My INR Dilemma - what would you do???

I am 2.5 weeks post ablation for afib / flutter and doing great! feel great and back exercising lightly.....BUT........my INR as of Monday was 1.6......I took Lovenox shots for 5 days post ablation and 5 MG Warfarin........first INR was 1.0 nowhere.......tenI went to 7.5 and 1.6 and now 10MG since Monday with a new INR test tomorrow (Friday)....my EP says if ot at leat 2.0 then Pradaxa.....which I do not want!

Here's the deal.....my CHAD is zero........I am fit, lean, athletc, perfect diet use Ubiquinol, fish oil, mag, hi K diet etc etc......I have read ON THIS SITE that in some low risk cases they give aspirin only following an ablation...........what is my clot / stroke risk really......is it less after 2.5 weeks or more? is there clot risk due to the procedure? or due to quit afib? I have not had any skipped beats, nothing since the ablation, no afib ZERO.....

just looking for ideas in the end I will make my own decision.........maybe stay of 5 MG warfarin anyway? maybe switch to Natto and aspirin and fish oil and Ginko?

woud love to know what you would do?? and keep in mind I may be 2.0 by tomorrow AM

wow lot of action on the site this morning!!

damn afib!

Tom P

Tom,

Yeah, the INR is pain. If you are at 1.6 taking 10mg you will get there (as long as you stay away from the spinich salad). In fact, don't be surprised if you overshoot the mark.

Did Holshouser mention Xarelto as an option? It is approved in the US and has an antidote (Pradaxa does not have an antidote). I have read positive comments on other sites about Xarelto, although it is expensive (you have probably satisfied your deductable at this point).

Since you are this close, unless it is just making you feel like crap, just stay the course.

Hang in there-

EB

thanks E B, we have a friend on Zaelto or Xarelto...? .........I am just hopeful that my INR goes to 2.0 tomorrow

TP

Does the CHAD score include "a recent ablation?" Or even a recent "heart procedure" of some type? My guess is that if it does not, it might not be all that relevant here.

As much of a pain as it is, I'd say you have to, like your EP suggests, stick with the coumadin for 90 days. I would also wonder if patients allowed to just use aspirin may have the opposite problem you are having. They may be hypersensitive to blood thinners, or have thin blood to begin with, and are consequently prone to bleeds.

Tom,

I would stick with the warfarin for at least 2 months after which the risk of a procedure-related clot should be pretty minimal. I stayed on it for six weeks myself. Once you are over that period there is no need for warfarin or aspirin with a CHAD score of 0. In any case, aspirin is next to useless when it comes to preventing or breaking down fibrin-rich clots which is what would be formed in the case of an ablation.

Hans

Hans thanks that's what I'll do......but......at 1.8 or 2.0 am I protected.......?

Tom

Tom P
Absolutely you need to be on Coumadin for at least 3 months post ablation. You obviously have genetic Warfarin/Coumadin resistance which can be tested for but the very fact that you are taking 70mg a week now and still are not at 2.0 is proof positive that yoy have Warfarin resistance

So do I! I need 13mg a day to get to around 2.3 to 2.4 INR stably. In 2008 I needed 15mg a day just to get to 2.2!

There s no down side consequence from needing to take a higher than typical dose. Your body simply metabolizes it much faster than the average person but there is no greater toxicity taking 15mg a day than there is 5mg a day so long as the INR level is the same!

The fact that your EP thinks that 10mg is a threshold where he would put you on Pradaxa if you need more than 10mg is surprising to me! Maybe he hasn't worked with many Warfarin resistant patients?

In any event, tell him you want to keep titrating upward on Coumadin for now ..next go to 12.5mg for 5 days and retest. if you are still not at 2.0 or above, then go to 15mg and retest in 5 days to a week, but stay lower than 3.0... You will likely need somewhere between 13mg and 15mg a day to get the INR locked in comfortably between 2 and 3 if you are only at 1.6 at 10mg. Maybe 12.5 will work but that is the lowest level that is within range of getting you to 2.0 from a levle of 1.6 now on 10mg a day.

Good luck,
Shannon

Shannon thanks makes total sense.....and appreciate the answer to a question I was wondering about.....if higher Warfarin is needed is it more toxic? thanks

Tom

Tom
My cardiologist is putting me Xarelto once a day 24 hours fast
Acting protection 1-2 hours.....wonder if this would be good for PIP Too?
Hans looks like my TIA puts my Chad score at 2 now
What does that means in terms of ablation? Can I eventually wean
Myself off? The neurologist told me I would be at the same risk at general
Population with a successful ablation?

