sounds like "A Failure to Communicate" to me!

Are you aware of the studies being conducted with On-X Valve Recipients? One of them has Low Risk (Aortic Valve Replacement patients with NO other heart / medical issues) taking ONLY Aspirin or Plavix for anti-coagulation.

The other study has slightly higher risk patients using anti-coagulation (Coumadin) but at lower levels than is normally specified for 'other' mechanical valves.

Bottom Line: An INR of 1.8 with an On-X Valve in the Aortic Position is "Probably" not a concern, especially if your INR is still rising. On the other hand, I can understand physicians being a little concerned, especially right after surgery. Then again, by taking Lovenox injections right after surgery, there is slightly higher risk of a bleeding event. Bridging is "so much fun". When are you scheduled for another INR check?

'AL Capshaw'

 

[geebee]

Have they increased your coumadin dose since your last INR test? Also, when was the last test?

I, too, am confused about a surgeon who is uncomfortable with using Lovenox with a mechanical valve. That is one of the primary reasons for needing Lovenox. There must be some more to the story.

I would get another test if it has been more than a couple of days since the last one and just see where you are.

 

[Natanni]

My husband was discharged @ 4 days post AVR w/Carbomedics (and post of A fib ) with an INR of 1.8. If I remember correctly, I believe he dropped to 1.6 when I called the PAC begging for Lovenox. The surgeon said no need even when the PAC thought it would be a good idea. I am completely confident that there are posts here to the anticoagulation board from those exact days. I understand being frustated for having to wait! Can you get your INR checked at all over the w/e?

 

[Fast Eddie]

AL::
You said your surgeon is uncomfortable using Lovenox with a Mechanical Valve??? HUH? Bridging (with either Lovenox or IV Heparin) IS the usual protocol. Sounds like "A Failure to Communicate" to me!
Turns out what they were saying was that they were more concerned about bleeding along the suture lines of the aneurysm graft than the risk of an embolism. Also my PCP did not seem to remember that the On-X valve was the one used.

Are you aware of the studies being conducted with On-X Valve Recipients? One of them has Low Risk (Aortic Valve Replacement patients with NO other heart / medical issues) taking ONLY Aspirin or Plavix for anti-coagulation.
Yes, I am aware of the trial. I will be awaiting he final outcome most eagerly! I could not get into the Plavix+aspirin group, though. I believe my right atrium was 1 mm too large! I might have gotten into the lower Coumadin level group, but as I understood it, I would have been randomized into either the lower or b\normal Coumadin groups. So at this point I'm not part of the trial. I will be discussing this more when I see the surgeon in 3 weeks or so.

Bottom Line: An INR of 1.8 with an On-X Valve in the Aortic Position is "Probably" not a concern, especially if your INR is still rising. On the other hand, I can understand physicians being a little concerned, especially right after surgery. Then again, by taking Lovenox injections right after surgery, there is slightly higher risk of a bleeding event. Bridging is "so much fun". When are you scheduled for another INR check?

Seems that my INR after this morning's draw was 2.8 anyway. I am on 7.5 mg of Coumadin at this point. Next draw will be Tuesday or Wednesday.

Ross::
1.8 isn't anything to get ragged about. The next test could prove to be higher, even if tested the same day. In any event, how many mg's are you taking per day? Any other meds? Increasing the dose by 10% over the week should put right where you need to be, but bare in mind, as your activity level increases, your INR will drop, needing more adjustment.
As I mentioned above, today's INR was 2.8. I'm at 7.5 mg per day now. There are some other meds, including Metoprolol, Lipitor and a few others I can't recall right now.

So it'll be interesting to see how my PCP does at managing the dosage. Might have to buy Al Lodwick's book at some point.

 

[ALCapshaw2]

Eddie wrote: "So it'll be interesting to see how my PCP does at managing the dosage. Might have to buy Al Lodwick's book at some point."

I recommend that you buy Al Lodwick's DOSING GUIDE right NOW ($5) and give a copy to your PCP (and anybody else who might be interested in your INR management).

Yep, you have just witnessed the 'Balancing Act' between Bleeding Risk and Stroke Risk that ACT patients go through for Each and Every 'Invasive Procedure'. Welcome to the Club !

'AL Capshaw'

 

[Ross]

As I mentioned above, today's INR was 2.8. I'm at 7.5 mg per day now. There are some other meds, including Metoprolol, Lipitor and a few others I can't recall right now.

So it'll be interesting to see how my PCP does at managing the dosage. Might have to buy Al Lodwick's book at some point.

How many doses have you had? 7 full days worth? If so, one more test should tell the story and he/they should hold your dose where it is for now.

 

[Fast Eddie]

How many doses have you had? 7 full days worth? If so, one more test should tell the story and he/they should hold your dose where it is for now.

