Prothrombin Time

Prothrombin Time

Greetings to the board…..I am diagnosed with Permanent Lone A-fib, am a non-anticoagulated patient, and have a PT INR of 1.0 within the 0.8-1.2 range. Should it be my objective to be in the INR 2.0 – 3.0 moderate intensity therapeutic range that one would be maintaining if following vitamin K antagonist therapy practices? Can one get there by means other than use of anticoagulated drugs? If so, using alternative methods, what protocol would be follow?

I have a CHADS2 risk criteria score of 0. The just completed routine follow-up with my cardiologist where we reviewed results of a recent echocardiogram showed a healthy heart in all respects, including normal ventricular size and function. Wall thicknesses were all within normal ranges, and ejection fraction close to 60%. No remodeling was evident. As their training is allopathic medicine, both my Primary Care doctor and Cardiologist would prefer that I be on vitamin K antagonist therapy, but they do appease and work with me as I pursue alternative approaches to treatment. I fully understand choices and consequences which lie before me.

Though in prior posts on this board I have provided information about my A-Fib history, I am again including some of that here to make it easier for the reader to understand my background.

Am 68 years of age, vegetarian for 37 years, vegan for many, but currently consume salmon, tuna, eggs and raw cheese. Seldom eat processed foods and intake is mostly organically grown. Exercise daily and am a non-smoker. During summers of 2009 and 2010, I began noticing how easily I tired but passed it off to thinking it was a result of increased heat and humidity which we experience in Central Florida. In January of 2011, while undergoing an annual physical with primary care doctor, the ECG identified an irregular heartbeat. Though much of it was silent, in retrospect, there were many signs which went overlooked at the time, as not knowing what atrial fibrillation even was, they went unaddressed. Both my Cardiologist and EP confirmed I was already in permanent A-fib. Underwent routine tests such as nuclear medicine stress, echocardiogram, etc., which identified healthy heart with no identifiable heart disease or structural abnormalities. Arteries were clear but I was faced with heart electrical issues. I have worn the Holter monitor twice over the past 18 months, with findings each time reaffirming permanent A-fib with heart rate at times in the 120 to 130 BPM range.
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Over the next couple months I completed a series of tests with the Primary Care Doctor, a Complementary/Alternative Medicine MD and Natural Practitioner (herbalist). I have over the past 18 months addressed mineral electrolytes, adrenal and thyroid issues, as well as chelation therapy, and am a much improved individual today compared to the person which I was 18 months ago. Seldom feel my heart, and when I do it is usually upon awakening during the night, and is a minimal quiver.

Current supplements consist of:
General:
• Vitamin B-12 (DaVinci 2000 mcg; 1 1000 mcg tablet mid morning)
• Folic Acid (Doctor’s Best 400 mcg; 1 cap mid morning)
• Vitamin B-6 (Solgar 100 mg cap with lunch) *B12, Folic Acid and B-6 to be replaced with Homocysteine Supreme next month.
• Vitamin D-3 (Ortho Molecular 5000 IU; 1 cap with dinner)
• Vitamin K-2 MK-7 (NOW 100 mcg; 1 cap with dinner)
• Water/MSM (1 16-ounce glass with breakfast)
• Kelp Cap (NOW 325 mcg; 1 cap with breakfast)

