Cochin Cardiac Club

Health Blog by Dr.Uday Nair


Giving medicines to a child

The most important point to be considered when medicating children is the dosage. Always keep the following in mind:
  • A child is not a small adult. So their dosage cannot be calculated directly. Dosages of medicines vary widely in children, and are based more on their weight than their age.

  • Never self medicate your child. If you think that the existing dose is not bringing adequate effect, DO NOT increase the dose on your own. Chances are that something else is wrong or he needs another medicine.

  • Do not try to coax your child into taking medicine saying it is a sweet treat or chocolate. In your absence, the child may remember what you said and consume dangerous amounts.

  • Do not treat medicines lightly, by keeping it in the open, or hiding it when your child is watching. The kid will be inquisitive enough to find it out and try to consume it when you are not around.

  • Follow strict instructions for doses. A teaspoon is different from a tablespoon. A teaspoon is the small spoon used for salt, etc. A tablespoon is much larger, close to a soup spoon in size. A slightest difference in doses (2-3 ml) can bring about significant adverse effects in children below 3 years of age.

  • Keep your medicines also away from the kid. He might be inquisitive to know what you are eating, and if it is better than his, which is a dangerous experiment.

Taking medications when Pregnant/ Breastfeeding

  • Remember that all drugs will cross the placenta to pass through to the baby, so as a matter of precaution it is important that NO MEDICATION IS CONSUMED WITHOUT CONFIRMING WITH YOUR DOCTOR.

  • In general, try to take minimal medication during pregnancy, especially for minor ailments. The temporary discomfort will not be as serious as the possible effects on the baby in case of drug reactions.

  • In any problem, be sure to consult your doctor before you take even any OTC drug, as unexpected side effects may occur even with these.

  • When you are breastfeeding your child, remember that the medicines can pass through breast milk too, so do not take any medications by yourself. If you already have, then observe the baby closely for any possible side effects like rashes, and breathing problems after having breastfed him. Report to the doctor immediately.

Medication for the Elderly

Many elderly patients can have coexisting health problems like high blood pressure, diabetes, glucoma, depression, Alzheimer's, etc that may be either untreated, or being treated with medicines. In either case, side effects are very likely. Even common drugs can have untoward side effects in the elderly.

Some common interactions are-
  • Dextromethorphan commonly found in cough syrups reacts with MAOI- a type of antidepressant, to produce side effects.

  • Painkillers are capable of causing gastrointestinal bleeding in old age. Do not consume painkillers for more than 2 times a day, continuously for 3-4 days without consulting your doctor.

  • A lot of medications are likely to interact with blood pressure medicines, and anti-diabetic drugs specially in old age. So it is important to tell your doctor if are taking any such medications.


Prasugrel, a new thienopyridine is superior to clopidogrel at reducing rates of ischemic events after percutaneous coronary intervention in patients with acute coronary syndromes — but at a cost of increased bleeding events.

Although prasugrel is similar to clopidogrel, it is about 10 times more potent and has a quicker onset of action.

Prasugrel also differs from clopidogrel in that it may be less prone to drug-drug interactions and patient nonresponsiveness

Prasugrel appears to be a promising treatment option for patients with acute coronary syndromes who are undergoing percutaneous coronary interventions.



The burden of atherosclerotic disease in the United States,India and across the world is vast. Although the symptoms of atherosclerosis may manifest in several different ways, the most urgent and life-threatening are acute coronary syndromes. The use of percutaneous coronary intervention (PCI) has evolved to be the optimal treatment for many patients experiencing acute coronary syndromes, both as an elective and an emergency option. A PCI procedure provides better safety and efficacy than thrombolysis and obviates cardiac bypass surgery in some populations.Although bare-metal and drug-eluting stents used during PCI provide rapid revascularization, short-term and long-term dual anti-platelet therapy with aspirin and a thienopyridine is required to help ensure that the stents remain patent and free from thrombosis.
For many years, the combination of the thienopyridine ticlopidine and aspirin has been known to effectively lower the risk of stent thrombosis and carries a lower risk of bleeding compared with other strategies, such as the use of anticoagulants.Although ticlopidine has been shown to be effective in treating patients with acute coronary syndromes who have received a coronary artery stent, it was subsequently replaced with a newer thienopyridine, clopidogrel. Clopidogrel appears to have lower rates of major adverse cardiac events and mortality compared with ticlopidine, with a better safety-tolerability profile, most notably a lower risk of neutropenia.Clopidogrel has since remained the recommended thienopyridine by the American College of Cardiology– American Heart Association guidelines.

Unfortunately, there are limitations associated with clopidogrel use, including potential drug-drug interactions, slow onset of action, irreversibility of platelet inhibition, and wide variability of patient response, including no response. It would be desirable to have a thienopyridine that lacked significant drug-drug interactions but also provided a quick onset of action, a consistent patient response, and minimal risk of bleeding. Prasugrel is a new thienopyridine antiplatelet agent approved by the United States Food and Drug Administration (FDA) on July 10, 2009, for the treatment of patients with acute coronary syndromes who are undergoing PCI..

Best candidates.

Prasugrel plus aspirin may be a sensible choice for coronary syndrome patients who are undergoing PCI, have no risk factors for bleeding, and get to the hospital early enough for doctors to determine whether they might need bypass surgery instead.

In contrast, patients with a history of strokes or transient ischemic attacks should avoid prasugrel. (Studies so far have not linked clopidogrel, at least at the approved dose, with increased risks for those patients.) People age 75 or older should probably stick with clopidogrel in most cases, particularly since prasugrel is not recommended for use among this population. For patients who weigh less than about 130 pounds, the package insert says that doctors could consider halving the maintenance dose of prasugrel; although, there is no direct evidence that this smaller dose is actually safer or as effective.

People with active bleeding should avoid both drugs. Those who need bypass surgery should not take prasugrel or, if they've already started, should stop taking it at least a week before their operation. (Clopidogrel should generally be stopped five to seven days before surgery.)

Individualizing the choice.

