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Re: Aortic Valve Replacement
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Re: Aortic Valve Replacement

Posted By Nate Jones on January 26, 1999 at 12:13:00:

In Reply to: Re: Aortic Valve Replacement posted by CCF CARDIO MD - CRC on January 25, 1999 at 13:49:26:






I am a 37 year old male in good health.  I have Aortic Valve Replacement at Fairfax hospital by Dr. Edward Lefrak on January 23, 1996.  I had a St. Jude Mechanical valve placed.  I am Warfarin resistant.  I take 23.5 mg of Coumadin per day to maintain an INR of between 2.5 and 3.5.  I had to be hospitalized twice in the first 6 months post surgery.  Once for a Basal Ganglion Infarction, from which I recovered completely and once simply to be placed on Heparin due to a low INR.  I have been ok since then.  I would like to get rid of this valve.  Are there any other options availible to me?  Have there been any advances in cloned valves?  As a young, active person I am not sure an animal valve is the answer.  I just feel as though I am literally a ticking bomb.




________


: Dear Christopher,
Thank you for your question.   If you are able to achieve and maintain an adequate INR on warfarin (coumadin) I would not think it worthwhile to change your valve.   Some people will require higher dosages and yours is one of the higher ones I have seen.  However, now that things have stabilized  the risks of subsequent surgery may outweigh the benefits of being off anticoagulation.   There is nothing in the near future with cloned valves and if you received a tissue valve it would most certainly need to be replaced several times.  I suppose one option might be to start an injectable heparin called low molecular weight heparin.    This type of heparin does not require blood monitoring but is costly and is not FDA approved for this indication.  
Be sure that you are not doing anything that could be interacting with the coumadin.  There are many drugs that interact with coumadin (see below).  Common foods such as grapefruit juice, leafy green vegetables and many drugs can change coumadin levels.  Smoking also changes drug levels.  Also be sure to take the same brand of drug each time and always take the drug at the same time of day (usually 6pm).
The following is information on warfarin and it's drug interactions.  
Coumadin (generic name Warfarin) is a anticoagulant (blood thinner) that is used for a variety of conditions.  Common reasons for coumadin use are in atrial fibrillation to reduce the risk of stroke, in persons with clotting disorders, in persons with mechanical heart valves, and sometimes in people with severe heart failure.  The usual dosage is somewhere between 1 and 15 mg a day.  Potential side effects include bleeding, hair loss, nausea, vomiting, stomach cramps, diarrhea and leukopenia (low blood cell count).  The half life (amount of time for half the drug to be cleared from the body is 42 hours but varies widely depending on the individual).  
Many drugs interact with coumadin and may cause more anticoagulation effect (clofibrate, diazoxide, ethacrynic acid, nalidixic acid, phenylbutazone, salicylates, aspirin, sulfonamides, alcohol, allopurinol, amiodarone, cimetidind, phenytoin, erythromycin, gemfibrozil, propranolol, thyroid drugs) or decreased anticoagulation effect (smoking, estrogens, vitamin K, aluminum hydroxide - antiacids, cholestipol, spironolactone).  See complete list below.  The effects of coumadin must be carefully monitored by a blood test called an INR.  Usually this is checked more often at the onset of taking the drug and less often once a steady state has been reached.  Therapeutic INR is usually 2 to 3 depending on the condition being treated.
Pregnant women and those with a hypersensitivity to coumadin should not take this medication.  
The medication should not be taken with food and any signs of bleeding should be reported to your doctor.  Use a soft toothbrush, avoid hazardous activities, carry Medi-Alert ID identifying drug useage and notify your doctor if you have any dark brown urine or red or tarry black stools.
Known Drug interactions with Warfarin
Increased Effect :
                       Highly Probable
                            Alcohol (if concomitant liver disease)
                            Amiodarone
                            Cimetadine
                            Clofibrate
                            Cotrimoxazole
                            Erythromycin
                            Fluconazole
                            Isoniazid
                            Metronidazole
                            Miconazole
                            Omeprazole
                            Phenylbutazone
                            Piroxicam
                            Propafenone
                            Propanolol
                            Sulfinpyrazone
                       Probable
                            Acetaminophen (Tylenol)
                            Anabolic steroids
                            Aspirin
                            Chloral Hydrate
                            Ciprofloxacin
                            Dextropropoxyphene
                            Disulriam
                            Quinidine
                            Phenytoin (Dilantin)
                            Simvastatin
                            Tamoxifen
                            Tetracycline
                            Influenza vaccine
                       Possible
                            Disopyramide
                            5-Fluorouracil
                            Ifosphamide
                            Lovastatin
                            Metolazone
                            Nalidixic Acid
                            Norfloxacin
                            Ofloxacin
                            Topical salicylates
                            Sulindac
                            Tometin
                       Doubtful
                            Cefamandole
                            Cefazolin
                            Gemfibrozil
                            Heparin
                            Indomethacin
                            Sulfisoxazole
Decreased Effect
                        
                       Highly Probably
                            Barbiturates
                            Carbamazepine
                            Chlorodiazepoxide
                            Cholestyramine
                            Griseofulvin
                            Nafcillin
                            Rifampin
                            Sucralfate
                       Probable
                            Dicloxacillin
                       Possible
                            Azathioprine
                            Cyclosporine
                            Etrelinate
                            Trazodone

No Effect
                    
                       Highly Probable
                            Alcohol (if no liver disease)
                            Antacids
                            Atenolol
                            Bumetanide
                            Diflunisal
                            Enoxacin
                            Famotidine
                            Felodipine
                            Fluoxetine
                            Ketorolac
                            Metoprolol
                            Moricizine
                            Naproxen
                            Nitrazepam
                            Nizatidine
                            Psyllium
                            Ranitidine
                       Probable
                            Ibuprofen
                            Ketoconazole
                            Ketoprofen
                       Doubtful
                            Diltiazem
                            Tobacco
                            Vancomycin

Other Web Sites:
http://search.excite.com/search.gw?c=web&s=coumadin+or+warfarin&showSummary=false&start=20&perPage=20&prev=Previous+Results
Package insert and patient information:
http://www.dupontmerck.com/coumadin/cnsmindx.htm
Food interactions with coumadin:
http://www.rncentral.com/library/health/warfarin.html
Patient information and links:
http://www.hsforum.com/HeartSurgery/TLC/Coumadin/Coumadin.hsf

I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.


DEAR Christopher:
     I found that taking coumadin on an empty stomach about 1 hour before meals helped me maintain my INR levels which slipped when I took it with food.
Nathan
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