too soon, too low ??

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wlaldridge

In hospital INR 2.5

Three day out 2.3

Six days out 2.0

Surgeon sent me back to cardio with appointment in a month with a target range of 2.0 to 3.0. The surgeons nurse monitoring my INR told me not to be tested for two weeks and then talk to the nurse at the cardio office who will monitor my dose.

Does this sound right since I am increasing my exercise each day and eating more regularly as well as reducing the amount of acetominophen and other pain relief I am taking?

Just puzzled by this. The surgeon said lots of places in the world people are not anticoagulated at all with a mechanical valve in the Aortic position due to the pressures and velocities it sees there. Clotting is just not a big deal for me, so he says.

Great if that is right but I read where the recommended target range in the first 3 months is 2.5 to 3.5 yet I am told my 2.0 is perfect.

Any opinions from those more knowledgeable??
Thanks

Bill
 
Hi Bill

I thought I'd just jump in on your post only because I distinctly remember both Tyce's surgeon, hospital cardio and his own personal cardio all saying that they like to keep AVR's at 2.5-3.5. They wouldn't even release him from the hospital until he was 2.7. That was on a Sunday and they told him to see his regular cardio and have another test done the week he got home. I think the expert, Mr. Al, might be able to help you out more here, but I do know that we stay, or should I say TRY to stay in the 2.5-3.5 range. Yesterday Tyce tested at 3.6, so dinner included a salad and we will test again on Monday after a few walks on the beach and a few more salads or veges. Don't know if that's any help at all.........

Do you have your own machine yet? I do hope you get one as they're absolutely wonderful and help you monitor every day.

Evelyn
 
It's not the individual numbers that would alarm me, but the downward trend. If it were me (and I actually did this when my numbers did the same thing) I would press for a retest in a week, not 2.

The 2.0 sounds low to me, so I would follow up assertively. I disagree about clotting being no big deal for you. At least one member here has had a reoperation due to a clot after AVR.

(personal advice, as I'm not qualified to offer medical advice).
 
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I think you should insist on testing more often. I was tested several times a week for the first few weeks, and then switched to once a week after I had been somewhat regulated. Only recently have I moved to every other week, only because the INR has become much more stable.
Your surgeon may say that some are not given anticoagulation therapy, but isn't he a lone voice? The vast majority say that the INR should be kept at 2.5 or more for our kind of surgery. I would want to be sure about this business before risking a clot.
 
The American College of Chest Physicians sets the standards for the use of warfarin. They say that the INR should be 2.5 to 3.5 for mechanical valves with the exception that two leaflet valves in the aortic position could have a goal of 2.0 to 3.0.

I've written this before to others -- I have been involved as an expert witness in several lawsuits against doctors. I would love to get this doctor on the stand opposite me. He wouldn't have a ghost of a chance. You would be more valuable ($$-wise) to your family dead than alive.

Its true that in some places in the world people do go without anticoagulation -- I read about a guy in Turkey who went 30 years. But that does not mean that is the standard of care everywhere in the world. Ask your doc if he'd like to drink water from the same pond that sewage was being dumped in -- I saw it done in Vietnam. We don't all have to conform to the lowest common denominator.

You should expect your warfarin dose to increase as you increase your exercise. As you get better, you metabolize your warfarin more efficiently. This has been reported by well-known heart surgeons in well-done studies.
 
Bill

Bill

I agree with everyone. I even had to go back in the hospital after being out for a week and a half because my INR was too low. They would not release me till it up to a normal readin. It finally did after two days reaching 2.5. So, ask for tresting a lot more than just every two weeks. Mine was every week till we were sure it would stay in the normal range. Mine still flunctuates, but stays in range. So have it checked more till it is normal.

Caroline
09-13-01
Aortic valve replacement
St. Jude's valve
 
Now, latest news after losing my Monday test, I was retested Wed(10 days after the 2.0 reading) I was down to 1.6 INR.

New dosing
This Thursday(10/3/2002) 10 mg
then 5 mg per day except on
Saturday and Wednesday take 7.5 mg. retest in 10 to 14 days

My questions are:

What day is best for the test to get a fair reading? It seems if I do it on the wrong day the larger dose will make INR look higher than it is running, as well as vice-versa.

Should I insist on a script that allows for a uniform dose daily rather than a 50% increase on two days per week? That is get some 1 mg doses to take with my 5 mg?? I am not so pumpheaded that I can not keep track.

Does this kind of dosing schedule sound "normal" ?

Thanks for the help,

Bill
 
I believe there is a time component to the the dosing...in other words what you took last night shows up in your numbers over time and not immediately. I'll defer to allodwick on that..

Regarding your question about is this a "normal" type of dosing schedule, here's mine:

Su: 7.5 M: 7.5 Tu: 5.0 W:7.5 Th:5.0 F:7.5 Sa:5.0

This works well for me...but remember, your requirements may be very different.
 
I was sent home from the hospital nearly a year ago with a prescription for 2.5 tablets -- perhaps that is a standard beginning dosage.
My dosage now I almost identical with Johnny's:
7.0 on Friday, Sunday, Tuesday
5.0 the rest of the days.
I plan to get a prescription from my cardiologist for 6's, since that will come closest to giving me the same dosage every day.
I still think that you need to be checked at minimum once a week for a while until you are regulated. I don't think you're regulated at 1.6.
 
