Can't stop bleeding will have to hold warfarin for awhile

[Sean Wolfe]

Hi all,

I cant stop bleeding from the graft site following my periodontal surgery. I had to go back to the office 4-5 times since then to have it cauterized by laser. The surgery was 2 weeks ago and the site won't clot long enough to heal. I have done frequent INR testing and have been within therapeutic range. Now the periodontist wants me to hold the warfarin for a few days and I'm a little concerned. I definetly hate the trips back and fourth to the peridontal office (sometimes after-hours), but I also don't want a thrombotic event either. I guess I just need a little reassurance that i'll be alright off the warfarin for a few days.

Aortic Valve Replacement - On-X #25mm
Aortic Root Replacement
Jan 2010, Cleveland Clinic Foundation
Performed By Dr. Gosta Pettersson

 

[dick0236]

I would be very careful about going off warfarin for a FEW(??) days. I would get my cardio involved....there are "bridging" drugs to protect you from stroke while you are off warfarin. Gum bleads are temporary.....strokes are forever.

 

[Luana]

I would not go off it. Dick is spot-on. Blood cells can be replaced, brain cells cannot. Call your cardio's office now or whoever monitors your ACT.

 

[Jkm7]

I would suggest discussing this with your cardio and whoever manages your ACT. Do not just do it upon the recommendation of a dentist. IMO He just wants you to stop bleeding and is not necessarily considering your whole health picture.

Had you held coumadin prior to the procedure? Did you bridge pre-procedure with lovenox?

 

[njean]

I agree with all previous posts. Do not go off the coumadin unless you check with your cardiologist first!

Take care and I hope your issues are resolved soon!

 

[Sean Wolfe]

Thanks for the advice. I feel the same as what dick0236 stated.

I would be very careful about going off warfarin for a FEW(??) days. I would get my cardio involved....there are "bridging" drugs to protect you from stroke while you are off warfarin. Gum bleads are temporary.....strokes are forever.

I did contact my cardiologist and he definitely does not want me to hold my warfarin. He does however, want me to check my coag status often and try to keep it on the low end of the therapeutic spectrum. I checked today and my INR was 2.2, which is good. I havent had any bleeding for 24 hours so I hope this bleeding is behind me. I think my periodontist was getting frustrated with having to treat me every other day. She said that I had the most bleeding complications of all her other patients. My only other concern is with bacterial contracting endocarditis because all these oral bleeding issues. My periodintis put me on a course of penicillin. I hope this is enough. Thanks all for your comments.

 

[Lynlw]

Thanks for the advice. I feel the same as what dick0236 stated. I did contact my cardiologist and he definitely does not want me to hold my warfarin. He does however, want me to check my coag status often and try to keep it on the low end of the therapeutic spectrum. I checked today and my INR was 2.2, which is good. I havent had any bleeding for 24 hours so I hope this bleeding is behind me. I think my periodontist was getting frustrated with having to treat me every other day. She said that I had the most bleeding complications of all her other patients. My only other concern is with bacterial contracting endocarditis because all these oral bleeding issues. My periodintis put me on a course of penicillin. I hope this is enough. Thanks all for your comments.

Im glad you called your cardiologist before stopping your coumadin. I don't think they would advise bridging in this situation, since whatever they bridged you on, most likely would also keep bleeding or even cause more bleeding. So probably the "safest" option to help with the healing/stop bleeding and prevent clots is as they said stay on the Coumadin but a lower INR.

Hopefully, since you haven't beed for 24 hours things are healing, just be carefull and not do anything that could dissolve or mess with the clots, like te things they normal tell you to avoid the first day after having a tooth pulled, like no hot liquids etc

 

[Bina]

That INR of 2.2 is very good for now.....keep an eye on it since you started taking the antibiotics. Good Luck.

 

[Protimenow]

It's good to get the cardiologist involved. Earlier threads implicated the problems with the cotton wad you put into the surgery area pulling those clots open when you remove it. Oral surgery and bleeding can be a problem.

However, it looks like you have an On-X valve, which is reputedly not a valve that forms clots easily. (You didn't say if it was Aortic or Mitral - which may make a bit of a difference in the likeliness of a clot). Also, more recent guidelines, with more recent valves, don't stress the importance of forming a clot on the valve. You may be safe with a low INR for a day or two. (I've previously posted a link to guidelines at Duke Medical School (or Hospital) that calls for an increase in warfarin dosage if INRs fall even down to 1.2 or so, and don't recommend bridging - you probably would have been okay without warfarin for a day or two). The situation with Dick was one where he had a valve made in 1967, and went for days without warfarin -- I believe that the risk of a day or two without warfarin and a new valve that is less likely to be a site for clot formation is considerably different risk-wise.