Despite those general guidelines, doctors should choose the drug regimen based on each patient's particular risk of hemorrhages and blood clots. An increased hemorrhage risk from prasugrel seems to make clopidogrel more desirable, while the high risk of clotting favors prasugrel or the doubled dose of clopidogrel. 

Some factors that may increase the likelihood or consequences of bleeding, in addition to those listed above, include a history of excessive bleeding (for example, from dental procedures or other minor trauma), stomach ulcers, colon abnormalities, anemia, severe liver disease, and the use of other blood thinners, including nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin and generics), and naproxen (Aleve and generics). 

 Factors that may make clots more likely include previous clotting problems, heart disease, diabetes, small blood vessels, and the placement of multiple stents, the tiny metallic mesh tubes that prop open PCI-treated vessels.

In general, Consumer Reports medical consultants recommend against using prasugrel for unapproved uses, such as for the prevention of a second heart attack. But they say that off-label use of the drug might be considered for patients who experience a serious blood clot, heart attack, or stroke despite taking clopidogrel. That would be particularly reasonable if doctors can test for platelet responsiveness to clopidogrel.

Cochin Cardiac Club likes to add that Prasugrel might act like a  magic bullet but medicine doesn’t quite work that way.The new data fall in the tolerable range, provided doctors are willing to apply their own judgment to the pros and cons of prasugrel in individual patients.


Congenital heart defects are abnormalities in the heart's structure that are present at birth. Approximately 8 out of every 1,000 newborns have congenital heart defects, ranging from mild to severe.

Congenital heart defects happen because of incomplete or abnormal development of the fetus' heart during the very early weeks of pregnancy. Some are known to be associated with genetic disorders, such as Down syndrome, but the cause of most congenital heart defects is unknown. While they can't be prevented, there are many treatments for the defects and any related health problems

Types of Congenital Heart Defects

Congenital heart disease (CHD) can describe a number of different problems affecting the heart. It is the most common type of birth defect. Congenital heart disease is responsible for more deaths in the first year of life than any other birth defects. Many of these defects need to be followed carefully. Some heal over time, others will require treatment.

Congenital heart disease is often divided into two types: cyanotic (blue discoloration caused by a relative lack of oxygen) and non-cyanotic. The following lists cover the most common of the congenital heart diseases:


  • Tetralogy of Fallot.Tetralogy of Fallot is actually a combination of four heart defects. It includes pulmonary stenosis, a thickened right ventricle (known as ventricular hypertrophy), a hole between the lower chambers (known as a ventricular septal defect), and an aorta that can receive blood from both the left and right ventricles, instead of draining just the left. Because deoxygenated (blue) blood can flow out to the body, children with this defect often appear bluish
  • Transposition of the great vessels.In this condition, the pulmonary artery and the aorta (the major blood vessels leaving the heart) are switched so that the aorta arises from the right side of the heart and receives blue blood, which is sent right back out to the body without becoming oxygen-rich. The pulmonary artery arises from the left side of the heart, receives red blood and sends it back to the lungs again. The result is that babies with this condition often appear very blue and have low oxygen levels in the bloodstream. They usually come to medical attention within the first days of life
  • Tricuspid atresia.Blood normally flows from the right atrium to the right ventricle through the tricuspid valve. In tricuspid atresia, the valve is replaced by a plate or membrane that does not open. The right ventricle therefore does not receive blood normally and is often small
  • Total anomalous pulmonary venous return.The pulmonary veins normally are the blood vessels that deliver oxygenated blood from the lungs to the left atrium. Sometimes these vessels don't join the left atrium during development. Instead they deliver blood to the heart by other pathways, which may be narrowed. Pressure builds up in this pathway and in the pulmonary veins, pushing fluid into the lungs, decreasing the amount of oxygenated blood that reaches the body. These infants often have difficulty breathing and appear bluish
  • Truncus arteriosus.In an embryo, the aorta and the pulmonary artery are initially a single vessel. During normal development, that vessel splits to form the two major arteries. If that split does not occur, the child is born with a single common great blood vessel called the truncus arteriosus. There is usually a hole between the ventricles associated with this defect
  • Hypoplastic left heart.When the structures of the left side of the heart (the left ventricle, the mitral valve, and the aortic valve) are underdeveloped, they're unable to pump blood adequately to the entire body. This condition is usually diagnosed within the first few days of life, at which point the baby may be critically ill.
  • Pulmonary atresia.In this defect the pulmonic valve does not open at all and may indeed be completely absent. The main blood vessel that runs between the right ventricle and the lungs also may be malformed and the right ventricle can be abnormally small.
  • Some forms of total anomalous pulmonary venous return
  • Ebstein's anomaly


  • Ventricular septal defect (VSD).One of the most common congenital heart defects, VSD is a hole in the wall (septum) between the heart's left and right ventricles. These can occur at different locations and vary in size from very small to very large. Some of the smaller defects may gradually close on their own
  • Atrial septal defect (ASD).ASD is a hole in the wall (called the septum) that separates the left atrium and the right atrium
  • Patent ductus arteriosus (PDA).The ductus arteriosus (DA) is a normal blood vessel in the developing fetus that diverts circulation away from the lungs and sends it directly to the body. (The lungs are not used while the unborn fetus is in amniotic fluid — the fetus gets oxygen directly from the mother's placenta.) The DA usually closes on its own shortly after birth; it is no longer needed once a newborn breathes on his own. If the DA doesn't close, then a condition called patent ductus arteriosus (PDA) results, which can result in too much blood flow to a newborn's lungs. PDA is common in premature babies
  • Aortic stenosis.In aortic stenosis, the aortic valve is stiffened and has a narrowed opening (a condition called stenosis). It does not open properly, which increases strain on the heart because the left ventricle has to pump harder to send blood out to the body. Sometimes the aortic valve also does not close properly, causing it to leak, a condition called aortic regurgitation
  • Pulmonic stenosis.In pulmonary stenosis, the pulmonic valve is stiffened and has a narrowed opening (a condition called stenosis). It does not open properly, which increases strain on the right side of the heart because the right ventricle has to pump harder to send blood out to the lungs
  • Coarctation of the aorta.COA is a narrowing of a portion of the aorta, and often seriously decreases the blood flow from the heart out to the lower portion of the body
  • Atrioventricular canal (endocardial cushion defect).This defect — also known as endocardial cushion defect or atrioventricular septal defect — is caused by a poorly formed central area of the heart. Typically there is a large hole between the upper chambers of the heart (the atria) and, often, an additional hole between the lower chambers of the heart (the ventricles). Instead of two separate valves allowing flow into the heart (tricuspid on the right and mitral valve on the left), there is one large common valve, which may be quite malformed. Atrioventricular canal defect is commonly seen in children with Down syndrome.

