Lovenox and My Dad

[jojofromct]

Well, some of you know my fathers history, some dont, real quick I can break it down. My father had a stroke 12 years ago due to a blood condition - thick blood there is a name for it, its pretty long, he has been on Warafin for 12 years, is INR is almost always good.

A year and a half ago at his yearly visit to the cardio, he was told his valve has worsened, since his stroke he has been seen by the cardio for a leaky valve, I believe the aortic.

So since a year and a half ago he has been having EKGs and stress test every 6 months. The cardio was surprised my father was still working and not having many symptoms. My parents decided after a year of this to get a 2nd opinion. That cardio also suggested the valve probably will need to be placed within in the year.

So my parents had an appt with the first original cardio this week...AND the cardio is still surprised my father is doing ok, besides always be tired...he works 60 hours a week and of course being tired is a symptom. He has no other symptoms. The cardio suggested they do a cath to check the valve and its happening THIS coming Friday. So, tomorrow night my father is to stop the Warafin, and Monday night he will have his INR checked at the Coumdin Center. Tuesday I believe he is to start the LOVENOX injections at home. My father has a heart procedure done 12 years ago to stop palputations and I remember he ended up with clots in his legs. That was 12 years ago, he didnt have any injections at home. I am thinking positive about this, He will be closely monitored all week before the cath is done Friday. They have a good team looking after my Dad. AND the 2nd opinion cardio is doing the cath too.

They are doing this to see how bad the valve really is. I guess it can two ways, the valve is not ready to be replaced just yet or its time.

I am of course very nervous, so are my parents but we are really trying to stay positive. My father is 62 years old and in pretty decent health and physically strong. I am just nervous.

Anyone ever taken lovenox before a procedure or even open heart surgery?

 

[tobagotwo]

Lovenox is a low-molecular-weight heparin. Lovenox also keeps bloodclots from forming, and is the standard "bridging" product for those on AntiCoagulation Therapy (ACT) in the US.

Heparin and warfarin (Coumadin) have somewhat different means of creating a non-clotting environment, but both are highly effective. The main downfalls of Lovenox are that it has to be given by injection and that it has a much shorter span of activity in the body.

However, the useful thing about heparins is that their action can be turned off almost instantly with other, counter-drugs. It takes much longer to counteract warfarin. So if there were a requirement to stop some critical bleeding very quickly, it can be accomplished much more readily with heparin. This is why it's used for operations on those who are normally on anticoagulants.

Lovenox is not the type of heparin that's been in the news for contamination lately, so you shouldn't be concerned with that.

Best wishes,

 

[jojofromct]

Bob - thanks for the good info - very informaive. I come on this site before I even google anything. I have learned more on here than anywhere else. A lot of special people on here. Thanks again.

 

[Phyllis]

Your father will be in my thoughts and prayers on Friday. Be sure to check back and let us know how it went!

 

[jojofromct]

Thanks Phyllis. We are all worried about the HIGH risk for the open heart surgery with his blood condition. I do believe it will all work out.

 

[Bina]

JoJo, have faith in your Dad's doctors and get back to us soon with good news!

 

[jojofromct]

thanks Bina

 

[ALCapshaw2]

Lovenox is a low-molecular-weight heparin. Lovenox also keeps bloodclots from forming, and is the standard "bridging" product for those on AntiCoagulation Therapy (ACT) in the US.

Heparin and warfarin (Coumadin) have somewhat different means of creating a non-clotting environment, but both are highly effective. The main downfalls of Lovenox are that it has to be given by injection and that it has a much shorter span of activity in the body.

However, the useful thing about heparins is that their action can be turned off almost instantly with other, counter-drugs. It takes much longer to counteract warfarin. So if there were a requirement to stop some critical bleeding very quickly, it can be accomplished much more readily with heparin. This is why it's used for operations on those who are normally on anticoagulants.

Lovenox is not the type of heparin that's been in the news for contamination lately, so you shouldn't be concerned with that.

Best wishes,

It is MY understanding that Heparin can be reversed with other medications but LOVENOX can NOT be reversed, it just has to run it's (short) course (12 hours...or so)

JoJo -

I'm glad to see that your Father's Cardiologist is using Bridging to minimize his clot / stroke risk. Good Move.

