Lovenox for bridging with a Mechanical Valve

[Protimenow]

I'm with Pellilcle and Chuck C -- I don't bridge. I had a pacemaker implanted a little over a month ago. My doctor originally wanted me to bridge. I told him that I didn't want to, that a few days after the procedure my INR will be back to normal range, and my risk of clots was minimal. He honored my wishes (and if he insisted that I bridge, I still wouldn't have).

There was one somewhat interesting thing post-op: because I was taking an antibiotic, my INR WAS effected -- something my surgeon was probably unaware of. If this (and probably most other) specialist worried about bridging, shouldn't he have been equally, if not MORE concerned about how the antibiotic may effect my INR post-op? In my case, my INR dropped -- self testing showed this .

 

[pellicle]

I'm with Pellilcle and Chuck C

the thing is, its not either of us advocating something weird, its in the current literature.

Shouldn't our cardiologists be more up to date with this than us?
(*answers self evidently that they are not)

 

[pellicle]

FIVE DAYS???

WTF?

That's a sure way to get your INR to 1.0 or so, but it's overkill and seems unnecessary.

apparently self testing is not common or encouraged in MO

Are you sure your doctor is up to date on anticoagulation, or reading from a 30 year old protocol?

I'm pretty sure he's not

 

[tom in MO]

FIVE DAYS???

WTF?

That's a sure way to get your INR to 1.0 or so, but it's overkill and seems unnecessary.

Are you sure your doctor is up to date on anticoagulation, or reading from a 30 year old protocol?

I've done this INR drop three times for various things. My current doctor is in his 40s, and the old cardio, late 60s, had the same routine for the same and a different procedure. I don't believe you have the ability to determine a correct method to drop my INR or the competency of my cardiologist and orthopedic surgeon.

 

[tom in MO]

the thing is, its not either of us advocating something weird, its in the current literature.

Shouldn't our cardiologists be more up to date with this than us?
(*answers self evidently that they are not)

Just because it's in "the literature" even the "current literature" does not make it correct. Literature findings have to be assessed by competent EXPERTS before they become treatment plans. Each valve, each patient, the placement of each valve, etc. is unique. Remember when eggs were bad for you and Cold Fusion would save the world? All lies published in the "current literature."

 

[Protimenow]

I've done this INR drop three times for various things. My current doctor is in his 40s, and the old cardio, late 60s, had the same routine for the same and a different procedure. I don't believe you have the ability to determine a correct method to drop my INR or the competency of my cardiologist and orthopedic surgeon.

The method for lowering INR is one that has been long established. Five days is too much, unless your body is so different from that of other humans who are also on Warfarin. Even if the doctors have been using a 'routine' for years, it doesn't necessarily follow that it's the right routine.

Yes, not taking warfarin for five days WILL lower your INR, but so will two or three days. Why should you be at risk (with a lower INR than is safe any longer than you have to be?


As for your other comment about experts -- what makes you think that these published reports of clinical trials or historical results weren't carefully peer reviewed before they were published?

Yes, research conclusions can be re-evaluated and new recommendations made, but your ridiculous statement that researchers 'lied' is crazy.

So -- skip your dose for as long as the doctors tell you. Enjoy sticking that long needle into your abdomen. Relish the minutes of burning after the injection and the bruising at the injection site. Perhaps you might even think about the people who go safely through their procedures after not taking warfarin for two or three days, without bridging.

 

[pellicle]

Five days is too much, unless your body is so different from that of other humans who are also on Warfarin.

easy to establish with daily (or half daily) measurements even if it is. Judgement isn't needed when you can measure it.

 

[tom in MO]

The method for lowering INR is one that has been long established. Five days is too much, unless your body is so different from that of other humans who are also on Warfarin. Even if the doctors have been using a 'routine' for years, it doesn't necessarily follow that it's the right routine.

Yes, not taking warfarin for five days WILL lower your INR, but so will two or three days. Why should you be at risk (with a lower INR than is safe any longer than you have to be?


As for your other comment about experts -- what makes you think that these published reports of clinical trials or historical results weren't carefully peer reviewed before they were published?

Yes, research conclusions can be re-evaluated and new recommendations made, but your ridiculous statement that researchers 'lied' is crazy.

So -- skip your dose for as long as the doctors tell you. Enjoy sticking that long needle into your abdomen. Relish the minutes of burning after the injection and the bruising at the injection site. Perhaps you might even think about the people who go safely through their procedures after not taking warfarin for two or three days, without bridging.

I never said I bridged. I've never needed to bridge.