Causes and Risk Factors.

These problems may occur alone or together. The majority of congenital heart diseases occurs as an isolated defect and is not associated with other diseases. However, they can also be a part of various genetic and chromosomal syndromes such as Down syndrome, trisomy 13, Turner syndrome, Marfan syndrome, Noonan syndrome, and DiGeorge syndrome.
No known cause can be identified for most congenital heart defects. Congenital heart diseases continue to be investigated and researched. Drugs such as retinoic acid for acne, chemicals, alcohol, and infections (such as rubella) during pregnancy can contribute to some congenital heart problems.

Signs and Symptoms of Heart Defects

Because congenital defects often compromise the heart's ability to pump blood and to deliver oxygen to the tissues of the body, they often produce telltale signs such as:
  • a bluish tinge or color (cyanosis) to the lips, tongue and/or nailbeds
  • an increased rate of breathing or difficulty breathing
  • poor appetite or difficulty feeding (which may be associated with color change)
  • failure to thrive (failure to gain weight or weight loss)
  • abnormal heart murmur
  • sweating, especially during feedings
  • diminished strength of the baby's pulse

Diagnostic Tests

Several tests can show what kind of heart disease your baby has. Tests can also check on your baby's condition, to see how the heart is working. Here are some tests your baby might have:
  • ECG -An ECG shows the heartbeat as a line tracing. It measures activity in different parts of the heart.
  • Pulse oximetry--This test shows how much oxygen is in the baby's blood.
  • Echocardiogram--This test gives the doctor an ultrasound "picture" of the baby's heart.
  • Chest X-ray--This can show how well the heart is growing and if your baby's lungs have fluid in them.
Cardiac catheterization--This test uses dye in the heart to give the doctor a clear picture of the heart problem.

How are congenital heart defects treated?

Although many children with congenital heart defects don't need treatment, some do. Doctors treat congenital heart defects with:

  • Procedures using catheters to repair the defect
  • Surgery to repair the defect

The treatment your child receives depends on the type and severity of his or her heart defect. Other factors include your child's age, size, and general health. Treatment can be simple or very complex. Some children with complex congenital heart defects may need several catheter or surgical procedures over a period of years, or may need to take medicines for years.

Procedures Using Catheters

Catheter procedures are much easier than surgery on patients because they involve only a needle puncture in the skin where the catheter is inserted into a vein or an artery. Doctors don't have to surgically open the chest or operate directly on the heart to repair the defect. This means that recovery can be much easier and quicker.

The use of catheter procedures has grown a lot in the past 20 years. They have become the preferred way to repair many simple heart defects, such as:

  • Atrial septal defect. The doctor inserts the catheter through a vein and threads it up into the heart to the septum. The catheter has a tiny umbrella‑like device folded up inside it. When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is secured in place and the catheter is then withdrawn from the body.
  • Pulmonary valve stenosis. The doctor inserts the catheter through a vein and threads it into the heart to the pulmonary valve. A tiny balloon at the end of the catheter is quickly inflated to push apart the leaflets, or "doors," of the valve. The balloon is then deflated and the catheter is withdrawn. Procedures like this can be used to repair any narrowed valve in the heart.

Doctors often use an echocardiogram or a transesophageal echocardiogram (TEE) as well as an angiogram to guide them in threading the catheter and doing the repair. A TEE is a special type of echocardiogram that takes pictures of the back of the heart through the esophagus (the tube leading from the mouth to the stomach). TEE also is often used to define complex heart defects.
Catheter procedures also are sometimes used during surgery to help repair complex defects.


A child may need open-heart surgery if his or her heart defect can't be fixed using a catheter procedure. Sometimes, one surgery can repair the defect completely. If that's not possible, a child may need more than one surgery over a period of months or years to fix the problem.

Open-heart surgery may be done to:
  • Close holes in the heart with stitches or with a patch
  • Repair or replace heart valves
  • Widen arteries or openings to heart valves
  • Repair complex defects, such as problems with where the blood vessels near the heart are located and how they develop
Rarely, babies are born with multiple defects that are too complex to repair. These babies may need a heart transplant. In this procedure, the child's heart is replaced with a healthy heart from a deceased child that has been donated by that child's family. 


Avoid alcohol and other drugs during pregnancy.

 Doctors should be made aware that a woman is pregnant before prescribing any medications for her.

 A blood test should be done early in the pregnancy to see if the woman is immune to rubella. If the mother is not immune, she must avoid any possible exposure to rubella and should be immunized immediately following delivery.

Poorly controlled blood sugar levels in women who have diabetes during pregnancy are also associated with a high rate of congenital heart defects during pregnancy.

Experts believe that some prescription and over-the-counter medications and street drugs used during pregnancy increase the risk of heart defects.

There may be some hereditary factors that play a role in congenital heart disease. Genetics does appear to play a role in many diseases, and multiple family members may be affected. Talk to your doctor about screening.

Expectant mothers should receive good prenatal care. Many congenital defects can be discovered on routine ultrasound examinations performed by an obstetrician. The delivery can then be anticipated and the appropriate medical personnel (such as a pediatric cardiologist, a cardiothoracic surgeon, and a neonatologist) can be present, and ready to help as necessary. Such preparation can mean the difference between life and death for some babies.

Congenital Heart Disease At A Glance

  • Congenital heart defects are problems with the heart's structure that are present at birth. Congenital heart defects change the normal flow of blood through the heart.

