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  • Nose Bleeds???

    Hi all, it's Veronica, Genaro's wife, he had a mechanical valve replacement (aortic) a week ago and today all of sudden he got a nose bleed, not alot, just like a napkin, spots. His INR was 2.7 and they decreased his dose to 1mg instead of 2mg. I'm worried. Thank you, Veronica.

  • #2
    No Prob. (From What I Was Told.....)

    Hi Vero.
    I had the same surgery a week ago today except I had the root and valve replacement job on the aorta. I have a mechanical (St. Jude's) so I'm getting on the Coumadin train myself. I was told by the Coumadin clinic I go to that nosebleeds may happen to me and not to be alarmed. That being said, I haven't had any problems like that yet. I'm sure there are plenty of old pros around here that can give you better advice. My thinking on all of this bleeding stuff due to Coumadin is that if I bleed enough to get scared (and I'm sure I will some day) I'll just go to the emergency room and live with it. I hope everything works out OK.
    AVR/Aortic Root Reconstruction---University of Alabama-Birmingham on April 15, 2005


    • #3

      One of the things you need to get used to and fast is the fact that doctors often respond too quickly when changing coumadin doses.

      An INR of 2.7 is right where Genaro should be. A few spots of blood from the nose can happen to anyone, even those not on coumadin.

      I would be much more worried about them cutting his dosages in half because of this. His INR could drop way too fast and put him at risk for a stroke.

      Please question this decision. His dosage should not have been changed if his INR was at 2.7. The range for Aortic mechanical is 2.0-3.0.


      • #4
        Hey Gina, I'm sorry I forgot to mention that I took my husband to emergency room night before last (because of palpitations) and they took his INR then, it was 3.7, that is when the pharmacist cut the dose from 2mg to 1mg this was yesterday:

        Wed INR 3.7 took 2mg
        Thurs no test, called pharmacist took 1mg
        Friday INR 2.7, again prescribed 1mg.

        I hope I made sense. Thank you, Veronica.


        • #5
          OK - now I feel better . Be sure and test in 3 days or so to see how the dosage change worked out.

          3.7 IS too high and could have been responsible for the slight nose bleed. I rarely have nosebleeds and the ones I have had were when I had colds and my nose was "very active".


          • #6
            WHOA Veronica !

            It takes 3 to 4 days for the FULL effect of a dose change to 'settle out' so changing dose after only 2 days will almost GUARANTEE a wildly swinging range of INR.

            Dosing is really based on a WEEKLY basis. Are you saying the pharmacist told him to go from 2 mg every day to 1 mg every day? That would be a 50% reduction, WAY TOO MUCH of a change. If this is the case, I would suggest he get tested 3 or 4 days after the change. My guess is that his INR will then be too LOW (and if you see that same pharmacist, he will recommend too much of an increase and on and on and on.... sorry, but the sad fact is some people simply don't know how to properly manage Coumadin. Find a GOOD Coumadin Clinic ASAP and let them be your guide.)

            When a small change is needed, the WEEKLY dose is usually adjusted by 10% spread over the whole week.

            Please read Al Lodwick's Website on managing Coumadin at

            BTW, a few drops of blood from a nose bleed (or anything else) is TRIVIAL. That could be caused by dry air, even in someone NOT on Coumadin.

            Here is another 'rule of thumb' guideline related to rectal bleeds. Pink on tissue, NOT SERIOUS. Pink in the commode water, call / see your Doctor. Heavy RED in the commode water, get to the ER ASAP. This probably can be generalized to any type of bleed. For cuts, use gause and PRESSURE.

            Being a Heart Patient takes some 'getting used to' with a New set of Normals. One of my favorite sayings is "Heart Disease isn't for Sissies!" :D

            Another saying (from Al Lodwick, our Coumadin GURU) is that "It's easier to replace Blood Cells than Brain Cells" which means that it is better to have a slightly higher INR (>4 or 5) and possible bleeding than to have too LOW an INR (<2)and a possible STROKE.

            'AL Capshaw'


            • #7
              Hi Veronica,

              Jim used to get really heavy nose bleeds bedore his AVR. Had a vessel in his nostril cauterised a couple of times. Then for a week or two after he was home, he had some light ones like you describe - his INR was always in range (2-3) bar one reading of 3.2, so his dosage wasn't changed at all (it has since increased due to increasing activity levels). It seemed weird that they weren't heavier with the warfarin, but we believe the high blood pressure he had with the regurgitating valve may have caused the nose bleeds pre-op, so after the replacement that was no longer a problem.