When I asked several surgeons about their protocol for Bridging for Open Heart SURGERY, I got 3 different answers.

Some use NO Bridging,
Some Bridge BEFORE but NOT After
Others Bridge Before and After, balancing the Bleeding Risk vs. the Stroke Risk when deciding exactly when to resume Lovenox (or Heparin) following Surgery.

That said, I went through a Heart Cath using Lovenox Bridging before and after.

I'm pretty sure the Lovenox was discontinued 24 hours Before the Cath (as opposed to 12 hours for lesser procedures).

AFTER the procedure, my Nurse gave me Coumadin the night of the procedure (i.e. 8 hours after the cath) but NO Lovenox.

The next day I had to threaten to "raise the roof" to get a Lovenox Injection. My Nurse said "but you already took your Coumadin" DUH! Obviously this Nurse had NO CLUE that it takes 3 or 4 DAYS for Coumadin to be fully metabolized. My Coumadin Clinic agreed with me (I called them from the Hospital and one of their Nurses came to the Hospital), BUT the Hospital Nurse still refused to give me Lovenox (i.e. they ignored the recommendation of the Coumadin Clinic Nurse).

FINALLY the Hospital Nurse called my Cardiologist who ordered that Lovenix be given (24 hours post cath).

Obviously there was a "Failure to Communicate" and no continuity of care from ER to Cath Lab to Hospital Admission (3 different Cardiologists involved... apparently they all *assumed* that "someone else" was in charge).

Bottom Line: MY current thinking on Bridging is to Stop 24 Hours Before the Procedure, and Resume 24 hours After the procedure. (There have been some bleeding incidents reported here on VR.com when Lovenox is given before 24 hours post procedure). Continue Lovenox Injections (or Heparin drip) along with Coumadin until INR is 'in range' (i.e. within his Cardiologist's recommended range).

Note that Lovenox (and Heparin) work on a Different Part of the Coagulation Process and do NOT show up in the INR test results which only reflects the anti-coagulation level due to Coumadin / Warfarin.

'AL Capshaw'

 

[Ross]

Bottom Line: MY current thinking on Bridging is to Stop 24 Hours Before the Procedure, and Resume 24 hours After the procedure. (There have been some bleeding incidents reported here on VR.com when Lovenox is given before 24 hours post procedure). Continue Lovenox Injections (or Heparin drip) along with Coumadin until INR is 'in range' (i.e. within his Cardiologist's recommended range).

'AL Capshaw'

With my still fresh experience with Lovenox, I totally agree with this statement. DO NOT RESUME the lovenox until the bleeding has positively been stopped. For a catheterization, 24 hours may not be long enough, but should be.

 

[jojofromct]

Thank you Al and Ross, my two fav Coumdin people on here. I was hoping you both would respond. I will know more about the bridging tonight. My parents are off to the Coumdin Clinic. He stopped Coumdin Saturday night and I believe starts the LOVENOX shots either tonight or tomorrow, I am really not sure but I will get his schedule and let you all know.

Al, thanks for thinking bridging is GOOD!

Not sure what the cath will show or not, but thats why they are doing this.

 

[jojofromct]

I just spoke to my mom, my fathers company does not offer long or short term disability. My parents are devistated right now. My father has worked for the same company for over 45 years BUT they got bought out a few times while he has been working and last year this company bought them out and they dont offer long or short term disability, My parents have a mortgage and bills. I dont know what to do. I am so upset about this. They have very little savings and from what I hear going on state takes forever...I thought in my state a company has to offer at least long or short term.
Any ideas for me and my family?

 

[jojofromct]

I guess disibility and or earlier retirement but then he doesnt qualify for medicare because he is 62 so I guess he would have to pay a large amount for his health insurance if this happens...and YES I want my Dad healthy more than anything but my parents works so hard to get where they are today, they are middle class hard working and they have a mortgage and I hope they dont lose their house

 

[Bina]

Jo, don't apologize, there have been many discussions on how to get help for medical expenses in various states. Good Luck.

 

[jojofromct]

Thanks Bina, after Friday I will start to worry about that then. Once he has the cath, we will know, then we can make decisions.

Does anyone know of anyone that has had a cath to see how bad the valve is?