  • Congenital heart defects are the most common type of birth defect, affecting 8 out of every 1,000 newborns. Each year, more than 35,000 babies are born with congenital heart defects.

  • There are many types of congenital heart defects ranging from simple to very complex.

  • Doctors don't know what causes most congenital heart defects. Heredity may play a role.

  • Although many heart defects have few or no symptoms, some do. Severe defects can cause symptoms such as:

    • Rapid breathing.

    • A bluish tint to skin, lips, and fingernails. This is called cyanosis.

    • Fatigue (tiredness).

    • Poor blood circulation.

  • Serious heart defects are usually diagnosed while a baby is still in the womb or soon after birth. Some defects aren't diagnosed until later in childhood, or even in adulthood.

  • An echocardiogram is an important test for both diagnosing a heart problem and following the problem over time. This test helps diagnose problems with how the heart is formed and how well it's working. Other tests include EKG (electrocardiogram), chest x ray, pulse oximetry, and cardiac catheterization.

  • Doctors treat congenital heart defects with catheter procedures and surgery.

  • Treatment depends on the type and severity of the defect.

  • With new advances in testing and treatment, most children with congenital heart defects grow into adulthood and can live healthy, productive lives. Some need special care all though their lives to maintain a good quality of life.  


Warfarin (Coumadin) is an anticoagulant medication that is used to prevent thrombosis (clots) and embolism in many disorders.Warfarin activity has to be monitored by frequent blood testing for the International Normalized Ratio (INR).Warfarin is a synthetic derivative of coumarin, a chemical found naturally in many plants -- it decreases blood coagulation by interfering with vitamin K metabolism.


Warfarin is prescribed to people with an increased tendency for thrombosis or as prophylaxis in those individuals who have already formed a blood clot (thrombus) which required treatment. This can help prevent formation of future blood clots and help reduce the risk of embolism (migration of a thrombus to a spot where it blocks blood supply to a vital organ). Common clinical indications for warfarin use are atrial fibrillation, artificial heart valves, deep venous thrombosis and pulmonary embolism.

Dosing of warfarin is complicated by the fact that it is known to interact with many commonly used medications and other chemicals that may be present in appreciable quantities in food. These interactions may enhance or reduce warfarin's anticoagulation effect. Many commonly used antibiotics, such as metronidazole or the macrolides, will greatly increase the effect of warfarin by reducing the metabolism of warfarin in the body. Other broad-spectrum antibiotics can reduce the amount of the normal bacterial flora in the bowel, which make significant quantities of Vitamin K, thus potentiating the effect of warfarin. In addition, food that contains large quantities of Vitamin K will reduce the warfarin effect; and medical conditions such as hypo- or hyperthyroidism will alter the rate of breakdown of the clotting factors.

Therefore, in order to optimise the therapeutic effect without risking dangerous side effects, such as bleeding, close monitoring of the degree of anticoagulation is required by blood testing (INR) . Initially, checking may be as often as twice a week; the intervals can be lengthened if the patient manages stable therapeutic INR levels on an unchanged warfarin dose.

When initiating warfarin therapy ("warfarinisation"), the doctor will decide how strong the anticoagulant therapy needs to be. The target INR level will vary from case to case dependent upon the clinical indicators, but tends to be 2-3 in most conditions.

Side-effects and complications

The only common side-effect of warfarin is hemorrhage (bleeding). The risk of severe bleeding is small but definite (1-2% annually) and any benefit needs to outweigh this risk when warfarin is considered as a therapeutic measure. Risk of bleeding is augmented if the INR is out of range (due to accidental or deliberate overdose or due to interactions), and may cause hemoptysis (coughing up blood), excessive bruising, bleeding from nose or gums, or blood in urine or stool.

A feared (but rare) complication of warfarin is warfarin necrosis, which occurs more frequently shortly after commencing treatment in patients with a deficiency of protein C. Protein C is an innate anticoagulant that, like the procoagulant factors that warfarin inhibits, requires vitamin K-dependent carboxylation for its activity. Since warfarin initially decreases protein C levels faster than the coagulation factors, it can paradoxically increase the blood's tendency to coagulate when treatment is first begun (many patients when starting on warfarin are given heparin in parallel to combat this), leading to massive thrombosis with skin necrosis and gangrene of limbs. Its natural counterpart, purpura fulminans, occurs in children who are homozygous for protein C mutations.

Another rare complication that may occur early during warfarin treatment (usually within 3 to 8 weeks) is purple toe syndrome. This condition is thought to result from small deposits of cholesterol breaking loose and flowing into the blood vessels in the skin of the feet, which causes a blueish purple color and may be painful. It is typically thought to affect the big toe, but it affects other parts of the feet as well, including the bottom of the foot (plantar surface). The occurrence of purple toe syndrome may require discontinuation of warfarin.

Warfarin can harm an unborn baby or cause birth defects. Do not use warfarin if you are pregnant or may become pregnant. Never take a double dose of this medication or take it together with other products that contain warfarin or coumarin. You should not take warfarin if you have a bleeding or blood cell disorder, blood in your urine or stools, an infection of the lining of your heart, stomach bleeding, bleeding in the brain, recent or upcoming surgery, or if you need a spinal tap or spinal anesthesia (epidural).

Warfarin may cause you to bleed more easily, especially if you have: a history of bleeding problems, high blood pressure or severe heart disease, kidney disease, cancer, surgery or a medical emergency, a disease affecting the blood vessels in your brain, a history of stomach or intestinal bleeding, if you are 65 or older, or if you are severely ill or debilitated.

Many drugs (including some over-the-counter medicines and herbal products) can cause serious medical problems or death if you take them with warfarin. It is very important to tell your doctor about all medicines you have recently used. Ask your doctor before taking any medicine for pain, arthritis, fever, or swelling. These medicines may affect blood clotting and may also increase your risk of stomach bleeding.

Any doctor, dentist, surgeon, or other medical care provider who treats you should know that you are taking warfarin. Avoid making any changes in your diet without first talking to your doctor.