              Although it seems like Genaro's pharmacist was right to reduce the warfarin with an INR of 3.7, it does seem like a big change to make - 50%... A change of 1mg doesn't make a huge difference to someone on, for example, 6mg a day, but when it's half your dose that's a big deal! I'm with Al on this one - if the pharmacist suggests a big change again at Genaro's next INR test (assuming it has dropped too low of course), question it.

              Good luck!


              • #8
                Someone said an INR of 3.7 is too high...what about someone like me who has to have a rate of 3.5-4.0?...I had a nosebleed but then my INR level was 7.9.... :eek: ...


                • #9
                  3.7 is not that bad. In fact, I wouldn't even change the dose for it, maybe pig out on some greens and such. Nosebleeds can occur for many different reasons. I'm having them almost daily and it's because of this messed up weather we are having. It's been unusually dry, combined with allergies and away it goes. Who recommended 3.5 to 4.0 for you?


                  • #10
                    Joe gets nosebleeds every once in a while. They are unrelated to his INR, some happen when it is low, some when it is high and some when it is in range. He has a vulnerable blood vessel in his nose, and when it gets irritated--too dry, for example, it can bleed a little.

                    Just a thought, but Genaro probably had oxygen in the hospital for a while, right? That can dry out your nasal passages. Possibly this is a left over problem that will straighten itself out.


                    • #11
                      Chloe suffered badly with nosebleeds for about a year after her replacement, although would that be cos kids are more prone to them anyway?! And when I say badly - i mean she had one which didnt stop for 3 days!!!! (although not that heavy throughout the whole time!)
                      But her INR has always been between 3 and 4 (in the UK where the INR's seem to be set higher) so i wouldnt have considered 3.7 to even be that high - well not to justify a drop in dosage like that. Make sure you test again in about 3 days cos I would guess he may go too low now.
                      Hope it gets sorted out soon!
                      [SIZE="2"][COLOR="Magenta"]Chloe is my heart child born 31/10/99 with COMPLETE AVSD. 3 OH surgeries. RBBB, mild mitral & and tricuspid leak. Mitral valve replacement - ON-X 25mm. On enalapril & warfarin and doing well! Uses coaguchek.[/COLOR]
                      [COLOR="DeepSkyBlue"]'Some people only dream of angels... I've held one in my arms'. (Callum 26/10/07)[/COLOR][/SIZE]


                      • #12
                        Sorry for any confusion. When I said 3.7 was too high, I just meant it was too high for an aortic valve (since the range is 2.0-3.0). I did not mean it was dangerously high. However, a 3.7 (in a new coumadin user) could concievably cause the slight nosebleed Veronica was describing.

                        My range is 3.0-4.0 because I have a mechanical mitral and a-fib. So 3.7 is in range for me and where I like to see my INR (3.5 or above). I have gradually built up to that level.

                        Didn't mean to worry anyone, especially someone new at this.


                        • #13
                          First off, why is the pharmacist telling you to reduce your dose? Shouldn't a Dr be the one giving that advice?


                          • #14
                            Most anticoagulation clinics are managed by pharmacists. I have been doing it full time for the past 8 years. I suspect that you got a "fill in" pharmacist. Anybody who would make a 50% dose reduction for an INR of 3.7 and check the INR again two days later does not have the slightest idea of how warfarin works. I don't care how much the nose was bleeding. You must NEVER put someone at risk of a stroke for a bloody nose. You have every reason to be worried.

                            BTW, I appologize to whoever really first said that it was easier to replace blood cells than brain cells. I wish I had thought of it first but I know that I didn't. I admit to having repeated it, but I have not tried to lay claim to it.


                            • #15
                              Just a quick note on INR scores...

                              I saw my cardiologist this past Wednesday and one of the things we talked aobut (briefly) was where my target INR's should be.

                              He said anywhere between 3.0-4.0 is just fine, with a plus/minus variation of maybe 3 tenths or so of a point.

                              So I can be as high as 4.3 or as low as 2.7 without any real cause for alarm.

                              He also said that if I stay consistantly at say, 2.8, then an adjustment might need to be made (I test monthly right now) and that because I have an artificial tricuspid valve, he'd like to see higher scores than would be typical for MVR/AVR's...

                              Now then, the fun part is when I tell my clinic people this. They get all fidgity when I say stuff like, "4.2 is just fine..." because that's not what they've been told.

                              But then, I'm the ONLY patient in the group practice that has an artificial tricuspid valve...

                              I asked once.