Vitamin K antagonist therapy and nutrition
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The doctor may permanently prescribe anticoagulants for you for the following indications, among others:
Atrial fibrillation - when the heart gets out of rhythm
Atrial fibrillation is a cardiac rhythm disorder that results in the atria not beating in synchrony with the ventricles. The symptoms of atrial fibrillation range from irregular heartbeat to dizziness and fatigue all the way to shortness of breath or chest pain. But often it also goes unnoticed.
Atrial fibrillation can usually be brought under control with medication. Catheter ablation is also frequently undertaken in which points in the cardiac tissue are targeted for obliteration with electricity. This interrupts the conduction of certain electronic impulses that are responsible for the rhythm disorder. If stable normalisation of the heartbeat cannot be achieved through these measures, however, the persons affected require anticoagulant therapy. This is to prevent clots (thrombi) from forming in the heart due to the slowed blood flow. Because when these break loose, they can clog a vessel in the brain, for example, and cause a stroke.
Predisposition for thromboses - when clots become dangerous
A thrombosis is the closure of a blood vessel by a clot. Increased or repeat formation of thrombosis is called a predisposition for thrombosis (thrombophilia). This phenomenon can be congenital or acquired.
The danger of a thrombosis strongly depends upon which blood vessel it is located in. Particularly risky are deep vein and pelvic vein thromboses because on the one hand, they often remain unnoticed for a long time by the individuals affected, and on the other hand, they can lead to a life-threatening pulmonary embolism.
Those affected require clot inhibiting therapy so that the clots dissolve before they wander into the bloodstream. Frequently these medications are prescribed long-term in order to prevent thrombosis formation anew.
Mechanical heart valve - heart valve replacement made of plastic or metal
Heart valve replacement may be necessary for a congenital, as well as for an acquired heart defect (e.g. heart valve calcification). There are two types of heart valve prostheses: biologic valves that are produced from pig or cow hearts, and mechanical heart valves, also called artificial heart valves. The later are made of plastic or metal and required life-long blood thinning with an anticoagulant from the vitamin K antagonist group. This is because the blood flow is altered by the foreign material in the body so the risk of a clot, and as a result, a stroke, is elevated many times over in people with a mechanical heart valve.
What does coagulation self-management mean?
For your health, it is necessary to take anticoagulants (such as for example, Sintrom® or Marcumar®) and to regularly monitor your coagulation values.
Measurement of the coagulation values by the doctor
As a rule, the doctor performs a check of the coagulation every four to six weeks on average. That means, you go into the doctor’s office. There, your blood is taken from a vein and the INR value is determined in the office laboratory. This treatment is now part of your life, however it must not dictate your life.
In contrast to many other diseases, at your diagnosis, you have the option of monitoring your coagulation values yourself. As a rule, for coagulation self-management with the CoaguChek® INRange Coagulation Monitor, you conduct a weekly check after a training session. If there are changes in your lifestyle or an illness, more frequent monitoring is advisable. Coagulation self-management helps you to rapidly identify deviations in your values from that specified by your doctor as your personal therapeutic range. If necessary, you can react immediately to these changes and adapt the dosage of your anticoagulant to the new situation. As studies have shown, you can lower the risk of complications in this way and consequently increase your safety and quality of life. Even if you measure your coagulation values yourself and adjust the dose of the medication, your doctor naturally remains your partner. He tests the values obtained together with you at regular intervals, evaluates the results and advises you.
Higher therapeutic quality
The regular self-monitoring of coagulation values makes timely recognition of changes in values possible. If necessary, you can immediately adjust the dose of your anticoagulant.
Better therapeutic understanding
Due to the fact that you receive comprehensive training on blood coagulation and are regularly engaged with your own INR values, you get a better understanding of your therapy.
Better therapeutic overview
You can view your INR values over the course on the CoaguChek INRange or through a connection with a USB cable to the computer. In this way, you can see, for example, your INR values in comparison to the previously set personal INR target range.
Through the timely adjustment of your values in the event of fluctuations, there is the opportunity to avoid complications.
