[HSF] Unusual response to warfarin

[Tea Acuff]

Bob,
Thanks for you insights. Fortunately I did not have to give my daughter Vit K so I really did not get a feel of back a forth with Vit k and coumadin like I might using TNG and epi.
tea


----- Original Message ----
From: "Rwmfglycar at aol.com" <Rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, July 11, 2007 8:09:24 AM
Subject: Re: [HSF] Unusual response to warfarin


In a message dated 7/10/2007 10:26:23 P.M. Eastern Daylight Time,  
prasannasimha at gmail.com writes:

> I  think that there are probably patients who are quite "brittle" to borrow 
a  word (sorry, Ben). 
> The other thing to consider is the usefulness of  home testing and 
patience. Even a mg or two a day when the patient is taking  10mg can make a 
difference.  There is a lag of around 48 hours or so  before what ever you did is 
noticed. (I learned this  treating my  daughter at home despite two decades of 
"managing coumadin" in my  practice...all three points) What you describe is the 
same thing with the  hypersenitive and heavy handed yet diligent nurse (or 
anesthesiologist, anyone  but us) pushing the BP from 60 to 200 and back to 60 
with drips in the ICU.  Bet you have seen that, too.
> The last thing to remember (for which i  would like confirmation from our 
experts) is that our targets (much like our  "best practices") are misleading 
as are my analogical thoughts. As in the ACT  on CPB higher is not necessarily 
"more" anticoagulated or more to the point,  less thrombotic, right Ben?, but 
decreases the frequency of drop to below  anticoagulated. I was told by 
another expert that an INR over 2 is all that is  needed, but a level of 2-2.5 means 
that the patient spends frequent time below  2. (See above.)
> tea
>



Tea,
It is all about Titration and the variability of individual response  whether 
you are dealing with inotropic or vasoactive drugs, coumadin or heparin  or 
adjusting preload with volume. As you say patience is crucial and also direct  
involvement. Titration by proxy is never quite the same and that brings us to  
the unstretchable nature of time and the very difficult issue of the  use of 
our time.
Coumadin is one of the worst drugs we use or should I say most difficult.  
With some patients it is a breeze but in others always tricky. Your comments are 
all apt. Yes the patient is likely to spend time below 2  or  above 2.5 if 
the hoped for range is 2-2.5. Only the people on home testing  can tell you 
this. What can we possibly know with weekly or monthly testing? The  good news is 
that most patients who are trying to follow directions  avoid  valve 
thrombosis and hemorrhage most of the time. The consequences of not  following 
instructions can vary to an extraordinary degree; I saw a patient who  thrombosed her 
valve completely in two weeks while under anticoagulated and  another who 
stopped attending the coumadin clinic, could not be found and  puttered along for 
a year before finally coming to the ER with pulmonary edema  and a mixture of 
pannus and thrombus. (Note that I did not mention emboli: the  primary 
purpose of coumadin is prevention of valve thrombosis; platelet active  agents are 
needed to prevent emboli, although trials are underway to test   effectiveness 
at preventing thrombosis).
Tea you observed a 48 hour lag in response to changes in dosage. In  a 
patient who had been bleeding and in whom a reduction  in anticoagulation effect was 
desired what would be the lag after an  oral dose of Vitamin K?  (I get asked 
these kinds of  questions).
For Prasanna: Dieter Horstkotte ran the Gelia trial and determined  where the 
lines depicting hemorrahge and thrombosis crossed.
Bob





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