Why both Warfarin AND aspirin?

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Amy

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Hello all. I’m 5 months post-op with a mechanical St Jude AVR. My incision finally closed up enough to get an echo done today, and the new cardiologist I saw afterwards advised me to stop taking the daily 81 mg of aspirin. Meanwhile my surgeon has said I need to take it for the rest of my life.

Of course neither of them seem to care that their advice is contradictory. Leave it up to the patient to figure out who to believe! (Or else mindlessly follow whatever the most recent doctor says to do....)

I found these papers, concluding that “warfarin PLUS aspirin significantly decreased thromboembolic events” -



I know lots of you all take both. Does anyone know specifically why? Should I keep taking the aspirin or not?

Thank you.
 

Superman

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Because they’re delicious!

And I’m told they act on different mechanisms. Aspirin won’t impact your INR, but can make your platelets a little more slippery as I understand it. Beneficial for the heart in other ways. Many people without valve issues are advised to take an aspirin a day.

I was on Warfarin for 19 years without it. Then I had a second surgery due to aneurysm and they decided after that to add it to my regimen. Not for any particular reason other than standard procedure has changed over time. I’ve been on both for nearly 12 years now.

And show your cardio the research. If they have no interest in research, maybe time to shop for a new cardio.
 

almost_hectic

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To be clear you only need to take the small 81mg aspirin. What is often referred to as baby aspirin. So not a full size aspirin. The 81mg is a low dose so it can't really hurt you, but its enough to be beneficial when taken every day. Your surgeon is the one I would believe. I can't imagine your cardiologist would be upset if you were taking the 81 daily. If so, he might be behind in his reading.
 

dick0236

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I have taking warfarin and 81mg aspirin for several years. Like Superman, my cardio told me that "it will make your platelets a little more slippery"......whatever that means. It does not affect my INR.....or anything else, as far as I know.
 

pellicle

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@Amy

Its an interesting question and I'll have a bash at answering as best I can (and simply).

Aspirin (as mentioned above) acts on platelets, while warfarin works on the clotting factors. From Wikipeida: Warfarin inhibits the vitamin K-dependent synthesis of biologically active forms of the clotting factors II, VII, IX and X, as well as the regulatory factors protein C, protein S, and protein Z.

They work differently (Platlets and Thrombin) and its pretty complex, but the thing is that there is a term "platelet activation" which is key here. Platelets and Thrombin work together to (usually) plug any holes caused by injury. A "spanner" is thrown in the works by the mechanical valve causing activation of platelets (lets call it "smacking them on the arse on their way through the closing door" which isn't strictly correct but it'll do). Aspirin essentially blocks a compound needed for platelets to start aggregating (this one), making this slower.

Platelets are formed 24/7 in the blood but by taking an amount of aspirin you cause damage to some of those around when you're taking the Aspirin. Now Aspirin only has a half life of 20 minutes (so if you take 100mg in 20 min there's 50mg in your blood, then at 40min there's 25 ...) and so it won't effect many of them and they'll recover (which is why you take it daily) because platelets last about 10 days in the blood before new ones replace them.

So because we have a mechanical valve in the "stirring pot" it can cause problems for platelets with bruised arses banding together and forming clots where they aren't wanted (like up in your brain).

The slowing of this allows the body to mop up any roving bands of stuck together (aggregated) platelets before they get any ideas of blocking blood supply in the wrong places ...

Myself I didn't take aspirin after the first year, but recently I've started noticing some strange small vision related things which have "gone away" by me taking Aspirin. So I now take 50mg (half a standard 100mg tablet) every second day.

Seems to be working for me ...

HTH
 

Chuck C

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Hi Amy.

I'm really glad to hear that your wound has closed.

As you know, I have the same valve you have, St Jude mechanical. I was on aspirin 81mg/day (baby aspirin) for about 5 years prior to surgery, just to slightly lower my risk of having a heart attack or stroke. After surgery, both my surgeon and my cardiologist want me to continue taking the aspirin.

Did your cardiologist explain why he wanted you to stop taking it? The literature would suggest that it is beneficial for those of us with mechanical valves.
 
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Amy

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And show your cardio the research. If they have no interest in research, maybe time to shop for a new cardio.
This is already the fifth cardiologist I’ve tried in as many months. None of them really seem to give a ****. Or seems to know what they’re even doing. It’s... disheartening, to say it in a nice way..... but that’s just the way it is. I don’t know how to find a decent one. I’ve tried letting my surgeon recommended one, going by internet reviews, letting the clinic’s secretary recommend the one with ‘good bedside manner’, having a PCP refer me..... it’s a complete joke, this searching for a good cardiologist and not finding one.

@pellicle -
Maybe I’ll try taking one every other day then, like you, and see how it goes (if any vision issues develop, etc). Thanks for sharing your experience.
 

Sheenas7

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@Amy

Its an interesting question and I'll have a bash at answering as best I can (and simply).

Aspirin (as mentioned above) acts on platelets, while warfarin works on the clotting factors. From Wikipeida: Warfarin inhibits the vitamin K-dependent synthesis of biologically active forms of the clotting factors II, VII, IX and X, as well as the regulatory factors protein C, protein S, and protein Z.

They work differently (Platlets and Thrombin) and its pretty complex, but the thing is that there is a term "platelet activation" which is key here. Platelets and Thrombin work together to (usually) plug any holes caused by injury. A "spanner" is thrown in the works by the mechanical valve causing activation of platelets (lets call it "smacking them on the arse on their way through the closing door" which isn't strictly correct but it'll do). Aspirin essentially blocks a compound needed for platelets to start aggregating (this one), making this slower.