Higher quality of life
Regular self-monitoring helps you to better understand and assess the processes in your body. This can help you to prevent unnecessary stresses and limitations in everyday life. The regained independence and security in your decisions makes it possible for you to have a more pleasant life.
More flexibility or independence
Whether at home or on the road – with the CoaguChek INRange, you have your coagulation values in view at all times. Coagulation self-management gives working patients in particular more flexibility in the monitoring of their values.
Through the training and the coagulation self-management, you adjust your anticoagulant independently, if necessary, and consequently optimise your treatment.
1. Speak with your doctor!
If you are interested in coagulation self-management, you should first speak with your doctor. He will provide information about all medical questions and can then refer you to a training facility in your vicinity.
2. Assumption of costs by health insurance
Coagulation self-management is reimbursed by health insurance. So that you can benefit from this reimbursement, your primary care physician should obtain a confirmation of coverage from your health insurance prior to registering for the course. Specifically, this means informing the health insurance in writing that you will be managing your blood thinning yourself in the future and need the CoaguChek® INRange Coagulation Monitor to do so.
Register together with your doctor at the training centre in your vicinity.
4. Training for coagulation self-management
At the training facility, you will learn practical and theoretical knowledge on the topic of blood clotting and haemostasis, INR and Quick values, personal therapeutic range, anticoagulant therapy and coagulation self-management. Additionally, you will practice using the CoaguChek® INRange Coagulation Monitor, independent measurement of your values and the dose adjustment of the anticoagulant that may possibly be required as a result. The training will be directed by a training physician. It is conducted in small groups and lasts approximately six to eight hours. After a transition period of several weeks at home, there is once again a repetition and a check of what has been learned.
In these training centres, you will be instructed as a patient in the handling and use of the CoaguChek INRange. For registration and other questions associated with training, please contact the training centres below directly:
Foundation for Patients with Haemodilution (Coagulation Care)
Cantonal Hospital St. Gallen
Prof. Dr. med. H. Rickli
9007 St. Gallen
Tel. 071 494 10 51
Consultation d’enseignement à l’auto-mesure de l’INR capillaire
Service de Cardiologie et Unité d’Hémostase
Hôpitaux Universitaires de Genève
Rue Gabrielle-Perret-Gentil 4
1211 Genève 14
Madame Karin Zellweger, Service de Cardiologie
Tel. 022 372 72 14
Fax 022 372 72 29
Centre de formation pour l'autogestion de l'anticoagulation de Lausanne
Prof. Lucia Mazzolai
CHUV Service d'angiologie
Chemin de Mont-Paisible 18
Registration by phone:
Tel. 021 314 20 91
Fax 021 314 07 61
Servizio di Ematologia – IOSI Ospedale Regionale di Bellinzona e Valli
Dr. Bernhard Gerber
Tel. 091 811 86 65
University Children's Hospital Zurich - Eleonora Foundation
Tel. 044 266 73 07
Patients who are taking anticoagulant medications (such as for example, Sintrom® or Marcumar®) can monitor their INR and Quick values themselves with the CoaguChek® INRange Coagulation Monitor at any time and at any place.
The prerequisite for successful coagulation self-monitoring is individualised training in which you not only practice how you best determine your coagulation value with the CoaguChek® INRange Coagulation Monitor, but also receive important information all about treatment with anticoagulants. A very significant part of the training is handling the values you have measured, i.e. the adjustment of the dose of the anticoagulant.
The training will be directed by a training physician. It is conducted in small groups and lasts approximately six to eight hours. After a practice period of several weeks at home, there is once again a repetition and a check of what has been learned.
How does blood clotting work?
Blood clotting is essential, because without it, bleeding from injuries would not stop. The solidification and coagulation of the actually fluid blood is a complex process in which many of the body’s own substances are involved (e.g. clotting factors and blood platelets). Blood clotting is based on the following three pillars:
In healthy persons, clotting functions reliably without dangerous clots forming in the body. In other words: The system is in balance.
What anticoagulants are there?