McHale,

The CHADS2 score applies to people with atrial fibrillation. If, after a successful ablation, you no longer have afib it no longer applies to you.

Hans

McHale,

You can come off the Xarelto prior to your ablation. Your surgeon will have a protocol for that; during surgery you will be on Heparin or something a lot more powerful that Xarelto. Post op, if your surgeon puts you on Xarelto you don't have to do the INR dance like Tom P is going through.

I have read good things about Xarelto, fewer side effects than coumadin, has an antidote (unlike Pradaxa, which does not). About the only downside I have read is the cost. Quite a bit more expensive than coumadin.

Good luck, hope it works well for you until your procedure-

EB

EB, I've been on Xarelto since May and wasn't aware that an effective antidote has been identified. Could you tell me more? That's been my biggest concern with the medicine, I've had no GI or other issues and it's easy to use since there are no dietary restrictions or required tests.

I did stop Xarelto 72 hours before my ablation (6/25), was on more potent blood thinners during the procedure, and went back on it the evening following surgery.

Cathy,

There is NOT an effective direct and fast antidote for Xeralto, as yet!!! This is misleading information, no doubt promoted by Xeralto's manufacturer to address the biggest hesitation toward wider adoption of these new blood thinners.

The reversal agent they did find that 'technically' seems to work is Prothrombin Complex Concentrate or PCC which is NOT found and not stocked in any ER or Trauma Center in the USA! My niece is Chief Attending Physician at one of the largest Trauma Centers in Houston Texas and just completed a large presentation to be sent to all many trauma centers outlining the dangers of these new agents, from the ER physicians perspective, until and whenever there becomes a widely available and truly fast acting 'direct' reversal agent.

From the ER docs perspective they recommend sticking with Coumadin unless there is some obvious contraindication for VKA type blood thinners. Its a case of the devil we know in this case is overall safer than the new devils we are just getting to know now.

She has outline one horror story after another they have had to deal with, including one man on Pradaxa not long ago who came into their Trauma Center with a small cut in his ear lobe and it tuned into a 22 hour massive struggle to save his live with over 60 full units of blood transfused and a last minute dialysis needed to finally save his life. Had this man come into any typical smaller ER and not a full scale Level 1 Trauma Center in a major city, he would have been dead for sure!

Back to PCC, it is not a very fast acting agent as well such that its practical usefulness in a real emergency is highly questionable at best!

Yes, they are technically correct is saying that PCC has been shown in couple of studies to reverse the blood-thinning effects of Xeralto as it moves out of the system. But it's very easy to imagine that in many cases the damage from excessive bleeding will already have been done before anyone could ever have a chance to have PCC injected and then the time required for its reversal action to start taking effect.

So don't be mislead thinking this is the magical answer to all our dreams. PCC is not a real answer in a practical sense for anyone at this point in time.

If you start taking Xeralto now and wind up in an ER/Trauma Center for some issue involving bleeding, it is exceedingly unlikely you would even get any PCC before the natural metabolizing function of the drug has already slowly reduced its blood thinning effect, which the ER docs will try to speed up with transfusions .. and if need be a dialysis .. in any event.

Xeralto also has a big black box warning about significantly increased risk of stroke when someone has to stop Xeralto, without carefully re-titrating back up on Coumadin or moving to Pradaxa.

Chosing these new agents at this point is a role of the dice! And we all know Coumadin has its well know risks, hassles and downsides too. The AFIB docs who are on board with these new drugs use the Pharmaceutical reps statistics showing that the small reduction in bleeding risk with Xeralto versus warfarin will mean less bleeds overall needing to be addressed in the ER, but that is debatable and is small comfort in any event for any one having an emergency involving bleeding while on these agents. At least with Warfarin, usually they can get you reversed pretty quickly with Protamine or Vitamin K injections and every ER in North America and Europe, no matter how small, knows just how to do this.

Xeralto does seem to be better than Pradaxa and certainly seems to pose less GI troubles than Pradaxa. And at least PCC does technically work with Xeralto even if it is not the kind of practical solution to this problem at all that Janssen Pharmaceuticals would like us all to buy intoi Alas, Pradaxa has no reversal agent at all at this point!

I hope Eliquis (which is Apixiban), whenever it is finally approved, comes with a more effect reversal agent before long than either of these first two new blood thinners now have. Until then, doing weekly rather than monthly or bi-weekly INR tests with Coumadin/Warfarin (using a home meter makes it more convenient) may be the overall safer approach for most afibbers?!