Cold fusion being real and eggs being bad for you were put forward with great hoopla as truth by multiple experts who wanted to be "noticed." They were both false. Is that a lie? Is in MO, but this is the Bible Belt

I never stated what procedures I had. The procedure sets the requirements for your INR before surgery and whether or not one bridges. Given the procedures I had, 1 was the target INR per the surgeon and my cardio set the time I should stop. Five days was what was needed to drop my INR to 1 from the INR it was at. If my INR had been lower, it would have been 4 days.

 

[mecretired]

I had a colonoscopy last month. Cardiologist insisted on bridging. Stopped warfarin 5 days prior. They didn’t seem to care that, based on previous bridging, my inr drops quickly. 3 days prior would be enough. Oh well I survived. NOW I’m having a right hemicolonectomy due to polyps they couldn’t remove during colonoscopy. Same procedure—stop warfarin 5 days prior. Start Lovenox 3 days prior. Was told I would get Lovenox while in the hospital. From personal experience I know I drop quickly but come back up slowly.

 

[pellicle]

They didn’t seem to care that, based on previous bridging, my inr drops quickly.

interestingly many medical clinical people fought against "evidence based practice", its actually a good subject to acquaint yourself with and a fun read where psychology of clinicians is explored.

https://jamanetwork.com/journals/jama/article-abstract/400956

 

[Protimenow]

You might ask your surgeon what risks he is trying to avoid by having you bridge so early.

The risk of thromboembolic stroke for people with your history and INR below 2 for a few days in minimal, if not miniscule. Bridging will prevent something from happening that isn't going to happen whether or not you bridge.

Lovenox is low molecular weight heparin. You'll be given heparin in the hospital. Bridging 3 days preop may make the doctor feel good, but is probably not necessary.

 

[Protimenow]

interestingly many medical clinical people fought against "evidence based practice", its actually a good subject to acquaint yourself with and a fun read where psychology of clinicians is explored.

https://jamanetwork.com/journals/jama/article-abstract/400956

Evidence? What good is evidence when you've learned everything you'll EVER need to know in Medical School?

 

[pellicle]

What good is evidence when you've learned everything you'll EVER need to know in Medical School?

 

[dwhist]

I had posted this a few years back. I am told to keep my INR between 2.5 and 3.5. I had a knee replacement scheduled for a Thursday. Was told to stop warfarin on Sunday and start Lovenox shots on Tuesday, but only a shot Wed morning. Had surgery Thursday morning and remember hearing I was down to 1.02 on my INR. Friday was still in hospital and they had held Lovenox because of concern of bleeding in knee. They may have given me a dose of Warfarin Thursday night, I do not remember. PT came in Friday morning and had me get out of bed and walk around room. That is last I remember for 2 days. Nurse came in after PT left and found me disoriented. She called a doctor and he had a stroke alert sent out, which resulted in a room full of docs so I am told. My wife was called and told to come to hospital so she could sign the papers to allow me to be given the clot buster drug. I had 3 ct scans that day and 2 days later had another ct scan and an MRI. Was put in ICU to keep close eye on me. MY wife says my cardiologist sat in my room for 4 hours the evening of the stroke. Due to covid she had to leave at 8. I was kept another 4 days and have no residual effects.

I will be more cautious next time. Cardiologist said we will be more careful next time as I need to stay higher on my INR as the clot came fast for me. I hd discussed with orthopedic doc and he was aware of the blood thinner and said it would be no issue.

I did talk to hospital doc when I was coherent, and he said they were having a hard time getting my INR up so keeping me a few more days. I explained in the past I doubled up my does on the first 2 says and that usually worked and he had it done and it worked.

 

[pellicle]

Hi

I had posted this a few years back.

that's a very interesting report. Thanks for posting it. I just wanted to react to a few things in it which may be incorrect assumptions: namely that the clot was because of your valve and your ACT.

Such surgery is notorious for bleeds and subsequent clots. My uncle died from a massive stroke days after a similar invasive surgery. He had no heart issues, was not on warfarin and was basically a very healthy 50yo. Accordingly they take strokes caused from all the massive bleeding that is involved with cutting into everything to put a new knee joint in (that's bone and muscle).

It sounds that they handled everything perfectly

She called a doctor and he had a stroke alert sent out..
I had 3 ct scans that day and 2 days later had another ct scan and an MRI.


I was kept another 4 days and have no residual effects.