A-FIB:
• Nattokinase (Doctor’s Best 8,000 FU; 2000 FU morning on empty stomach, 2000 FU mid afternoon on empty stomach, 4000 FU before bed on empty stomach)
• Magnesium (Doctor’ Best 900 mg High Absorption 100 % Chelated; 300 mg with breakfast, 300 mg with lunch, 300 mg with dinner)
• Potassium Gluconate (NOW 2,160 mg; 540 with breakfast, 540 with lunch, 540 with dinner and 540 spread through the day in drinking water)
• Taurine (NOW 3000 mg; 1000 mg with breakfast, 1000 mg with lunch, and 1000 mg with dinner)
• D-Ribose (Healthy Origins 7 g; 1 heaping tsp mixed with water and MSM drink noted above)
• Fish Oil (Rx Omega-3 Factors 800 mg EPA, 400 mg DHA, 1,260 mg Omega-3 fatty acids; 1 cap with breakfast and 1 cap with dinner)
• Selenium (Source Naturals 200 mcg plus 30 IU Vitamin E, 2 mg Vitamin B2, and 150 mg broccoli seed extract; 1 cap with lunch)
• L-Carnitine (NOW 500 mg from L-Carnitine Tartrate; 1 cap with lunch)
• CoQ10 (Healthy Origins 200 mg; 1 cap with breakfast)
• Cayenne (Mountain Rose Herbs 600 mg; 200 mg with breakfast and 300 mg with dinner)
• Turmeric (Mountain Rose Herbs 300 mg with lunch)
• Raw garlic cloves, blueberries, and other blood-thinning foods are consumed daily with meals
• In addition, Super Foods such as chlorella, spirulina, etc. are added into fruit and green smoothies consumed daily.

The combining of foods and supplements gets me to approximately 1,700 mgs of magnesium daily, and I have yet to reach a level of intolerance. The April 2012, EXA result for magnesium was 34.4 within reference range of 34.0 – 42.0, so I am still working to reach the higher end of the range. The combining of foods and supplements gets me to approximately 6,000 mg of potassium daily. The April 2012, EXA result was 108.5 within reference range of 80.0 – 240.0, so I am still extending myself here as well. Potassium to sodium was 21.2 within reference range of 19.4 – 38.9. I try to keep sodium between 500 and 1000 mg daily, and am still trying to get myself averaging the 4/1 ratio.

The May 2, 2012, blood results showed fibrinogen at 252, platelet count of 162, and ECG at 87 BPM. June 20, 2012, ECG at 92 BPM. I take my pulse several times daily and it never exceeds the mid to high 80s.

Now, if you are not dozing and have hung in there with my dribble, I am back to where I began. As I am not on anticoagulation therapy, should my objective be to get within the 2.0 – 3.0 INR range that one would be maintaining if they were following moderate intensity antagonist therapy? Is that even possible? As anticoagulation drugs do not really thin blood, but rather delay the clotting process, is there an alternative avenue to drugs which would get me into the 2.0 - 3.0 range required to delay the clotting process? If so, can someone provide thoughts which would help me navigate to that end? Thanks.

Hi Larry - On the blood viscosity topic, you won’t find a correlation between your Nattokinase therapy and INR or PT which makes it difficult if doctors only want to see the INR level. Nattokinase works on lowering fibrin levels and is measured by the fibrinogen level – your level of 252 is under the recommended 300 mg/dL which is good. Did they also measure ferritin?

Since I have a low platelet count, anticoagulant therapy was always a challenge for me when I was forced to submit to it. For that reason, I did the research on the fibrinolytic enzyme, nattokinase, as a means to lower blood viscosity and consulted with nattokinase expert, Ralph Holsworth DO, for the basic protocols. Additionally, there was strong evidence based on the hemorheology research work of the late biotech pioneer, Kenneth R. Kensey, M.D., that regulating blood viscosity was critical for a number of health issues and not just for arrhythmia.

At present, the culmination of Dr. Kensey’s research at Rheologics is perpetuated by Meridian Valley Laboratories and has been referenced here by Shannon in his posts on the newly available viscosity testing.
[www.afibbers.org]
[www.afibbers.org]

Dr. Kensey’s book, The Origin of Atherosclerosis, Volume 1: An introduction to Hemodynamics and a relevant thesis
A Study of Non-Newtonian Viscosity and Yield Stress of Blood in a Scanning Capillary-Tube Rheometer offer the background of viscosity study if you care to strain your brain and delve deeply into the topic.
[dspace.library.drexel.edu]

However, and thankfully, a recently-published article in Townsend Letter for Doctors and Patients is an article Measuring Blood Viscosity to Improve Patient Outcomes by Pushpa Larsen, ND and Ralph O. Holsworth, DO, which provides relevant details without the brain strain. It’s available online at this link. [www.townsendletter.com]

Dr. Holsworth is the #1 nattokinase expert in the US and works with Jonathan Wright MD at the Tahoma Clinic in Renton, Washington.

