do i need coumadin for a one time only afib?

[dck265]

my dad had aortic valve replacement in may 2010.  he is 88 yrs old and this was his 2nd valve.  one month later he developed afib(one time only) next weeks test (ekg) was good...next week showed "wandering? something"   next test was fine   dr put him on 5mg? of coumadin daily...he has been on this drug since june to present(sept) with no more afib...when can he stop the coumadin?   last week his count was 7something and he had to take one dose of vit k  which brought it right down to normal again...so today he count was 4.3    seems like he needs to go off completely...please advise

[Angel_001]

Hi DCK!

No - I haven't been on line in a couple of days.  How's everything going with your dad??
You're use of the esercise ball for elevation of his legs is a fantastic idea!!!  As far as his saphenous vein striped for his bypasses - that should have no effect on foot/arterial pulses.  My dad broke his leg the end of July and still has horrible swelling.  He also has cornary artery disease.  I gave him your advise of the exercise ball for elevation (THANK YOU) for swelling (he is not edemenous).  We have him wearing support stockings and we also had him on a blood thinner like coumidin to protect from deep vein thrombosus.  He is also very active - so this gives us peace of mind.  He is "Pa Pa" to my 2 year old and 4 month old. :)
How did you last appt go???
If he is still edemenous in his legs...it sounds like he is still in Cohgestive heart failure.  Perhapse following up with you cardiac surgeon as another perspective for his current status is a good idea.
Though, Your Dad has had a long history of cardiac battles - he is the Champion and will continue to prevail!!
Cheers
Angel

[dck265]

hi    i have to ask you if you ever responded to my 9/28 @ 11am email. the reason i ask is that i saw an email from medhelp at 3 o clock or so but when i went to open it...it was blank

[dck265]

hello

i dont remember anyone ever taking the pulses in his legs...could it be b/c he has had both legs stripped of veins back in the 70's?   going to cardiologist 2morrow(wed)   will ask..after that sat nite bday party when his legs got swollen...he laid down on bed and my mom put an excersise ball under his legs(we always use to do that before his valve surgery) and they eventually got a bit better. the next morning the legs were still a little puffy so he decided to wear his stockings to the next party on that day (which was 40 minutes away and he kept his feet up) and they also decided to take another 10mg of lasix.   so his legs were much better that nite after returning home from party...took stockings off and laid on bed with ball again...monday they put a call to cardiologist to advise them of the situation over the w/e ...but office never called back...prob will c/b today but i wanted the dr to know that he took extra lasix(which they said he could do but to please let them know....so 2morrow is his dr appt ...they will check the coumadin level (last friday it was 2.4)  and he got one of those shots(i always forget the name of shot)  to increase his bone marrow production of hemo and i think that will be checked in one more week(he goes to hemo every 3 weeks) thanx for thinking of pulses in ankles....will def ask tomorrow

[Angel_001]

Hi dck!

You're dad sounds like an amazing guy!  You're family too - for all your love and support through his health issues!  

I agree with increasing the lasix regimine.  How are the pulses in his ankles??  Is the edma in the legs so bad that it is deminishing blood flow to his lower legs??  Is he wearing any compression leg stockings???  Since your dad is so active - it might be a good idea to have him wear the stockings in order to prevent edema and promote healthy leg circulation. Has his hemoglobin improved?? Is he still on coumidin??