I say this for two reasons

1. to hopefully bring that angle to your attention (perhaps belaying any anxieity)
2. to clarify to readers that its not a simple single variable matter of being off warfarin (the surgery itself is risky)

I'd say that your team handled that perfectly. Some interesting reading here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498016/

A National Inpatient Sample database study conducted by Rasouli et al. evaluated 1,762,496 patients who underwent THA or TKA [5]. Based on inpatient administrative data, they found the incidence of perioperative stroke to be 0.14%. Predictors of stroke were pulmonary circulation disorders, diabetes, arrhythmia, peripheral vascular disease, renal disease, and revision surgeries. Although the study had a significant sample size, it was inherently limited by the administrative data available in the dataset.​

which suggests you are unlucky and perhaps some other factor from your heart actually played into this, it certainly can't be ruled out. Do you for instance have and incidence of arrhythmia?

To do justice to responding (and only if you want to) I'd be keen to know a few things about your INR prior to the surgery.

• What was your INR testing frequency (weekly, fortnightly, monthly) prior to the surgery
• Had you had any TIA's before the knee surgery (for instance was your INR range set 2.5 ~ 3.5 due to an event?)
• did you have any periods of low INR before the months or even year prior to surgery (I'm wondering if all that cocktail of heparin actually dislodged a small thrombosis from somewhere).

Anyway, glad you're fine

Best Wishes

 

[dwhist]

which suggests you are unlucky and perhaps some other factor from your heart actually played into this, it certainly can't be ruled out. Do you for instance have and incidence of arrhythmia?

To do justice to responding (and only if you want to) I'd be keen to know a few things about your INR prior to the surgery.

• What was your INR testing frequency (weekly, fortnightly, monthly) prior to the surgery
• Had you had any TIA's before the knee surgery (for instance was your INR range set 2.5 ~ 3.5 due to an event?)
• did you have any periods of low INR before the months or even year prior to surgery (I'm wondering if all that cocktail of heparin actually dislodged a small thrombosis from somewhere).

Thanks for the replies.

Pellicle, I will read the report you attached. The cardiologist is the one who said it was a clot from the mechanical valve. But I can see it can be from the knee work too.

No incidences of arrhythmia.

I have a machine and test weekly for the last 5 years. Knee surgery was 2 years ago. I have been good at staying within my range. Three years ago I had a spontaneous bleed in the replaced knee that created problems. Knee blew up like a balloon in a matter of less than what seemed like an hour. Saw doc and he sent me to er. Normally they would have stuck a needle in and drained, but said because I was on blood thinner, they would not try. So had to wait for body to absorb it and had many weeks of PT as the quad did not work. Cardiologist said I should try to stay in the 2.5 to 3 range after the bleed.

No other TIA's. I have bridged maybe 4 times since valve replaced on 2011 for a colonoscopy in 2013, a colonoscopy, angiogram and a surgery in 2018 for diverticulitis. Knee was done in 2020.

Let me know if I am missing anything.

 

[pellicle]

Morning

The cardiologist is the one who said it was a clot from the mechanical valve. But I can see it can be from the knee work too.

its interesting, I see the same thing in many places ... people seldom thing critically or statistically and so when they sort apples all day, show them a lump under a blanket and they'll guess its an apple.

I recently posted above on the resistance to evidence and statistically based clinical practice. The problem is experts form opinions based on the biases they see. This can be good but it can also be bad when they are misinformed. I've seen many cases of misinformed cardiologists here.

Being honest how could he know where the clot came from? If he didn't say "probably" then he's not being honest. Perhaps not being honest is what "the public" generally want.
¯\_(ツ)_/¯

I have a machine and test weekly for the last 5 years. Knee surgery was 2 years ago. I have been good at staying within my range.

those are good indicators and would minimise what I was concerned about (no need to provide me full data of durations and events out of range).

Three years ago I had a spontaneous bleed in the replaced knee that created problems. Knee blew up like a balloon in a matter of less than what seemed like an hour. Saw doc and he sent me to er. Normally they would have stuck a needle in and drained, but said because I was on blood thinner, they would not try.

So a year after surgery? Makes me more suspicious. Again, miserable and out of date practice from what I see in the journals about this. Chuck here has had a procedure similar in his neck and what they did then was to lower his INR to 1.4 (see this blog post for details). If your cardiologist is against that sort of thing, well then that would trigger time for a new Cardio in me.

No other TIA's. I have bridged maybe 4 times since valve replaced on 2011 for a colonoscopy in 2013, a colonoscopy, angiogram and a surgery in 2018 for diverticulitis. Knee was done in 2020.

good, I'll assume the similar bridging process you went through was similar to the knee?

Let me know if I am missing anything.

nope, looks pretty sound.