Hi Bill.....

Tyce's schedule is:

SU2.5 M 5, T 2.5, W 5, TH 2.5, F 5, S 5. That has kept him pretty well regulated....matter of fact, this a.m. when we tested it was 3.1 on the Protime. I don't think the day of the week you test makes a difference, but I do think consistency is the key. Until Tyce got into the "3's" we tested twice weekly....not his choice, mine because I can get paranoid! Now we are testing once weekly and he has been pretty consistent. What we've found through this list, is that if he's over 3.5, he eats more greens like broccoli, spinach, salads, etc. If he's around 2 he has an extra glass of wine, which he doesn't mind one bit. We do keep a record of his dosage and the times we test and fax it to the cardio's office once a month if it's been within range, or immediately if it is out.

One person on this list mentioned the 10% rule which seems to work very well for us....perhaps Al or Max (I think mentioned it) would care to expound on that subject......basically we just increase or decrease the dosage by 10% over or under what he is presently taking and that usually brings us into range.

Hope that's of some help to you.

Evelyn

PS....how are you feeling????
 
Trend continues

Trend continues

Bill, I don't mean to alarm you but the downward trend that I mentioned earlier seems to be continuing and I just noticed that you are now at 1.6! I show your readings to have been 2.5, 2.3, 2.0, and now 1.6. I hit 1.6 myself once, and I didn't wait 14 days to get retested.

You don't mention how much your dosage has changed other than the 10mg for one day. It doesn't appear to me that your levels are being managed aggressively enough. Just my opinion.
 
I agree,

my dose is 5 per day since out of the hospital.

thanks,

Bill

PS to Ev--I am feeling fine and increasing my walking etc.

Just am anxious about the low INR and the surgeon's nurse not thinking a steady decline warranted a little increase in dose.

Will have to be tested after the 10mg dose is not a factor.

Bill
 
Hi Bill

So glad to hear you're doing so well!!! Keep on walking, it's great for you. Tyce is doing super, too. It's phenomenal how quickly you get back to a normal routine. In our case, he is now only working part time, and that's great for us. I think he would go back full time, but I said "NO WAY!!" It's amazing how you appreciate all the little thing in your life so much more---like a trip to Walmart!!

I certainly would be more agressive with your coumadin therapy and I hope you look into getting the Protime machine, it truly gives you freedom! You strike me as the type of person who is in charge in your life.....why shouldn't you also be in charge of your testing? We still go to the cardio's about once a month/6 weeks for their test when he has his appointments, but it sure beats every week; in your case it sure is safer than every two weeks. Is it your surgeon's office that is doing the testing? What about your cardio's office, don't they continue your home care? Our surgeon just turned all that over to our cardio. We've only seen the surgeon once since the surgery in June, EVERYTHING else has been managed by our cardio.

Stay well!

Evelyn
 
Bill, I think they need to be more aggressive about your warfarin dosage. An INR of 1.6 is 0.9 units below your desired range. Your warfarin dose should have increased by about 20% at that stage. It sounds like you are doing fine, but don't let this one little pill wreck it all.
 
Evelyn

I see Tyce is alternating between High and Low doses of Coumadin, totaling 27.5 mg / week which averages to 3.93 mg / day. I wonder why they don't just put him on 4 mg/day which is way more consistent.

I too was originally on a high / low alternation. When I proposed going to 3.5 mg / day which was close to my previous weekly average on the high / low scheme, my nurse told me OK, go for it since the weekly total was within 0.5 mg of the being the same.

I'm still not sure what formula or table they use for calculating dosages, but it all seems to be based on weekly totals.

'AL'
 
Hi Al....Beats the heck out of me how they figure it. Tyce is testing today, and I'll let you know what he reads. He's always been on an alternating dosage....never one-sized pill all 7 days. Maybe that gives it more flexibility, who knows???? We have a cardio appt. on the 24th of Oct....will definitely ask him the reasoning behind it. He really hasn't had too much of a problem with it, and maybe it's just easier if he has to increase to increase one day's dosage.....How about that Mr. Lodwick??????

TTFN

Evelyn
 
I just had avr surgery recently and my inr levels were/are up and down alot. When I was at 2.04 my doc wanted me to be tested in five days. I was tested in three and I dropped to 1.4. That was with being on 5 mg. daily. I am now on 6 mg daily and I am now at 2.4. My family doc said that he doesn't want me tested for ten days. He said that if I am within my ranges in ten days I can be tested once a month. I am also wondering if I should be tested a little more often. Good Luck to everyone.

Creed3
 
Hi Al....Just tested and Tyce is 2.5 on the nose. Last week he was 3.2. Faxed results to our cardio to see if they want to do any adjustment, but I don't think they will. We have been doing alot of exercise over the weekend and during the week, working in the yard, etc., so who knows.......I know Mr. L. said exercise definitely affects the way the liver metabolizes the coumadin, so that's what I attribute it to. Haven't been eating very many salads, etc or veggies high in K, so we'll see what Monday brings.


Ev
 
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