 

[Jkm7]

Many (most ? ) of us valvers have TEE and Cath (angiograms) to determine the condition of our valves, whether our arteries are clear or need bypass in addition to the work on our valves. Very few go into surgery without having these tests. Some have MRI and other tests in addition.

Hope it goes well for your Dad.
I understand your unhappiness at learning his company is so unsupportive at a time he could use their help.

Given what is going on with all these 'bailouts in our economy', it probably stings just a little bit more.

Good luck. Please let us know how Dad is doing.

 

[jojofromct]

THANK YOU! I really love this board ! You have no idea the strenght it gives me. I just read my to my Dad was Al Capshaw wrote to me. I wish my Dad would join up on here. Their home computer is slow. LOL.

Well he has been off the Coumdin since Sat night, and tomorrow he goes to the Coumidin Clinic for his INR, the Loveknox injections and another blood test his 2nd opinion doctor suggested he get done. My Dads cardio and 2nd opnion cardio are actually working together a bit.

Does anyone know how long my Dad is safe being off the Coumidin until the lovenox injections? He will have his first one tomorrow night but from Saturday to Tuesday seems so long to me.

 

[ALCapshaw2]

The Safest answer to your Question about how long it is safe to wait between going OFF Coumadin and beginning Lovenox is to actually test INR and then start the Lovenox when INR drops to 2.0

It all depends on how fast his INR drops.
Fast Metabolizers drop faster than Slow Metabolizers.
A One Day wait is generally considered to be NO Problem.
I'm thinking even 2 days is not 'too risky', especially if they actually test his INR to be sure.

ALL of this stuff can be a little "unnerving" the first time around!

It's amazing what we Heart Patients learn to be blase' about as we (successfully) undergo 'invasive procedures'.

It sounds like your Dad's Doc's are doing all the right things.

Best Wishes to you and your family.

'AL Capshaw'

 

[jojofromct]

Thank you Al, I was hoping you would post a reply! The 3rd day he will be getting the LOVENOX. I think they are giving him one at the Coumdin Clinic tomorrow evening.

My father takes a super high dose of Warafin, I think 10 mgs a day, or 10 , 9, 10 , 9 - something like that. I know its high. So 3 days off the Warafin makes me nervous...But they are under doctor care and my parents love the Coumidin Clinic...

 

[tobagotwo]

My answer that LMWH can be mitigated was based partially on this, from the Lovenox site, among other descriptions:

The anticoagulant effect of the drug is inhibited by protamine. A slow i.v. injection of protamine will almost completely neutralize the anticoagulant activity of enoxaparin (i.e., the anti-IIa activity); however, the anti-Xa activity is only partially neutralized (maximum about 60%). The dose of protamine should be identical to the dose of enoxaparin injected, that is, 1 mg or 100 units of protamine to neutralize the anti-IIa activity generated by 1 mg enoxaparin.

How it's handled by individual hospitals and doctors is up for grabs. I don't know, but suspect that your case was being handled by people who were not the most experienced with ACT, and that their handling of your situation probably included some delay from their uncertainty and deliberations on how to proceed. I imagine they were petrified that they would go too far the other way. They would likely take the most conservative approach that they could, which would not necessarily provide you with the quickest or most effective relief, but would look reasonable to anyone reviewing it later.

I certainly bow to your experience and the fact that you have it on the line with bridging and I do not.

Best wishes,

 

[Ross]

I guess disibility and or earlier retirement but then he doesnt qualify for medicare because he is 62 so I guess he would have to pay a large amount for his health insurance if this happens...and YES I want my Dad healthy more than anything but my parents works so hard to get where they are today, they are middle class hard working and they have a mortgage and I hope they dont lose their house

Depending on the outcome, if surgery is required, have mom or dad apply for Social Security disability immediately. If he's eligible for disability, he should automatically be eligible for Medicaid until Medicare takes effect which won't be until 2 years after disability begins. It varies from state to state so check with the dept of job and family services where you live about the Medicaid. I'm telling you right now, get an attorney that specializes in SS Disability. They get paid out of back benefits, so there is no money to fork out up front. Without an attorney, he may be denied several times and stalled for prolonged periods, which no one needs when there is no income.