Although considerably more expensive, Garry F Gordon, MD. DO, MD(H), President, Gordon Research Institute. www.gordonresearch.com
is a big fan of lumbrokinase... he says:
For those seeking natural alternatives to Coumadin, I recommend that they switch to far safer and even more effective enzymes such as Boluoke (Lumbrokinase), or Nattokinase. Lumbrokinase is extracted from Chinese earthworms, while the Nattokinase enzyme is derived from fermented soybeans that the Japanese call Natto. Both of these natural substances target fibrins in the blood, helping the body naturally break down and digest blood clots safely.

As additional consideration-- While doing the nattokinase research, I learned of the work done at Hemex Laboratories using heparin for managing fibrin and blood viscosity in patients who either could not tolerate warfarin (the only thing available back then) or had specific hypercoagulation disorders that did not respond well or easily to warfarin. The founder, David Berg, has sold his business but much of the data remains accessible thanks to the Internet and Google. Here’s one reference: [www.anapsid.org]

I mention the Hemex research because of the links explaining causes of hypercoagulation as explained in this referenced article are important to recognize in situations such as yours….. leave no stone unturned to be safe. Anticoagulant drugs may prevent adverse clotting but it’s also important to rule out anything that may promote hypercoagulation. From that link:

Berg states that there are at least three possible causes for this thrombin malfunction:
• Viruses, bacteria and/or parasites can activate certain antibodies in the immune system, which in this case trigger the continual production of thrombin, generating excessive SFM and fibrin.
• Predispositional genetic defect in coagulation regulatory proteins (protein C, protein S, Factor VL, prothrombin gene mutation, PAI-1, Lp(a), or elevated homocysteine.
• Chemical exposure can result in changes that trigger the coagulation process.

In the original 2002 post titled Red Flags to Beat the Odds, specific markers for lab testing were reviewed as important for everyone but especially afibbers to request from their physicians. Many are still not included in routine testing.
[www.afibbers.org]

My last comment, Larry, is that if I were faced with going on an Rx anticoagulant drug, I’d be doing exactly as you are now. And...managing inflammation is a key factor so be sure that you ask to have the Cardiac or High Sensitivity C-reactive Protein test included. See the Red Flags post for details.

When I opted not to use the anticoagulant, my Functional Medicine MD insisted that I take at least 4 grams, preferably 6 grams a day of a high- quality (pure) Omega 3 Fish oil. She said that would keep my ‘platelets slippery’ and prevent them from clumping. I like the Natural Factors product you take, but I’d be taking more. Magnesium also is anti-platelet aggregation/clumping so continue to push to your maximum tolerance and tissue saturation.

Keep up the good work and let us know the details if you decide to order in tests from Meridian Valley.

Best to you.
Jackie



Edited 1 time(s). Last edit at 06/29/2012 02:52PM by Jackie.

Jackie, Am grateful to you for the thorough response. Your very first sentence provided the answer to my inquiry. I am going to take a day or so to digest all that you had to say and follow through in reading the links you provided. I will then summarize, and get back to the board. Thanks much.
Regards,
Larry

Jackie,
I believe the misunderstanding that I have had regarding vitamin K antagonist INR ranges and fibrinogen ranges has been cleared, and I now get it. As a non-anticoagulated patient, stroke considerations should not be directed to INR levels, but instead, be focused and directed to fibrinogen and the lowering of its levels.

