OAK BROOK, IL – In an effort to completely eliminate the risk of bleeding, newly-issued guidelines from the Radiological Society of North America (RSNA) now recommend that interventional procedures should only be performed once a patient’s INR, or international normalized ratio, has been appropriately lowered to a target goal of 0 or less.
Interventional radiologists are bracing for the backlash.
“Everybody else has strict INR targets, why not us? So hear us out,” said a spokesperson for the RSNA, Rudy Virchow, MD. “Primary care physicians insist on an INR between 2.0 and 3.0 if patients are on Coumadin for something like a DVT [deep venous thrombosis]. Cardiologists and cardiothoracic surgeons insist on an INR between 2.5 and 3.5 if a patient has, say, a mechanical mitral valve. Well, interventional radiologists, we want that INR ideally between -1.0 and 0. If that INR is greater than 0, in my mind, frankly, the procedure is contraindicated. It’s just not safe.”
Virchow continued on a long whiny explanation, stating that in the same way an INR > 5.0 might make a hospitalist nervous, so too does an INR > 0.0000001 for an interventional radiologist. “We always have the patient’s safety in mind,” he continued, “which is why we now insist that an INR not only be lowered to normal, but that it be lowered well beyond the lower limit of normal.”
Hospitalists at Emory University in Atlanta have observed that their interventional radiology (IR) colleagues have been slowly lowering the INR goal over the past several years, so the new guidelines aren’t surprising.
“Five years ago, one radiologist insisted on an INR less than 1.4, then a year later a few more started setting the bar at 1.0,” recalled hospitalist Emily Sage-Davis. “Then last spring, I was getting pushback because the INR was ‘normal but way too high.’ It finally got out of control over six months ago when they kept yelling at me for the INR still being a positive number. Before you know it, they’ll want that INR less than the square root of a negative number.”
Virchow is optimistic change will come with time, that other health care professionals just need some guidance.
“Going forward,” Virchow advised, “if your patient’s INR is > than 0.0000001, go ahead and give some vitamin K. If the INR is > 0.0001, go ahead and load them up with 30 units of FFP. If that INR is 1.5, if it were me, I’d go ahead and call Palliative Care and consider hospice.”