Warfarin side effects that require immediate medical attention

  • Severe bleeding
  • Black stool or bleeding from the rectum
  • Skin conditions such as hives, a rash or itching
  • Swelling of the face, throat, mouth, legs, feet or hands
  • Bruising that comes about without an injury you remember
  • Chest pain or pressure
  • Nausea or vomiting
  • Fever or flu-like symptoms
  • Joint or muscle aches
  • Diarrhea
  • Difficulty moving
  • Numbness of tingling in any part of your body
  • Painful erection lasting four hours or longer
Although rare, warfarin can also cause skin tissue death (necrosis) and gangrene requiring amputation. This complication most often happens three to eight days after you start taking warfarin. If you notice any sores, changes in skin color or temperature, or severe pain on your skin, notify your doctor immediately.

Less serious warfarin side effects to tell your doctor about

  • Gas
  • Feeling cold
  • Fatigue
  • Pale skin
  • Changes in the way foods taste
  • Hair loss

Before taking warfarin

You should not take warfarin if you are allergic to it, or if you have:
  • hemophilia or any bleeding disorder that is inherited or caused by disease;
  • a blood cell disorder such as anemia (lack of red blood cells) or a low level of platelets in your blood;
  • blood in your urine or stools, or if you have been coughing up blood;
  • an infection of the lining of your heart (also called bacterial endocarditis);
  • stomach or intestinal bleeding or ulcer;
  • recent head injury, aneurysm, or bleeding in the brain;
  • if you have recently had or will soon have any type of surgery (especially brain, spine, or eye surgery); or
  • if you undergo a spinal tap or receive spinal anesthesia (epidural).
You should not take warfarin if you cannot be reliable in taking it because of alcoholism, psychiatric problems, dementia, or similar conditions.
Warfarin may cause you to bleed more easily, especially if you have:
  • a history of bleeding problems;
  • high blood pressure or severe heart disease;
  • kidney disease;
  • cancer;
  • surgery or a medical emergency;
  • a disease affecting the blood vessels in your brain;
  • a history of stomach or intestinal bleeding;
  • if you are 65 or older; or
  • if you are severely ill or debilitated.
Warfarin can cause birth defects or fatal bleeding in an unborn baby. Do not take warfarin if you are pregnant or may become pregnant. Use effective birth control and tell your doctor right away if you become pregnant while taking warfarin.

How should I take warfarin?

Take warfarin exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label. Never take a double dose of this medication or take it together with other products that contain warfarin or coumarin.

Your doctor may occasionally change your dose to make sure you get the best results.

Take warfarin at the same time every day. Warfarin can be taken with or without food.
Avoid dieting to lose weight while taking warfarin. Tell your doctor if your body weight changes for any reason.

Call your doctor if you have any illness with diarrhea, fever, chills, body aches, or flu symptoms.

While taking warfarin, your blood will need to be tested often. Visit your doctor regularly.

Any doctor, dentist, surgeon, or other medical care provider who treats you should know that you are taking warfarin. You may need to stop taking the medicine for a short time if you need antibiotics, surgery, dental work, a spinal tap, or spinal anesthesia (epidural).

Drugs that interact with Warfarin

Warfarin, like any other medication, can interact with drugs, vitamins or herbal supplements. Be ready to provide your doctor with a complete list of everything you're taking.

Drugs that can interact with warfarin include:
  • Aspirin or aspirin-containing products
  • Ibuprofen (Advil, Motrin, others) or naproxen (Aleve)
  • Acetaminophen (Tylenol, others) or acetaminophen-containing products, especially when the dose of acetaminophen exceeds 1,500 milligrams a day
  • Many antibiotics
  • Heparin
  • Cold or allergy medicines
  • Birth control pills
  • Medications that treat abnormal heart rhythms, such as amiodarone
This isn't a complete list. Many other medications interact with warfarin. You should always consider that a new medication could interact with warfarin until your doctor, nurse, or pharmacist tells you otherwise

Warfarin diet

There is no specific warfarin (Coumadin) diet. However, certain foods and beverages can make it so warfarin doesn't effectively prevent blood clots. It's important to pay attention to what you eat while taking warfarin.

One nutrient that can lessen warfarin's effectiveness is vitamin K. It's important to be consistent in how much vitamin K you get daily. The average daily allowance of vitamin K for adult men is 120 micrograms (mcg). For adult women, it's 90 mcg. While eating small amounts of foods that are rich in vitamin K shouldn't cause a problem, avoid eating or drinking large amounts of:
  • Kale
  • Spinach
  • Brussels sprouts
  • Parsley
  • Collard greens
  • Mustard greens
  • Chard
  • Green tea
Certain drinks can increase the effect of warfarin, leading to bleeding problems. Avoid or drink only small amounts of these drinks when taking warfarin:
  • Cranberry juice
  • Alcohol
Talk to your doctor before making any major changes in your diet and before starting any over-the-counter medications, vitamins or herbal supplements. If you are unable to eat for several days or have ongoing stomach upset, diarrhea or fever, consult your doctor. These signs and symptoms may mean you need a different dose of warfarin.


Most of us avoid the thought of aging. What we see, read and hear about aging is frightening; progressive deterioration and degeneration with concomittant loss of independence, loss of control-of everything from our finances and living arrangements to control of body functions. Not exactly a picture to dwell on.

To age “gracefully” in a culture which idolizes youth requires inner strength and wisdom. Hopefully we can do away with some myths about aging which limit our quality of life, but also discover some of the “perks” of aging that we often ignore.

Two Basic Requirements of Graceful Aging

There are two “basic requirements” of graceful aging. To borrow from the “Serenity Prayer”, graceful aging requires the “serenity to accept the things we cannot change; courage to change the things we can; and wisdom to know the difference.”  Certainly acceptance of aging is a key to aging gracefully – but which of the changes that commonly come with age are the “things we cannot change” and which are the “things we can change.