Though I have this past year been making an effort to maintain fibrinogen levels between 200 and 300 mg/dl, I had not understood vitamin K antagonist ranges should be of little concern to me. I feel certain that both my diet and supplements have had a direct impact to the lowering of fibrin and thinning of my blood, so I will begin a renewed focus towards reaching the lowest acceptable safe fibrinogen level. As much of the progress which I have made to date has been through trial and error, I maintained detailed notes of what appeared to be working and what was not. I will continue that process with enhancements. I, of course, do not want to cross the threshold of thinning the blood to the degree that would cause hemorrhaging, so I will proceed with caution. On those occurrences where I have recently received minor cuts while working outdoors, the blood thickness in appearance is like water, yet still clots without difficulty. Do you feel my present 8,000 FU dosage of Nattokinase is sufficient, or should an increase be considered? You mentioned your Functional Medicine MD wanted you at 4 to 6 grams of Omega 3 fish oils during the time which you were not anticoagulant, and you suggest an increase of my current 800mg EPA, 400mg DHA, and 1,260 Omega-3 fatty acids might be warranted. Would you mind providing an opinion on what that level should be?

There has been no ferritin measurement provided with my lab results. I had not been familiar with ferritin so consequently did not understand any importance it might be to me. From what I have read from your "Red Flags to Beat the Odds" link, I understand the importance of knowing its measurement. Knowing that I do have inflammation gives cause in itself.

The hs C-Reactive Protein lab result was a 0.7 which was in the optimal range. My Homocysteine has been the greatest of my concerns as that result was a high risk at 14 on March 15, 2012. I immediately added into my supplementation B12, B6, and Folic Acid, and the results from a retest just a little over a month later indicated a drop to 11.1. I have since added Vitamin C to the mix and have hopes that I will see a further drop in the next test results. I am about to transition from the B12, B6, and Folic Acid cocktail to the Homocysteine Supreme supplement by Designs for Health, which you recently recommended. The Lp(a) mass (mg/dl) result was 9, within optimal range.

I have been familiar with Meridian Valley Laboratories from earlier posts on the board, and have been in touch with them regarding the blood viscosity test. If I recall correctly, the cost is $195, plus lab fees at the location where blood is drawn. There has been confusion on my behalf about whether Medicare would cover the cost, but that was recently cleared up by Shannon's Meridian link which carries a statement that the test is not covered by insurance. As it is important that I establish a viscosity baseline, I will try to arrange my finances to move on it soon.

I greatly appreciate the time you have given in responding to my post. You are a Champion to many on this board. I look forward to any further comments, suggestions or links which might come my way.
Regards,
Larry

Back again, Larry… I’ll respond to your comments interleaved below:

Jackie,
I believe the misunderstanding that I have had regarding vitamin K antagonist INR ranges and fibrinogen ranges has been cleared, and I now get it. As a non-anticoagulated patient, stroke considerations should not be directed to INR levels, but instead, be focused and directed to fibrinogen and the lowering of its levels.
->Stroke considerations involve blood viscosity or thickness… and measuring by INR is the typical monitoring method preferred by physicians… If they had their way, they’d put every afibber on warfarin/Coumadin or similar anticoagulant to reduce the adverse clotting risk… although, as we know, it’s not a total guarantee and many variables need to be considered.


Though I have this past year been making an effort to maintain fibrinogen levels between 200 and 300 mg/dl, I had not understood vitamin K antagonist ranges should be of little concern to me. I feel certain that both my diet and supplements have had a direct impact to the lowering of fibrin and thinning of my blood, so I will begin a renewed focus towards reaching the lowest acceptable safe fibrinogen level. As much of the progress which I have made to date has been through trial and error, I maintained detailed notes of what appeared to be working and what was not. I will continue that process with enhancements. I, of course, do not want to cross the threshold of thinning the blood to the degree that would cause hemorrhaging, so I will proceed with caution. On those occurrences where I have recently received minor cuts while working outdoors, the blood thickness in appearance is like water, yet still clots without difficulty. Do you feel my present 8,000 FU dosage of Nattokinase is sufficient, or should an increase be considered?
-> Certainly, your approach makes sense. My experiences with using nattokinase (NK) have been similar to yours for minor cuts and such which form clots in the appropriate time.

The typical NK dosing in active afibbers is 6,000 FU in divided doses making sure that you never miss the dose that will carry you through the early morning hours when the adverse clotting factors are more prevalent. If you feel comfortable cutting back, it may save you a small amount of money.