Have a wonderful day
Angel

[dck265]

hello again

my dads legs and ankles started swelling on friday...they called dr and was told to increase lasix from 10 mg (1x) every 4 days to every 3days.  so he took one on friday nite and went to his bday party(89th) at my brothers house..when he got home his legs were big from the knees down to his toes...so he took another lasix on sunday morning.my mom is calling dr today to inform..but he will take another lasix today..why is this happening now...he was doing so great as far as his edema?  yes his appetite came back after rec from wound infection and then thrush...(from 146lbs to 157lbs in 3 weeks)  maybe he is walking too much(they walked around in a baseball field on friday)   im going to call cleve clinic today. would like to hear your thoughts....thanx

[dck265]

thank you   my dads hemoglo cnt is down from 10.9 to 10.4 in 2 weeks(he has been having a shot every 3 weeks to stimulate bone marrow for more blood count) but last visit dr was out and a PA told my parents to just wait for 2 weeks to see dr and if it goes up...he was doing very well before this (his count was 12 something)  so yesterday dr was very upset with his PA for not giving the shot to my dad 2 weeks ago! ( i was out of town and told them to call dr next day but they did not)    just one thing after another...have to keep on top of everything!  i spoke with them reg cleve clinic and i will call today . also his ankles are looking thicker...so mom is calling cardiologist .  dads lasix was decreased to 10mg every 4th day(from 20mg 2x per day/ then 10mg 2x per day to 10 per day and so to this...also some heart meds were decreased then eliminated...so maybe he needs more la six... oh   the answer your question reg medrol is no(not that we remember unless it was given in hosp meds)  bp is like 120/70 ...when he was taking the meds for the chest wound infection and the thrush  he had no appetite and lost 20 lbs(also being on so much lasix..)    now he is feeling better ..off the antibiotics and antifungals   and he has gained 10 lbs  but ankles are thicker(not per say swollen yet)  so i really appreciate your feedback...its so nice to have something in between dealing with dr offices and appts...just to bounce off one another and really communicate b/c we all know that even thru best intentions of drs and offices...they do have a schedule to maintain  and sometimes you need more than 15 -29 minutes with dr to discuss/examine/ and explain such complications...also ...this was my dads 4th redo of open heart surgery...1st one was quad bypass/2nd was aortic valve replacement and one bypass/3rd was double bypass when they used one mammary artery/ and the 4th was redo aortic valve replacement(and some building up of some stucture in there) and sometime inbetween there he had caratoid artery srgy  and then partial nephrectomy.....so.....now i think you know all...the drs sometimes refer to my dad as super bionic man...he is one strong minded guy (left norway when he was 17 to join merchant marines...then ww2 broke out...the rest is history...he saw alot of countries but not under the best of cicumstances(he also had malaria)  but when he saw america...he knew he was going to come back and stay....and he did...met my mom(she is 10yrs younger ) in brooklyn ny (her parents also from norway) married and had my sister and i in brooklyn   then moved to nj and had my brother...he has had a full life and he is a young 88yr old ....just 2yrs ago he was laying down patio pavers(oh ...just remembered...he had a hernia op also)...so thats where im coming from...trying to get him back from this operation  to himself again...its trying on all of us...but we will do it...i thank you again for your insight reg my dad

[Angel_001]