Shannon

Cathy,

Here is a link: [www.theheart.org]. Rivaroxaban is Xarelto.

There definitely is conflicting information on the internet; I saw several posts that said there was no antidote. One post stated that Activated Prothrombin Complex may be an effective antidote, however clinical trials had not been completed.

My EP told me there was an antidote, (I had asked him about Pradaxa, and he replied that there was no Praxada antidote, but there was a Xarelto antidote.) I plan to ask him again in a couple of months, that is rather curious.

Sorry for the conflicting information, I would have no reason to not believe my EP (and he said he was prescribing it for other patients).

EB

Hi McHale,
Glad to hear you are doing okay and that they have a plan for you! Xeralto may well be a good choice in your situation if the docs are confident they can get faster protection on board for you than with some combination of Coumadin titration and either Lovenox or Heperin in the interim while the Coumadin builds up to a protective INR level?

But in the interest of sharing as much relevant info as we now have, many top ablationist, including all of Natale's groups of EPs in Texas, Ohio and California, are strongly for sticking with Coumadin for two months to 6 weeks prior to the ablation, as well as unbroken continuous Coumadin coverage through the ablation.

During the ablation itself, the Natale trained EPs use supplemental IV Heparin in addition to your already therapeutic level of INR with Coumadin/Warfarin on board, to insure an ACT (Activated Clotting Time) of >350 prior to transeptal puncture.. This is a very safe protocol and range of ACT in helping to insure minimal possibility of any thrombotic issues during the ablation.

Afterward, Dr Natale prefers to keep people on Coumadin for up to 6 months after their ablation, after which, if they still need too continue with anti-coag for any reason, he supports either staying with Coumadin or switching to Xeralto. For some patients, he does allow the switch to Xeralto too fairly soon after the ablation.

But prior too and going through the actual ablation itself they have published studies showing a definite improvement in reducing any clotting issues as well as strokes/TIAs when not jumping back and forth from one type of agent to another in the weeks before as well as during the ablation and in the weeks and first months right afterward while the healing is still taking place.

Shannon

Hi EB,

Its understandable why your EP thinks there is a reversal agent. There have been one or two published small studies showing it technically works and most front line docs get their initial information and marching orders from the pharmaceutical reps as it is. I'm sure he is not trying to be misleading and is no doubt quite sincere. That is why my niece and many others at the front lines running large Trauma Centers who actually see the results all too frequently and better understand the practical limitations of getting, storing and using PCC in an ER/Trauma setting are so urgently trying to raise this alarm!

They are the ones who are spending many hours of critical response time trying to save some of these people coming in with all sorts of injuries or bleeding from any source while on Pradaxa/ Xeralto.

To be sure, not everyone who gets a bleed while on these agents has it turn into a life or death emergency. But it is happening with sufficient regularity that this has in the last two to three months become a BIG topic in the Trauma Doc's world .. worldwide.

Most EPs get have made the choice based on the drug makers stats to-date.. which are still very much subject to revision now that these drugs are finally getting out to the public at large and we are having enough time pass for these unexpected issues to become very real.

Every EP is anxious and excited as well for one of more of these new agents to prove themselves to work well and be safe, so there is a natural inclination for many of them to give these drugs the benefit of the doubt as well, now that they are approved and until proven otherwise with greater time and experience.

I hope that the work now toward a proper antidote that all the Pharmaceutical companies are no doubt desperately trying to develop will pan out as soon as possible to make the whole issue an easier and safer choice for all of us. Until then, buyer be aware that most drugs come out of the shoot with a lot more fanfare and promise than they wind up deserving long term. Even when supported by very well-meaning and excellent doctors and EPs.

Xeralto seems like a good blood thinner and with a proper antidote perhaps a great one?! However, just don't take any 'real-world' comfort from the supposed antidote of PCC at this time.

Shannon

P.S. EB

The 'PCC' acronym that I refer too above stands for 'Prothromin Complex Concentrate', so we are both talking about the same reversal agent drug. Alas it is a limited practical reversal agent for Xeralto (but not Pradaxa) and that also can be used to reverse Coumadin in people with significant bleeding and coagulopathy with an INR greater than 8.0 ... Alas, it is just not found in ERs anywhere and is not easy to use and has to be refrigerated etc.

Cheers! Shannon

Shannon, thanks for the information. Long story short, my first EP put me on the Xarelto before I knew anything about afib, and when I left that doc for one I was more comfortable with, the new EP was interested in seeing how I did on Xarelto because his hospital (Barnes - St. Louis) uses either wafarin or Pradaxa. When I prepped for the ablation, he just had me stop Xarelto cold, so much for the black box warning. I'm a little uncomfortable now, feeling more like a guinea pig than I'd like.