Platelets are formed 24/7 in the blood but by taking an amount of aspirin you cause damage to some of those around when you're taking the Aspirin. Now Aspirin only has a half life of 20 minutes (so if you take 100mg in 20 min there's 50mg in your blood, then at 40min there's 25 ...) and so it won't effect many of them and they'll recover (which is why you take it daily) because platelets last about 10 days in the blood before new ones replace them.

So because we have a mechanical valve in the "stirring pot" it can cause problems for platelets with bruised arses banding together and forming clots where they aren't wanted (like up in your brain).

The slowing of this allows the body to mop up any roving bands of stuck together (aggregated) platelets before they get any ideas of blocking blood supply in the wrong places ...

Myself I didn't take aspirin after the first year, but recently I've started noticing some strange small vision related things which have "gone away" by me taking Aspirin. So I now take 50mg (half a standard 100mg tablet) every second day.

Seems to be working for me ...

HTH
I had been taking aspirin low dose for more than 20 years due to eye curtain . I recently went off because it was causing blood in my stool. Cardiologist took me off recently.
 
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cldlhd

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I'm not on warfarin but I've been taking an 81 mg aspirin in the morning and one at night for a few years now. It seems to be one of those things that the doctor and cardiologist are kind of like "I don't think you need it but it probably won't hurt...." Like a lot of things in the medical or nutritional fields It seems to be something that is considered helpful by some and then others say not only don't you need it but it can be harmful.
 

Amy

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Did your cardiologist explain why he wanted you to stop taking it?
I just re-listened to our conversation and he said:

“Let’s stop the aspirin. You’ve been far out from the surgery. I don’t think that’s beneficial. This is a high-flow valve, and you’re on Warfarin... and no one generally takes aspirin. Your heart function is normal. This would be very unlikely for somebody young like you, and kind of otherwise okay, to be on that much of the blood-thinning..... (and) taking the aspirin could be contributing to.. the anemia.”

As a side note, I found out I was anemic even before the surgery, so even without the aspirin I’d probably still be. (That’s one of the many things I wish they’d told me pre-op - to have blood work done and get on iron supplements or whatever for a month or two to better prepare your body. If I’d done that, I wouldn’t have needed a transfusion before they started surgery.)
 
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Lynn

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As I have an anaphylaxis allergy to aspirin and a sensitivity to anything containing ASA so I obviously can’t take it. This was a consideration in my valve choice that I discussed at length with my cardio and surgeon. One concern was, that not being able to take aspirin, I could one day end up on a platelet drug or blood thinner anyway. ( I was on put on plavix by a previous cardio and I bruised terribly-present cardio took me off it) So at the end of the day the choice was an On-x. According to my surgeon, the low INR trials for On-x have included aspirin, so for me the low dose warfarin below 2 is out. My target without aspirin is 2.5, with a 2-3 range. This is fine. Pellicle‘s information has helped me to understand that 2.5 to 3 is a good risk/return trade off. I bruise much less on warfarin than i did on plavix.
 

RAS

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I know lots of you all take both. Does anyone know specifically why? Should I keep taking the aspirin or not?
I take both. Warfarin and aspirin work in different ways. There can be various reasons for adding aspirin.

Aspirin inhibits multiple coagulation related processes including platelet stickiness, thrombin formation, inflammation, fibrin. As a result there are a variety of reasons a given individual may be directed to take aspirin. Initially, I was not asked to take any aspirin. However that changed.

About 6 months after surgery, I had symptoms that led to a diagnosis of fibrin stands on my SJM Regent valve. Presumably some strands embolized causing some temporary blockage. The "standard" treatment for fibrin strands is aspirin. So I began taking 81mg aspirin at that time. After about 7 years the strands were finally gone (or at least too minimal to be visible via echo). During that time, I experienced no further stroke like symptoms although the strands must have embolized.

I continued the aspirin regimen and went the next 8 years with no evidence of strands. However this summer they were visible on my most recent echo. While correlation is not evidence of causation, the only thing I can attribute this to is the colonoscopy I had in February during which I was completely off any A/C therapy for 24 hours. After the echo, my cardiologist asked me to go to a 325mg daily dose for 3 months and then back to 81mg thereafter.

So in my case aspirin is recommended based on personal history specific to formation of fibrin strands. If not for that, I don't believe I would be taking a daily aspirin.
 

Amy

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Hi @RAS,

That’s interesting. Thank you for sharing your experience. I wish I knew whether cases like yours could/should be extrapolated so as to protect everyone with a mechanical heart valve, or not. Slogging through academic papers continues...

Take care. Thank you again.
 

Amy

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It seems to be something that is considered helpful by some and then others say not only don't you need it but it can be harmful.
And if that weren’t bad enough, you have condescending doctors like mine who wouldn’t deign to explain to the patient why they insist on one particular way, even when their opinion goes against recent published research...
 

Mister_James

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The problem is very simple, warfarin effects are measured by INR. Aspirin Effects are not so when you are at say INR 2.5 doctors know how to treat you if something happens that requires them to lower your INR.
Aspirin makes their work nothing but guess work.
 

Amy

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@RAS
I had symptoms that led to a diagnosis of fibrin stands on my SJM Regent valve.
What kind of ‘stroke-like symptoms’ did you have, if you don’t mind my asking?... like, couldn’t speak? Move something? Numbness somewhere? Didn’t anyone say, “we should’ve had you on aspirin from the start”? I guess they probably wouldn’t, at least not in the US.....
 
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