There are various groups of anticoagulant medications that are also colloquially called blood thinners. The medical term for these is anticoagulants. When these are taken, the natural coagulability of the blood is lowered and it takes longer until it clots.
The main groups of anticoagulant substances are:
Vitamin K antagonists or DOAK are worth considering for long-term or permanent anticoagulant therapy. Both are taken in the form of tablets. At the same time, vitamin K antagonists (coumarins) represent the therapy form for which there is the most experience since they have been used successfully for centuries. Its name is derived from its mode of action. They are adversaries (antagonists) of vitamin K, which in turn plays a central role in blood clotting. A great advantage of this medication: Patients who are treated with vitamin K antagonists can monitor the treatment themselves in the context of coagulation self-monitoring. That these close-meshed checks of the coagulation values are omitted with the direct anticoagulants (DOAK) is namely not always an advantage. It is precisely the regular measurement of their INR value that gives many individuals a high measure of security.
Why must coagulation values be measured?
When taking vitamin K antagonists, the coagulation value must be regularly monitored to check whether the medications are correctly dosed. If the dose is too low, clots can form; if it is too high, there is the danger of haemorrhage. It is important to keep these two risks in balance. For this reason, the doctor determines a so-called therapeutic range in which the coagulation value should move.
What do INR and Quick value mean?
The INR value stands for International Normalised Ratio. This unit, which is common worldwide, indicates to what extent blood clotting is slowed. For patients with an INR value of 2.0, it takes twice as long until his blood clots – compared with someone who takes no anticoagulant and consequently has an INR value of 1.0. The Quick value is also an established unit which, however, has lost significance in favour of the INR value because it can fluctuate greatly depending on the test substance with which it was measured. The Quick value is indicated in percent (normal value = 70-130%) and behaves the opposite of the INR value. That means that a high Quick value is equivalent to a low INR value and vice versa.
What does therapeutic range mean?
The treating physician determines the individual therapeutic range depending on which disease makes the anticoagulant therapy necessary. That is a target range which the INR value should not drop below or exceed because otherwise bleeding or a thrombosis threaten which as a consequence, can lead to a stroke or a pulmonary embolism. For atrial fibrillation for example, an INR value of 2.0 to 3.0 is recommended. For valve replacement, it lies between 2.0 and 3.5 depending on the type of heart valve and whether the heartbeat is regular. If a thrombosis or pulmonary embolism is the reason for anticoagulant therapy, the therapeutic target range usually lies at an INR of 2.0 to 3.0.
How frequently must it be measured?
The check of the INR value happens regularly at the office of the primary care physician. Weekly measurement is recommended as part of coagulation self-monitoring. Through the close-meshed controls, patients can recognise fluctuating coagulation values quickly and bring them into the therapeutic range again through immediate change of the medication dose. Studies have shown that through coagulation self-monitoring, significantly more values lie within the therapeutic range than at the control by the primary care physician.
What must I pay attention to in daily life?
If you are receiving permanent anticoagulant therapy with vitamin K antagonists, you should pay attention to a few things in daily life. Because of the elevated bleeding tendency, injuries must be avoided, for example. Also, as regards nutrition and when travelling, there are factors that can affect clotting or the effect of the medications.
Inhibition of blood clotting by medications
Artery; blood vessel that transports blood from the heart to the tissues.
Trade name of a pain medication that contains acetylsalicylic acid (ASA). Is also used to inhibit the activity of blood platelets and can increase the danger of bleeding.
The first series of artificial heart valve manufactured; e.g. Starr-Edwards® prosthesis
Heart valve replacement made of biological material - from cow, pig or human.
If bleeding is usually heavy or long, the treating physician must be consulted. This includes: heavy bleeding from the gums or heavy and/or prolonged menstrual bleeding, unusual or frequent bruising, nose bleeds, bloody urine. A doctor must be called immediately if vomiting “coffee grounds” and for black stool.
Thrombocytes; cells in the blood that are important for clotting Form a clot together with the fibrin threads.
Coagulation; includes the formation of a blood clot.