EB, don't worry about the possible misleading info - we're all learning from each other here. I've learned 100X more from support groups than I did from my doctors, I have to say!

Cathy

Shannon,

Thanks very much for the clarification- the link I posted was one of the studies you referenced.

I plan to discuss this with my EP on my next follow up-

Thanks

Hans Larsen Wrote:
-------------------------------------------------------
> McHale,
>
> The CHADS2 score applies to people with atrial
> fibrillation. If, after a successful ablation,
> you no longer have afib it no longer applies to
> you.
>
> Hans
Hans you're the best you know your stuff!
That's exactly what the head Neurologist just told me I go back to the risk of the general population since it's the afib throwing off my clots that caused the tiny mild strokes. I actually had a tiny mild ischemic stroke and two other older ones I didn't know about that showed on the MRI . Wow I dodged 3 bullets!
Cool! What a relief to know Chads no longer applies.

I second what McHale said, thank you Hans. Last year at my annual checkup I saw an EP, not my usual one, who said that my Chads2Vasc score was 2 - one for being female and one for being over age 65, so I should be on Warfarin, even though I have been in sinus rhythm for almost 10 years since ablation in Bordeaux. I declined.

My GP says that since I don't have Afib the Chads2Vasc doesn't apply. But this EP would have all females over the age of 65 on Warfarin for the rest of their lives, which seems crazy to me.

Gill

Gill, totally agree.......my question to EP / Cardiologist is "why am I being anticoagulated if I am not in afib"? sit back and listen to his answer!

As I said in another post we hae a female friend 64, new afibber......6 or so one hour episodes in the last 6 months......she is on flec and Xarelto.....I went wild!

I begged her to ask him his reasoning .......and now thanks to Shannon I know there isno real anecdote for this drug!! bleeding would be very hard to stop!
You................? 10 yrs NSR and anticoagulated? sorry I don't get it

Tom P

Tom

My excellent GP said that cardiologists are terrified by stroke risk because they see so many people who have had damaging strokes, and that's why they push for anticoagulation even for people in nsr. GPs see a wider range of patients so have a more balanced view IMO.

I listen to all the information and do as much research as I can, then make my own decisions.

Gill

Shannon,

Thank you for this very valuable "real world" information about the new anticoagulants. I do not understand how the FDA and Health Canada could approve these drugs knowing that there was no effective antidote and there certainly was not when they were approved. The term "criminal negligence" comes easily to mind.

Hans

FiveBox Wrote:
-------------------------------------------------------
> Cathy,
>
> Here is a link:
> [www.theheart.org][url=htt
> p://www.theheart.org/article/1279393.do][/url].
> Rivaroxaban is Xarelto.
>
> There definitely is conflicting information on the
> internet; I saw several posts that said there was
> no antidote. One post stated that Activated
> Prothrombin Complex may be an effective antidote,
> however clinical trials had not been completed.
>
> My EP told me there was an antidote, (I had asked
> him about Pradaxa, and he replied that there was
> no Praxada antidote, but there was a Xarelto
> antidote.) I plan to ask him again in a couple of
> months, that is rather curious.
>
> Sorry for the conflicting information, I would
> have no reason to not believe my EP (and he said
> he was prescribing it for other patients).
>
> EB
My cardiologist told me there is a reversal agent or the're working on one over the phone. As luck has it my 4 month followup with him is Tuesday. I tend to believe him because he is also sort of kind of a friend dated his wife's best friend a few years back. I'm a little concerned about Shannon's posts who I put great credibility in so I'm going to grill him. For now I need to keep anticoagulated real quick just in case there is still some clot left in my LAA. Today I got nauseous and a little weak in the heat after I got real angry so I went into a panic that I was having another attack. I think it was a panic attack so I went home quick and hung out with my doorman who watched me and we have Mt Sinai emergency room right up the block too! This is too scary now!

"Today I got nauseous and a little weak in the heat after I got real angry"
Hello Mchale. Your mention of getting real angry in the heat reminded me of myself. The one thing that is most likely to throw me into an afib episode is rage, and heat surely does not help that, probly makes it worse. Since i no longer associate with my teenage nephew, the one who lived with me for a while, these episodes have mostly stopped happening. Most of the things in modern life that can make one murderously angry are unavoidable, though, unlike pesty relatives. Best of luck to you in your dealings with whatever that was.

PeggyM