Taking Low-molecular-weight heparin (LMWH) when INR is below 1.7? (mechanical valve)

erik

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Hi there,

I have a mechanical St. Jude in the aortic position, but besides that no other heart problems
My therapeutic INR range is 2 - 2.5
My cardiologist suggest to take a LMWH (Fragmin) when it is below 1.7 (for example, when I forgot to take the pills, doesnt happen very ofthen though)

Is there anybody that also follows this procedure?
Is this a scientic proven measure?

Best regards,

Eric
 

pellicle

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Hi

Nothing wrong with that plan but it is injection administered and not cheap.

It's not scientifically proven but prudent. Perhaps overly prudent.

A better plan is to extend your INR range and change the thinking from a range to a target. I propose the not normal 2 ~ 3 range, and for a St Jude in aortic position I would suggest an INR target of 2.5

Combined with weekly testing and decision making about your dose for the next week I would expect your INR will be in range greater than 85% of the time (I'm regularly in the high 90% zone)

Let's discuss all this
 

LondonAndy

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Yes. I have a 29mm St Jude mechanical valve, and my surgeon set my INR range as 2.5 to 3.5, and was insistent that if my INR dropped out of range that I should inject Fragmin too. He said "Anti-coagulation clinics [in the UK] just don't get it" - the importance of maintaining range. Pellicle is usually right on these issues, so perhaps he was indeed overly prudent, but when I dropped out of range in the first few weeks after surgery and my clinic refused to prescribe Fragmin (despite it being written by the surgeon in my notes), the surgeon made out a prescription for me personally.

I only needed the Fragmin once, but it was reassuring to have a supply of the injections at home if needed again. But I manage my INR using my CoaguCheck XS and make minor "course corrections" to my INR level, by adjusting the dose, before it gets to the extremes of the range.
 

pellicle

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Mornin

LondonAndy;n885848 said:
... so perhaps he was indeed overly prudent
In my view there is nothing wrong with being overly prudent. I endorse that more than I do my own personal approach when it comes to others. Probably more so were I a working professional in this area.

....but I'd still give out the facts :)

hope your doing well mate :)
 

pellicle

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erik
interestingly I found this post which I have not checked source, but relates to your valve and your range

tom in MO;n846959 said:
The first question is how long can you be off coumadin? You don't have to take it. Your relative risk for stroke will increase.

The second question is "safe?" Nobody can answer that for you but yourself. However, every cardiologist, surgeon and GP in the USA will tell you that the relative risk of warfarin bleeding vs. a clot due to a mechanical valve indicates you should take warfarin. Years of warfarin usage indicate that it is a safe and effective drug when used as directed. Stopping and starting is not using it as directed.

The "new way" is lower INR ranges. That's why my St. Jude went from 2-3 to 2-2.5, and "we" don't get worried when it drops to 1.7.
 

erik

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Hi there all,
Thanks for answers; good the hear that the Fragmin procedure is used more cases when INR drops to much low range. I use the injections a few times a year, just to be prudent and avoid any unneccesarily risks.
pellicle . i have been doing the range 2 - 2.5 for some 1,5 year now, and its going ok. I prefer weekly testing, normally, the clinic suggest once per 3 weeks, but i found that to risky. Lucky, the insurrance is paying for the strips and fragmin injections if needed :p

I only take the fragmin when the INR is lower than 1.7.
I don't take warfarin, but acenocoumarol. INR levels can be fasted ajusted with acenocoumarol that with warfarin, but the side effect is that INR level can also drop faster if you forget to take your daily dosis.
 

pellicle

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erik;n885853 said:
I don't take warfarin, but acenocoumarol. INR levels can be fasted ajusted with acenocoumarol that with warfarin, but the side effect is that INR level can also drop faster if you forget to take your daily dosis.
I suspect this means you are in India (or perhaps Spain)

Myself I don't understand why anyone persists with that drug.

Given that aspect I would urge you to consider increasing your INR target to 2.5 because flirting with low INR on that anticoagulant is dangerous (which is why your also taking the heparin)

Why not move to warfarin? It's easier to stay in range and just as reversible in an emergency? It's not as if you are only on it temporarily, so a more stable experience would be better for your health.
 

tom in MO

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erik;n885841 said:
Hi there,

I have a mechanical St. Jude in the aortic position, but besides that no other heart problems
My therapeutic INR range is 2 - 2.5
My cardiologist suggest to take a LMWH (Fragmin) when it is below 1.7 (for example, when I forgot to take the pills, doesnt happen very ofthen though)

Is there anybody that also follows this procedure?
Is this a scientic proven measure?

Best regards,

Eric
I have an aortic St. Jude valve and the same range. I take warfarin. I went off warfarin for surgery and did not need to bridge with any drug, I just started up with warfarin a day or two afterwards. Per "is this a scientific proven measure", upon valve implantation, I was never given the choice to use acenocoumarol. Warfarin was the only anticoagulent discussed with me and the only one I found in the literature. I
 

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