Blood from the finest blood vessels in the body tissue, can be taken from the ear lobe or the fingertip.
Proteins formed in the liver that cause the formation of a clot after activation. Up to 30 different clotting factors are involved in blood clotting (coagulation) which are activated in a chain reaction, one after the other. At the end of this clotting cascade, soluble fibrin is transformed into its insoluble form.
Time period from the start of bleeding up to closure of the wound by a clot
CoaguChek® XS Coagulation Monitor
Measuring device for self-monitoring of coagulation
Device for measuring blood clotting, e.g. CoaguChek® XS
Measuring device for determination of clotting
A check of coagulation should be performed once per week, more often e.g. when there is a change in medication.
Active substances from plants such as sweet vetch or woodruff with different effects
Active substances derived from coumarin that are used for inhibition of blood clotting.
Used material can be disposed of in the household trash.
An adjustment of the anticoagulation dose should only be made in small steps.
Double winged prosthesis
Modern type of artificial heart valve, e.g. The St. Jude Medical Prosthesis® (SJM)
Blood clot that has come loose, floats freely into the blood vessels and blocks a vessel.
Protein that, as fibrin threads, is a significant part of a clot.
Here: biological half-life This is the time required by the body to excrete half of the quantity of substance of a medication taken.
Reaction of the body after injury to a vessel that closes the injured blood vessel via a multitude of individual reactions such as a temporary narrowing of the vessel and the formation of a blood clot: The bleeding is then staunched.
Acts like a valve on the heart and enables a directed flow of blood in the body. There is a pulmonary valve, a tricuspid valve, a mitral valve and the aortic valve.
Heart valve prosthesis
Valve replacement with artificial or biological material
International Normalised Ratio; unit of measure recommended by the World Health Organisation (WHO) for determination of blood clotting. Normal blood clotting is equivalent to INR = 1; INR = 2 means a clotting time that is prolonged two-fold.
Interplay of various substances, e.g. medications
International Sensitivity Index, which records the sensitivity of a reagent. Enables the comparison of various thromboplastin reagents mathematically.
Forgetting the tablets or confusing the number of tablets that should be taken.
Taken by mouth, e.g. tablets or drops
Anticoagulation therapy with tablets
Another term for thromboplastin time
Specification about the extent of the ability of the blood to clot in %
Rate of clotting, indicates the relationship of altered to normal clotting time.
Undesirable effect of a medication
Range in which complications are low during treatment with oral anticoagulants, low risk of bleeding or clot formation Is determined on an individual basis by the doctor.
A substance produced naturally in the body that triggers blood clotting. Is also used for the Quick test or for determination of the INR.
Time measured for clotting control from the addition of thromboplastin until the formation of a clot.
Disorder in the ease of flow of the blood in a blood vessel; triggered by a thrombus (clot).
Blood platelets; cells in the blood that are important for clotting. Form a clot together with the fibrin threads.
Blood clots, plural: thrombi
Tilting disc prosthesis
Artificial heart valve with a valve cover (tilting disc); examples: Björk-Shiley®-, Medtronic-Hall® valve prosthesis
Blood vessel that carries oxygen-poor blood back to the heart.
Blood taken from a vein, e.g. from a vein in the elbow
Vital substance that the body requires for the most varied metabolic processes. Essential vitamins - fat soluble or water soluble - cannot be produced by the body which is why these must be provided in the diet.
Essential vital substance that the liver needs for synthesis of clotting factors. Vitamin K is formed by intestinal bacteria, among others and is contained e.g. in vegetables.
Total number of tablets to be taken per week
Vitamin K - what effect does it have?
Patients always pose the question whether they should limit their vitamin K intake with food. The background for this is the fact that vitamin K is involved in the process of blood clotting. It represents a kind of opponent of the anticoagulants from the group of vitamin K antagonists and can weaken their effect. For this reason, one has long advised affected patients to avoid foods with high vitamin K content (primarily fruits and vegetables). This strict prohibition is meanwhile regarded as outdated. Experts rather advise a balanced diet. This means that fruit and vegetables belong on the daily menu plan and only an extremely high intake of vitamin K should be avoided.