In either case, if you've gone a day without bleeding, you're probably out of the woods and the issue of warfarin reduction is moot. Just, as others have noted, be careful not to break the clots open.

(I know that some of you will attack me for the sacrilege of not urging immediate bridging when INR goes below range, but I'm just working with some recent guidelines that don't overestimate the importance of bridging. Low INR doesn't always necessitate a knee-jerk response to bridge in all cases)

 

[Luana]

I would not have stopped even if cardiologist said to. My PCP said I could stop for a few days for a colonoscopy and I told her no, I would not do that.

As for the On-X valve not forming clots that easily, I would put no stock in that. It hasn't been around long enough to say for sure despite all the claims they make about it. Better safe than sorry.

Do you home test? I'd check again in 5 days or so after starting antibiotics.

 

[Protimenow]

The On-X may not have been around nearly as long as many of the St. Jude valves, but it DID have to go through extensive testing to get FDA approval. I don't know that the risk is lower with On-X or Medtronic (if they even make a mechanical aortic valve), but personally don't go crazy about stopping (or reducing) my dose for a day or so. I've recently somehow wound up with 1.1 - and did as described in a protocol used by Duke Clinic (associated with the Duke University Medical School, I think) -- double my daily dose, increase my weekly dose, retest in a few days. I didn't bridge. I didn't throw a clot or have a stroke or any other negative events.

Refusing to stop - even for a procedure - is not warranted, according to recent research. You just don't want to STAY below range for any longer than necessary, and to use an increased dose to bring you relatively quickly back into range.

It certainly helps to have your own meter and do your own testing -- even if you report the results to a doctor or anticoagulation clinic. I am thankful that I have a meter, every time I test (and I test weekly).

 

[dick0236]

Refusing to stop - even for a procedure - is not warranted, according to recent research. You just don't want to STAY below range for any longer than necessary, and to use an increased dose to bring you relatively quickly back into range.
.

"Youse has your druthers....and youse takes your picks". Personally, I choose NOt to play "russian roulette".....been there, done that:frown2:. My problem was that "any longer than necessary" turned out to be a short time. One day off warfarin is MY limit...without close supervision of a knowledgable medical professional.

 

[Lynlw]

I would not have stopped even if cardiologist said to. My PCP said I could stop for a few days for a colonoscopy and I told her no, I would not do that.

As for the On-X valve not forming clots that easily, I would put no stock in that. It hasn't been around long enough to say for sure despite all the claims they make about it. Better safe than sorry.

Do you home test? I'd check again in 5 days or so after starting antibiotics.

I agree with you, about not relying on being much safer with an ON-X valve over another brand. Why take a risk that if you lose you can lose big. (Massive stroke)
Plus I always remember one of the mothers who almost died because a clot formed on her valve during preganancy, even being followed by the very best experts, had an On-x valve that had to be replaced the same day they delieverred the baby early.

 

[Protimenow]

Dick: I understand your situation. I'm pretty sure that the valve you got more than 40 years ago was a lot more likely to cause clots to form than the more recent valves. In 1967, there wasn't much choice for you -- and the valve you got was probably the best choice available (in 1967). The likelihood of forming and throwing a clot if you have a newer valve is probably considerably lower than it was with your old valve.

Guidelines for more recently implanted bi-leaflet valves are undoubtedly based on more recent clinical experience. If I had your valve in my chest, I wouldn't want to be below target range for more than a minute at a time. The 20 year old valve I have in my chest fortunately (at least so far) has gone at least once with an INR around 1.1 without any negative events. Still, I test every week - or more often - just to be sure.....

 

[Cris N]

I've had a couple of surgeries since my valve was put in (mitral) and in each case my surgeon was comfortable with my INR at around 2.0. I was fairly comfortable with that idea as well, though I was anxious to get it back up as soon as possible. So, I guess what I'm saying is that when you're recovering from a procedure an INR of around 2 gives you modest valve clot protection and allows the wound site to go through its normal process. Home testing makes it much easier to monitor your levels and to help make on-the-spot adjustments in dosage. Another thing to remember is that while warfarin takes a few days to deliver its full effect, it's estimated that roughly 50% of the effect takes place in the first 24 hours.