You mentioned your Functional Medicine MD wanted you at 4 to 6 grams of Omega 3 fish oils during the time which you were not anticoagulant, and you suggest an increase of my current 800mg EPA, 400mg DHA, and 1,260 Omega-3 fatty acids might be warranted. Would you mind providing an opinion on what that level should be?
-> Yes, I think it would be reasonable for you to increased to a minimum of 4 grams a day total Omega 3 fatty acids.
I used the full 6 grams (divided doses) for 3 – 4 years and then much later, post-ablation, cut back to 3 – 4 grams daily. I like the protection of slippery platelets combined with age and the DHA for brain function support because of my age.

There has been no ferritin measurement provided with my lab results. I had not been familiar with ferritin so consequently did not understand any importance it might be to me. From what I have read from your "Red Flags to Beat the Odds" link, I understand the importance of knowing its measurement. Knowing that I do have inflammation gives cause in itself.
-> Yes… next time for labs make sure they do ferritin. If high, then consider donating blood until the number is lower.
If it’s high, you can read the many past posts offered by Isabelle on the topic of Iron Overload (hemochromatosis).

The hs C-Reactive Protein lab result was a 0.7 which was in the optimal range.
-> Excellent. That’s very comforting.


My Homocysteine has been the greatest of my concerns as that result was a high risk at 14 on March 15, 2012. I immediately added into my supplementation B12, B6, and Folic Acid, and the results from a retest just a little over a month later indicated a drop to 11.1. I have since added Vitamin C to the mix and have hopes that I will see a further drop in the next test results. I am about to transition from the B12, B6, and Folic Acid cocktail to the Homocysteine Supreme supplement by Designs for Health, which you recently recommended. The Lp(a) mass (mg/dl) result was 9, within optimal range.
-> At least you’re going in the right direction with the homocysteine… it can take considerable time to lower significantly so keep working at it.

I have been familiar with Meridian Valley Laboratories from earlier posts on the board, and have been in touch with them regarding the blood viscosity test. If I recall correctly, the cost is $195, plus lab fees at the location where blood is drawn. There has been confusion on my behalf about whether Medicare would cover the cost, but that was recently cleared up by Shannon's Meridian link which carries a statement that the test is not covered by insurance. As it is important that I establish a viscosity baseline, I will try to arrange my finances to move on it soon.
-> If you can manage to do it, I think it would go a long way toward validating the methods you’re using to maintain a favorable blood viscosity level and still not be using Rx anticoagulants. Keep good notes and give us a full report.

I greatly appreciate the time you have given in responding to my post. You are a Champion to many on this board. I look forward to any further comments, suggestions or links which might come my way.
Regards,
Larry

->Thank you Larry, you are far too kind. I’m glad to help however I am able and since the blood viscosity issue was a huge concern to me and with so much time spent on the research, I’m happy to share with anyone interested. I’ve commented in other responses, that thanks to the clot-lysing powers of NK, I didn’t have a calamity when a clot formed in the LAA after cardioversion, 103 days post ablation. In fact, I didn’t even know about it until about six weeks after the fact when I finally received a copy of the report on the post-procedural CT scan. Dr. Natale and I had a good chuckle about the powers of NK doing it’s job and the fact that I was still alive to tell about it! No laughing matter. I was off the coumadin by then but had resmed the 6,000 daily dosing just because I thought it was a good idea. When I think back, I’m most grateful for whatever force drove me to that decision.

I wish you every success with keeping your blood viscosity in a safe range. At some point in time, be prepared for your doctors to resist honoring your preference. For that reason, the Meridian Valley testing may become a valuable tool – either one way or the other.

Best to you,
Jackie

Hi All,
I am extremely interested in this thread (thank you to Larry and Jackie). I read it thoroughly and I am going to follow all the links. I have a lot to say on the subject, but I see the thread is 6 years old, so not sure if anyone out there is still listening/interested? If anyone (at all!) responds, I'll start posting! Thanks Rob