Heart healthy eating – what does that mean?
One of the greatest risk factors for heart attack and stroke are animal fats, which are primarily found in meat and milk products. These contain unsaturated fatty acids that have been implicated in arteriosclerosis. Heart healthy eating therefore means: Use plant-based oils instead of animal fats and eat meat and milk products sparingly. Heart healthy also means eating fruit and vegetables, legumes and nuts regularly – here too, the key is healthy quantities and in healthy balance.
Alcohol and cigarettes – how dangerous are they?
can promote blood clotting, still, as with healthy persons, for persons with anticoagulant therapy also, it is always a question of quantity. Furthermore, every body reacts differently to the intake of alcohol. This also speaks for a sensible approach: With an increasing alcohol level in the blood, the danger of injury increases which, particularly for individuals with anticoagulation, is not harmless.
Smoking can increase the tendency towards blood clotting and should urgently be ceased. Furthermore, it damages the cardiovascular system to a considerable degree which is particularly dangerous for heart patients. Because when, for example, after a successful heart valve replacement, a second heart disease comes along (e.g. coronary heart disease or heart attack), the risk of complications rises considerably for the affected individuals.
Travel & blood coagulation – what you should pay attention to
When travelling, a lot of things are different: the climate, the food and the daily routine. All of these can have an effect on blood coagulation. But because every body reacts individually to changes, no hard and fast rules can be set here. The nice thing about coagulation self-management is that you can measure your INR value anywhere and at any time and in this way, you can find out for yourself if something has changed while you have been out and about.
Luggage – what needs to be packed?
contents of your suitcase are naturally dependent upon the destination you are travelling to and the activities you have planned. But for your hand baggage, you should ask what you urgently need at your destination, should your suitcase happen to get lost on the flight. That could be:
And if you are a coagulation self-manager, of course, your measuring device, as well as sufficient test strips So that there are no problems in this regard at customs, we advise you to bring along a customs declaration. You can obtain this from our Customer Service Center from Monday to Friday from 8:00 a.m. to 5:00 p.m. at phone number 0800 80 66 80 or firstname.lastname@example.org
Travel prophylaxis – what is to be noted?
For many countries, immunisations or a particular medicinal prophylaxis (e.g. malaria prophylaxis) is recommended. Because some of these medications have an effect on blood clotting or can influence the effect of anticoagulants, you should let your primary care physician know about them.
Coagulation self-management - measure yourself and travel
How coagulation values are determined can be very different from country to country. There are holiday destinations where the measurements are conducted in laboratories. In other countries, this happens exclusively in hospitals. Also, the designations (INR or Quick value) may differ from country to country. This makes it clear that particularly when travelling, coagulation self-management offers clear-cut advantages. It doesn’t matter which corner of the world you are in: As coagulation self-manager, INR control is possible at any time and you can enjoy your holiday carefree.
Exercise & blood thinning – do these go together?
The answer is yes, because movement has countless positive influences on the body. But for people with anticoagulant therapy, there are a few things to look out for: Due to the elevated bleeding tendency, you should avoid sports with a high risk of injury.
Work out properly – with heart diseases
Even with heart diseases, for example, following a heart attack, exercise is not only possible, but even important. However, heart patients should generally refrain from sports with strong load fluctuations. This is true, for example, for many types of ball sports that cause the pulse to abruptly rise. It is best to join a cardiac exercise group because there, specially trained trainers ensure the correct amount. Speak to your primary care physician about it; he can certainly direct you to a cardiac exercise group in your area.
Healthy training – in four steps
The basic principle: Start slowly and increase in a measured manner.
Coagulation self-management - measure yourself and exercise
Whether exercise has a direct influence on anticoagulation is not clearly proven. What is certain: Movement strengthens the heart and circulatory system, promotes the provision of the body with oxygen and puts you in a good mood. Important: You should feel safe when doing it. Coagulation self-management can support you in finding out how your own body reacts to exercise.
INR: International Normalized Ratio
PT: Prothrombin time