What You Can and Cannot Change — Importance of Relaxation

These two major requirements of successful aging – accepting the aging process and not accepting what we can change — may at first seem contradictory.  Sometimes success in life involves the ability embrace the paradox that when we accept life at it is at the moment, it paradoxically opens a doorway for positive change.
The bottom line is the ability to relax with whatever challenges us at any given time and that includes the changes aging brings.
When we are relaxed, we are open to different ways of looking at things.
Relaxation brings us out of the “fight or flight” mode that causes us to act impulsively, and gives us more ability to reflect on things. Instead of running out to buy some new anti-aging product, we can spend some time examining our fears and learning whether they are based in reality or on some cultural programming that we’d be better off ignoring.

What We Can Change — The Role of Attitude and Lifestyle

It’s been discovered that attitude has an enormous role in how we age. Much of the decline that people experience with aging comes about due to the belief that decline in function and quality of life is part and parcel of aging. In addition, many of the problems of age are not due to the process of aging itself, but rather due to the effects of a lifetime of stress and poor health habits.
It’s never too late to change the two most important ingredients to graceful aging – attitude and lifestyle.

What We Cannot Change — Coming to Terms with Our Mortality

One thing we absolutely cannot change is the fact that every day brings us closer to death. This one fact alone may account for a great deal of our difficulty with aging.  As soon as we see signs of aging, we are reminded that this body is eventually going to die. As we age, we come face to face with our mortality, and to deal with this we are thrown upon our spiritual resources. Our “spiritual health” may well be measured by how we face the fact of our mortality.
With the rest of the things we cannot change, there is more of a gray area, as we are only now starting to make scientific discoveries about the aging process. Nevertheless, it’s safe to say that aging will bring change.  With menopause, both male and female, we begin to live with a different hormonal environment. The appearance and function of our body changes and requires that we adapt. Our roles change dramatically as our children grow older and leave home, and we become grandparents rather than parents. At some point, many of us become parents to our parents as they enter their final years.
Growing older also brings more loss. Not only is there loss of many aspects of being young, more people we know die. This may be one of the most difficult aspects of aging.  If we haven’t learned to grieve earlier in life, the all important task of learning to live with loss must be learned to avoid psychological and health problems.

Finding a Balance

Finally, graceful aging means finding a balance between acceptance of the inevitability of aging and doing what we can to remain vital and healthy as long as possible. Once again, we emphasize the importance of relaxing. Acceptance involves relaxation into life and the ability to flow with change. When we are relaxed, we stop fighting the inevitable. At the same time, relaxation is a key to better health and greater vitality.

Some Points to remember.

1) Everything has its season: learn it! On each birthday, we move past an age we will never revisit. It is gone, for better or for worse. The same for decades. Learn to make the most of what you have when you have it.

2) Strive for something:Set goals and attain them. The point is to remain independent and productive as long as possible. Aging gracefully can itself be a goal.

3) Maintain friendships, as a well as a sense of belonging in a community. Even when physical health may decline -or when a disability may set in- mental health can keep a smile on the face.Avoid the temptation in this age of wellness to link physical and mental health too closely.

4) Exercise regularly. You knew that advice was coming because physiologists, psychiatrists, and strangers sitting beside us on the train/ plane swear by it.  The consensus should convince you.

5) Hope. Don't stop believing that people and things can get better. Try to avoid being cynical, the failure to give people their due, the inclination to think less of people. Should you find yourself bothered by mistakes in your own past, reinvent yourself.

Remember as well that the grass is always greener on the other side of the fence. Probably all of us want what we don't have.

When did we become so big?

As we explore the world of senior citizens, We also discover that our role with our parents are changing-- that parent is becoming child and child is becoming parent. While our kids are growing up, our parents are growing old. While the grand kids are becoming stronger, more independent, our parents are becoming weaker and more dependent.

"When did parent become child and child become parent?"

I think the transformation begins when we stop asking and start telling our parents what to do: when we stop taking advice and start giving it: when we drive them to the doctor, dentist and supermarket: take them shopping for new clothes and shoes and insist they buy the most practical; take them to the market and suggest veggie instead of non-veg because it's easier to chew and digest. It begins the first time we remind them to take their vitamins, wear a warm coat and stay out of the rain. It starts when we haven't heard from them in a few days and we start to panic. You know: all the same loving, but aggravating, things they've been doing for us for more than half a century.

Role reversal isn't anything new. It's been going on since man began walking upright, pairing off and forming families. but how we deal with our elderly has changed, In India,especially kerala the elderly or infirm aren't deposited in nursing homes; they are cared for at home by their adult children, just as their parents did before them and so on. If it's at all possible, it's a practice my generation should and definitely will uphold.

For all those who think of nursing homes the realization that you all are going to be there someday is reason enough for compassion and a change of mind.

In Olden days taking in the elderly meant adding to an already crowded household. It meant three or four generations under one roof(joint family).  At times there would be slamming of doors, arguments galore and hurtful words screamed out in anger. It also meant there would be shrieks of joy, plenty of encouraging words, doors being opened, shared disappointments, comfort, hugs, and kisses. Most of all, it meant being a family


We are such an anti-fat society, it’s ridiculous.  We are so scared of being considered fat that we automatically think all fat is bad- when in reality, fat can be good.

We need fat on our bodies- it’s necessary so we can store fat soluble vitamins, like vitamin A, D, E and K and forms of fat, like fatty acids, are one of the building blocks of the cell membranes which surround every cell in the body. The way the cell responds to hormones, participates in the supply of nutrients and disposal of waste is dependent upon the health and integrity of these cell membranes.  

Fat also helps to keep your skin watertight and moist, and assists your nerves in transmission of signals. Fat is also critical for various functions regulating inflammation, blood pressure, and clotting.

There are some advantages to having a surplus of body fat, or in other words, being overweight. Not obese, mind you, but being above the chart norms used to classify healthy weights. Most women are above these numbers, and are still quite healthy.

A Healthier Heart

According to the British Medical Journal, women with larger thighs have a lower risk of heart disease and early death. Women with pin-thin legs faced the greatest chance of developing heart disease.