Ross

I THINK it's been at least 1 full week. I'm a bit fuzzy on when they started the Coumadin, but I'm pretty sure it's a full week or more. I am holding the dosage at 7.5 for now, and the next draw is Wednesday.

I'm hopeful this will be a straightforward process. Seems to me the key will be making my diet consistent, at least as far as Vit K is concerned. Consistent diet has never been my hallmark, which is why I also have always battled with weight. So now with having to make my diet Coumadin friendly, it may actually be EASIER for me to maintain my current healthy weight. It's an expensive, Draconian diet plan, though!

Eddie

 

[Ross]

Eddie let you in on a little secret, don't worry too much about the diet. Eat whatever you normally eat and like, in the amounts your normally do. If an adjustment is needed, which most likely it won't, it can be done easily. I'm not consistent at all and mine stays pretty solid.

Don't make your diet Coumadin friendly, Make Coumadin diet friendly. Don't diet the dose your on, but rather, dose the diet you eat.

Too many people fall for that "I can't have greens or things I like" routine and it's all bull crap.

And for Gods sakes, whatever you do, don't start trying to measure the amount of Vit K you eat in each and every meal. It doesn't work and only serves to drive you insane. Forget the Coumadin Cookbook, forget Vit K charts and just eat like you always have.

 

[geebee]

Eddie,

I will echo what Ross said - eat what you want. The problem that could come from Vit K. is if you never eat greens and then binge on POUNDS of such things. You would probably get sick before you could eat enough to really make a difference.

I always eat what I want without worrying about Vit. K content. The past few days I have been eating the most wonderful asparagus in the world because a dear friend sent me some from his farm. I just tested for the week and everything is spot on.

Please don't alter your lifestyle due to coumadin - there really is no need.

 

[dick0236]

Eddie...I echo what Ross and Gina say. I use a little common sense in watching my vit K intake, but I have never tried to diet around vit K. I eat healthy and eat what I want when I want it. Over the past several weeks my INR has slowly trended down to 2.4, probably due to increase in outdoor activity. I uped my dosage 2.5mg/wk (35mg to 37.5mg) and probably that will reverse the INR down trend. It is a lot easier to peridically adjust "the pill" than make wholesale change is lifestyle. For me it is most important to dose as prescribed, monitor regularly and adjust by small changes if necessary.

 

[Ross]

Basically so long as you don't make the mistake of eating something loaded with Vit K and LOTS of it on a binge, you'll be just fine with your normal diet. I'm saying something like sitting down and eating a whole bag of brussel sprouts, unless you do this everyday, or a bag of spinich, broccoli, etc.

When I eat brussels, if you pay attention to the Vit K content, you would only eat 5. Not me pal, 11 or more. Hopefully you get the jest of what I'm saying here.

Be sure to check out Al Lodwicks site too. www.warfarinfo.com especially these next two links
http://www.warfarinfo.com/outrageous.htm

http://www.warfarinfo.com/faq.htm

You cannot eat green vegetables while taking warfarin. Does this person think that no vegetarian ever took warfarin. The more vegetables you eat, the higher your warfarin dose will need to be because you will be taking in more vitamin K which is the antagonist of warfarin, but so what. Don't you need to eat a healthy diet?

You cannot eat anything green -- not even green Jell-o or jelly beans. Millions of kids would be dancing in the streets if Jell-o and jelly beans were suddenly declared vegetables.

 

[Fast Eddie]

Thanks for the comments

Thanks for the comments

Thanks to all of you for your comments on diet. I guess when I talked about changing diet to be 'Coumadin friendly' I didn't express myself very well. I think I understand that I need to arrange the Coumadin dosage around my diet.

I have always struggled with weight problems because of not paying a lot of attention to what/how much of certain foods I was eating. Luckily for me, at the time of surgery I was just coming off a medically supervised diet that allowed me to lose about 45 pounds. I have done this program before, which means I never REALLY adopted their methods as part of my lifestyle. Having this valve in place AND having to deal with Coumadin will, I think, allow me to more easily really change my eating habits in a way that will both help me maintain my current svelte 157 lb weight AND give me a more consistent diet so I can make the Coumadin management easier.

At first I expect I will be overly cautious with Vit K foods, but as I gain experience with the levels, I would bet I'll become a bit more lax.

So bottom line I think what you are all saying is exactly right: work the Coumadin around the diet. Except for me I want to take this as a good opportunity to make my diet a more healthy one in the first place!

Thanks again

Fast Eddie

 

[Ross]

Just remember it's binging on high content Vit k stuff that shows up. Not your normal everyday amounts. I'm fairly certain, unless you went to an all vegetarian diet, that your INR won't change or change very little with the diet you want to work with.