 

[Sean Wolfe]

Well, it's been 72 hours without bleeding so far. A suture fell out last night and still no bleed, so I think I am out of the woods. I home test and my INR was 2.9 (Must be the antibiotics). I lowered my dose again. I forgot to mention I'm on low dose aspirin also, so that didn't help with the bleeding issues. My therapeutic range is (2.0-3.0). I have an On-X valve inside a dacron graft in the aortic position. I wasn't too worried if my INR got as low as 1.5, but I didn't want it to go below that. I was going to be enrolled in the PROACT study when I got my valve but I couldn't do the follow up because I got my valve in Cleveland but live in Florida. In that study there is a group of patients who were going to be maintained on aspirin and warfarin with INR range of 1.5-2.5 and another group on plavix and aspirin. Thanks for all your insight.

 

[Lynlw]

Well, it's been 72 hours without bleeding so far. A suture fell out last night and still no bleed, so I think I am out of the woods. I home test and my INR was 2.9 (Must be the antibiotics). I lowered my dose again. I forgot to mention I'm on low dose aspirin also, so that didn't help with the bleeding issues. My therapeutic range is (2.0-3.0). I have an On-X valve inside a dacron graft in the aortic position. I wasn't too worried if my INR got as low as 1.5, but I didn't want it to go below that. I was going to be enrolled in the PROACT study when I got my valve but I couldn't do the follow up because I got my valve in Cleveland but live in Florida. In that study there is a group of patients who were going to be maintained on aspirin and warfarin with INR range of 1.5-2.5 and another group on plavix and aspirin. Thanks for all your insight.

I'm glad to see things look better, hopefully this will soon behind you. I'm surprised they didn't have you stop the aspirin.

 

[markp66]

Just saw this post. Can't believe your periodontist advised you to come off warfarin for a few days. I'm glad you got the advice from this forum and spoke to your cardiologist. Regarding the on x valve, there is no strong evidence about blood not clotting on the valve. The on x has great potential to have a lower INR range in the future but so far it is a complete gamble to come off warfarin. I think the best advice on this post is that "blood can be replaced, brain cells cannot!" There are reports that with the new valves there is only a 4-6% chance per year of having a stroke without anticoagulation. I have a feeling this is way lower than in reality. I think the general rule when it comes to any issues such as this post is to always speak to your cardiologist before you do anything. Doctors, dentists etc have very little idea about each individual situation. You also mentioned your INR was 2.2. Most surgeons and cardios seem to agree that 2-2.5 (for aortic valve/ without hypertension, a fib) gives the best outcome with the newer valves, especially with the ATS and ON-X. Hope everything has now sorted itself out.

 

[Luana]

Most surgeons and cardios seem to agree that 2-2.5 (for aortic valve/ without hypertension, a fib) gives the best outcome with the newer valves, especially with the ATS and ON-X. Hope everything has now sorted itself out.

The problem with that range is that it is so narrow it will be difficult to maintain, especially if someone is frequently jerking around with the dose. I see no problem with 2-3 as a range, and personally, I'd rather be a little bit too high than too low.

I don't care how much hype is written about On-X valves, going below 2.0 concerns me. To me, being at 1.5 is way way way too close to be totally anitcoagulated (I think 1.2 is the high end of normal range). The studies mean nothing is you have a stroke. I'd feel much safer with a range of 2-3 and being in the mid- to high-2s.

 

[Protimenow]

I've posted a few times here about being below 2.0 NOT being an instant death sentence if you've got a bileaflet valve, and are more than 3 months post-op, and increase your dosage so that you're back in range within a few days. This is according to a protocol used by Duke Clinic (it could have been the medical school, but I think it's the clinic), and a recent paper on anticoagulation. The recommendations were to increase dosage, and that bridging wouldn't be necessary in most people, if the INR comes back up in a few days. The point is that the risk isn't as high as many here seem to believe - IF THE OTHER CONDITIONS ARE MET. Bridging is not ESSENTIAL in cases where the other conditions are met - as long as you follow protocol to increase your INR.

I spent more than a week below 2.0 - it was scary until I saw recent research, but I STILL made it a point to get back into range quickly. (I couldn't afford Lovenox, have no doctor to prescribe it, and was quite concerned until I read that in my situation (bileaflet aortic valve, more than 3 months post-op), it was safe to just increase dosage and not necessary to bridge).

It doesn't matter to me WHICH mechanical valve we're discussing (though I think I brought up the On-X in this thread) - I still think 2.0-3.0 is a safe choice. Many of us try to stay in that range, and we lead normal lives. Other than testing and taking our daily dose, it doesn't really change our lives much. Plus, for some of us who lead mostly sedentary lives, it may also help us reduce the risk of deep vein thrombosis.

I agree with Luana -- 2-2.5 is a very narrow range, and hard to maintain. 2-3 is more possible, and more manageable. (Currently, I'm working my way DOWN from 3.7 - a new medication makes warfarin work better -- I test more frequently than usual and expect to be back in range in a few days)