Glowing Skin

Studies have found that between two sisters, the one with the higher BMI was judged to have a more youthful look. A sunken face can add years, so carrying an extra few pounds will help create a more youthful appearance- plus a fuller face wrinkles less.

Live Longer than Anyone Else

Studies have found that gaining a few extra pounds can add years to life.Overweight people actually outlive the obese, the underweight, and people at normal weight. Extra pounds protect against conditions that lead to premature death. It’s thought that fat stores can be used to help the body stay strong during illness and aid in recovery.

Increased Fertility

Studies found underweight women were 72 percent more likely to miscarry, while those women who carried a few extra pounds proved to have the opposite effect on their pregnancy.

Stronger Bones

Extra weight on your frame can ward off osteoporosis. Weight-bearing exercises are the best way to ward off the disease, and carrying a few extra pounds puts constant stress on your skeleton. Osteoporosis is less common in overweight women than thin women.

Protects against other diseases

Having a little extra weight actually seemed to help people survive some illnesses.
Also surprising was that overweight people were up to about 40 percent less likely than normal-weight people to die from several other causes including emphysema, pneumonia, injuries and various infections. The age group that seemed to benefit most from a little extra padding were people aged 25 to 59; older overweight people had reduced risks for these diseases, too.

Good Butt.

It turns out that women with more lush forms have some advantages over the models.

If a woman has the buttocks over 100 cm, the risk of death from heart attacks is reduced by as much as 87% compared with the "thin" representatives of weaker sex. And the threat of coronary heart disease and cardiovascular disease among larger women is reduced by 86% and 46% respectively.

The reason is that unlike the fat in the abdomen, in the buttocks' fat there is substance adiponectin , which prevents arteries to swell and block. As a result, women are full of more favorable outlook for the birth of children and housework -  a note to those who plans to marry.

Among men in the buttocks area were not seen anything similar, so their hearts on this factor is independent.


What is internal bleeding?

Internal bleeding is blood loss occurring within your body. Because it occurs inside your body, internal bleeding may go unnoticed initially. If the bleeding is rapid, enough blood may build up to press on internal structures or to form a bulge or discoloration under your skin. Severe internal bleeding can cause shock and loss of consciousness.

Internal bleeding occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. The amount of bleeding depends upon the amount of damage to an organ and the blood vessels that supply it, as well as the body's ability to repair breaks in the walls of the blood vessels. The repair mechanisms available include both the blood clotting system and the ability of blood vessels to go into spasm to decrease blood flow to an injured area.

Patients who take anti-clotting medication such as warfarin (Coumadin), clopidogrel (Plavix), heparin, or aspirin are more prone to bleeding than people who do not take these medications. These individuals may experience significant bleeding even with relatively minor injury or illness, and the risk of bleeding needs to be balanced against the benefits of taking the medication.

Some people have genetic or inborn errors of the blood clotting system. Minor injuries may cause major bleeding in these cases. Hemophilia and von Willebrand disease are two examples.

What are the Causes of internal bleeding


Bleeding is common in many types of cancer. Sometimes the bleeding is obvious, but more often, cancer-related bleeding is internal, with perhaps some external manifestations. For example, blood in the stool can indicate cancer of the colon or rectum, while vaginal bleeding could suggest cancer of the cervix, uterus, or ovary. Blood in the urine may signify kidney or bladder cancer. One sign of stomach cancer is vomiting blood; esophageal cancer can also produce vomiting or spitting up blood.


In this disease, which is most commonly caused by alcohol abuse, scar tissue forms in the liver and obstructs the flow of blood. In the advanced stages of cirrhosis, there may be heavy bleeding into the esophagus.

Colon polyps

Colon polyps are small, grape-like growths that form clusters inside the large intestine. Some are hereditary (familial polyposis) and have a high probability for becoming cancerous. More often, they are harmless; both types, however, are a common cause of hidden intestinal bleeding.


In diverticulosis, small out­pouches form along weakened segments of the colon wall. Sometimes these pouch­es become impacted with fecal material, causing inflammation. In severe cases, one or more of these outpouches may rupture, causing bleeding and spilling the colon contents into the abdominal cavity. This can lead to life-threatening peritonitis.

Gastric disorders

Gastrointestinal bleeding may be caused by a variety of disorders, as well as by certain medications. Aspirin, for example, can be the culprit if taken often and in high doses. Gastrointestinal bleeding ranges from mild to severe, and in conditions such as a peptic ulcer, it can cause massive hemorrhage and death if treatment is delayed. If massive bleeding occurs, other symptoms may include pain, heavy perspiration, vomiting blood, bloody stools, and shock.


This is an inborn defect of blood coagulation. It affects only males, although women carry the causative gene. Children who have it often bleed into the joints, resulting in joint pain, swelling and deformity. Even a trivial injury can result in severe internal and external bleeding.


Some forms of leukemia can cause internal bleeding. Other symptoms may include high fever, joint pain, fatigue, pallor, and abnormal blood counts.

Marfan's syndrome

This inherited disorder can cause weakness of the aorta, the largest artery that carries blood from the heart for distribution to all parts of the body. Severe, internal bleeding can occur if an aneurysm develops and ruptures.

Miscarriage and menstrual disorders

Severe vaginal bleeding may occur during a miscarriage. It also may be a sign of approaching menopause or failure to ovulate. Vaginal bleeding that is unrelated to pregnancy or menstruation is a common sign of cancer.

Vascular disorders

These are disorders of the blood vessels in which inter­nal bleeding is a likely symptom. Purpura, in which blood vessels are fragile and the person bruises easily, is one of the most common of these disorders. There may also be fever and joint pain

What other symptoms might occur with internal bleeding?

Symptoms accompanying internal bleeding vary based on the location and speed of blood loss. Pain may or may not be present. Rapid bleeding can quickly cause weakness, dizziness, shock and unconsciousness. Slower bleeding may ultimately cause anemia, with the gradual onset of tiredness, weakness, shortness of breath, and pallor. Bleeding into the gastrointestinal or urinary tract can cause blood in the stool, vomit or urine.