Hi!
Wow, what an exhausting roller coster youve been on.  First off, if he had valve surgery at Cleve Clinic there is a good chance they addreessed occluding his Left atrial appendage (LAA), although its more routinely done for Mitral Valve surgery due to enlarged atrium vs Aortic.  A CT scan or TEE (trans esophegeal echo) are tests that can see if he still has his appendage.  No worries if he still does have his appendage though.  The function of the LAA is that it secretes a hormone called NPH which helps regulate intravascular volume.  The heart has 2 - Right and Left atrial appendage.  Work much like our kidneys.  Some cardiologists feel strongly about possible clot formation in the LAA.  I would ask your cardiologist how he feels about it..
Coumadin levels are monitored by a blood test that measures INR - its an international unit to measure our ability to form clots normally (like when we cut ourself).  Normal levels are around 1.5.  Coumadin patients are usually around 2.3.  You are right when you speculate about his hemodynamics not being optimal.  Decreased hemoglobin levels can signal a possible dysfunctional coagulation process.  With levels drastically jumping around - showes me he has unstable hemodynamics that could be responding to the complecations you mentioned and affects of surgery.  Post surgical heart patients are 30% likely to have post op AF.  Most of the time the AF resolves itself when the inflammation process decreases.  Has your dad been on any steroids post op (like a Medrol dose pack )?  How is his Blood Pressure?  His anemia could be due to fluid retention/edema - is he on a water pill like Lasix (hydrochlorothiazide)??   All these things can affect his overall heart function and therefor overall health.  Does he still have AF??
Only patients who have a history of a coagulopothy or who are in dysrrhythmia (AF) should be treated with coumadin.  For example, when someones atria is fibrillating stagnant blood can form a clot (due to the quivering and its slow flow - its no longer dynamic).  We actually loose our atrial kick (fully emptying of the atrium of blood when our heart beats normally) - which accounts for a 20% decrease in overall cardiac function.  
Seeing how your dad had a reoperative valve procedure and given his age of 88 years old - its just taking his body longer to heal - up to 6 months.  it sounds like you are doing your due dilligence consulting his cardiologist and hemotologist on a regular basis.  But, peice of mind might be following up with your cardiac surgeon on his progress post op to this point and your concerns.  Since cleve clinic is the nations leading cardiac heart center they might have some insightful therapy that your home doctors might be overlooking.  
Best of luck!  Keep me posted!
Angel

[dck265]

hey  i just thought of something that might be connected to my dads varying coumadin levels...he was anemic before surgery...had one blood transfusion in hospital 2 or 3 days after surgery...then another 2 mo later...his hemoglobin count was down to 10.9  2 weeks ago and hemotologist did not give him his shot to stimulate the bone marrow to make more ...could this b related to the irratic coumadin levels?

[dck265]

i dont know the answer to that question reg left atrial appendage...how would i find out?he had his aortic valve replaced in may 2010 at cleveland clinic..but he lives in nj and nj cardiologist is taking care of him now.  he has had complications starting with the one time only affib, then the wandering pacemaker, then surgical site infection, then thrush in mouth and throat, has been on coumadin since affib incident and seems the level keeps at 1.4 to 1.7 now but went up to 7.0 before and was treated with vit k pill  which brought it down to 2.3, the back down below 2..cardio keeps readjusting dose of coumadin...today he was told to take 10 mg and tomorrow 7.5 and next 7.5  then 5 then get tested again...why cant he just get off this coumadin? do we ever get our coumadin levels checked during routine exams? how do we know if we are stable? should we all be on coumadin? just in case we might have a stroke?  

[Angel_001]

Hi Dck265!
I dont blame you Coumadin is a pain!  One more thing......did the surgeon surgcially exclude your fathers Left Atrial Appendage during the surgery?  2006 AHA/ACC guidelines for valve surgery recommend excluding the LAA in MVR patients.  Im guessing they did this.  The LAA is a source of clot formation due to trabeculations within the heart structure.  Complete occlusion/exclusion of this structure gives him better odds of throumbus not to form in the Left Atrium.  Decreasing stoke risk.  Let your cardiologist know about your concerns with Coumadin - there may be better alternative options after he gets 3 mon out from his surgery.
Best of luck!
Angel

[dck265]

thanx for your response..my dad has a cow valve now...before it was a pig valve...we will def ask about the holter possibility tomorrow at his dr appti also just read of a new test to detect if one is more likely to stroke or not(gene/dna) not sure...i just do not like this coumadin drug and i think the sooner the better for him to be done with it....but also its scary b/c what if..... .  

[Angel_001]

Hi!
Does your dad have mechanical valves or porcine valves???  If he has any mechanical valves - which it does not sound like - he would require a antithrombic like coumadin for daily use. It is very common for post-heart surgery patients to present in AFib up to 12 weeks post surgery due to inflammatory response.  However, it sounds like he has a high CHAD score -meaning he can be at a higher stroke risk if taken off the medication.  I would ask your cardiologist if its neccessary, probably do a Holter monitor to see if his AF is recurrent.  Hope this helps!
Good luck!