Common symptoms that may occur with internal bleeding in the head

Internal bleeding in the head may accompany other symptoms including:
  • Change in mental status
  • Confusion
  • Garbled or slurred speech or inability to speak
  • Headache
  • Loss of vision or changes in vision
  • Numbness or tingling
  • Paralysis
  • Weakness (loss of strength)

Common symptoms that may occur along with internal bleeding in the chest or abdomen

Internal bleeding in the chest or abdomen may accompany other symptoms including:
  • Abdominal, pelvic, or lower back pain that can be severe
  • Abdominal swelling, distension or bloating
  • Bruising around the navel or of the flanks
  • Chest pain
  • Coughing up blood (hemoptysis)
  • Difficulty breathing
  • Dizziness or lightheadedness
  • Enlarged liver or spleen
  • Shortness of breath

Common symptoms that may occur along with bleeding into the muscles or joints

Internal bleeding into the muscles or joints may accompany other symptoms including:
  • Bone or joint deformity
  • Loss of sensation
  • Pain
  • Reduced mobility (range of motion)
  • Swelling, redness or warmth

Other symptoms that may occur along with internal bleeding

Internal bleeding at other sites may accompany other symptoms including:
  • Abdominal pain or cramping
  • Bloody or pink-colored urine (hematuria)
  • Bloody stool (blood may be red, black, or tarry in texture)
  • Hematoma (collection of blood in body tissues)
  • Pain
  • Vomiting blood or black material (resembling coffee grounds)

Serious symptoms that might indicate a life-threatening condition

In some cases, internal bleeding may be a symptom of a life-threatening condition that should be immediately evaluated in an emergency setting. Seek immediate medical care if you, or someone you are with, have any of these life-threatening symptoms including:
  • Bleeding while pregnant
  • Bluish coloration of the lips or fingernails
  • Change in level of consciousness or alertness, such as passing out or unresponsiveness
  • Change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions
  • Chest pain, chest tightness, chest pressure, palpitations
  • Garbled or slurred speech or inability to speak
  • Not producing any urine, or an infant who does not produce the usual amount of wet diapers
  • Paralysis or inability to move a body part
  • Rapid heart rate (tachycardia)
  • Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing
  • Severe pain
  • Vomiting blood, rectal bleeding, or bloody stool

How is internal bleeding diagnosed?

The diagnosis for internal bleeding begins with the doctor taking a history and performing a physical examination on the patient. The situation and the source of the bleeding will focus the testing strategy on the part of the body that may be involved with the bleeding. Sometimes the direction of diagnosis is self evident; a motor vehicle crash victim who complains of abdominal pain will have attention directed to the abdomen. Sometimes it is less evident. A confused patient may have issues with bleeding in the brain, or may be so anemic (decreased red blood cell count) from blood loss elsewhere, that the brain is not getting enough oxygen and nutrients to function properly.

Blood tests may include a complete blood count (CBC) or hemogram to access for anemia and abnormal platelet count. INR (international normalized ratio) and PTT (partial thromboplastin time, a blood test that measures how long it takes for blood to clot) are blood clotting studies that may be measured to screen for abnormal clotting function. Depending upon the situation, the hospital blood banking system may be alerted to begin the process of crossmatching blood products for potential transfusion.

Diagnostic tests such as X-rays, Doppler ultrasound, and CT scan may be used depending upon the underlying medical problem associated with internal bleeding.

Computerized tomography (CT scan) is the primary tool used in emergency situations to access for bleeding or swelling in the brain. In a small fraction of patients who have bleeding from a ruptured cerebral aneurysm (a blood vessel that leaks in the brain), the CT will initially be normal and a lumbar puncture may be performed to help make the diagnosis.

CT scan is also one of the tests that can be performed to access for bleeding within the abdomen and chest. It is especially helpful in trauma to look for bleeding from the solid organs of the abdomen like the liver, spleen, and kidney. It is ideal for evaluating the retroperitoneal space for bleeding and can also evaluate fractures of the pelvis and spine.

In cases of potential bleeding from a major blood vessel, CT angiography may be considered to look for a specific blood vessel that is bleeding.

Ultrasound may be used to look for sources of bleeding, most often where there is an obstetric or gynecologic source of bleeding.

Endoscopy, colonoscopy, and anoscopy are used to look for sources of bleeding in the gastrointestinal tract. Using a flexible scope with an attached camera, a gastroenterologist may look into the stomach and intestine, rectum, and colon to find the source of bleeding. Using the same instrument, cautery (electricity used to coagulate or burn a blood vessel) can stop the bleeding if the source is found

How is internal bleeding treated?

The initial treatment plan of any patient with internal bleeding begins with assessing the patient's stability and making certain the ABCs are well maintained. This includes making certain the patient's:
  • Airway is open,

  • that the patient is Breathing, and

  • that there is adequate Circulation, meaning good pulse and blood pressure.
The definitive treatment of internal bleeding depends upon where the bleeding is occuring, the individual situation, and the stability of the patient. The basic goals include identifying and stopping the source of bleeding and repairing any damage that the bleeding may have caused.

What are the complications of internal bleeding?

Depending upon where it occurs, if not recognized, internal bleeding may cause organ failure, shock, and death. For example:
  • If there is uncontrolled bleeding in the chest or abdomen, the body may lose enough circulating red blood cells to compromise oxygen delivery to cells in the body. This situation is called shock. If the bleeding is not stopped and if fluid resuscitation and perhaps blood transfusion are not provided, the patient may die.

  • Internal bleeding in the brain may cause minimal damage, but if there is enough to cause increased pressure or if the bleeding increases, enough brain tissue may be damaged to cause stroke-like symptoms, coma, and death.

How can we prevent or take precautions?

Internal bleeding covers many organ systems and situations. Disease and injury prevention is the basis of maintaining a healthy lifestyle.

Key to prevention include preventing heart attack and stroke by controlling high blood pressure, diabetes and high cholesterol.

Injury prevention includes wearing appropriate safety equipment for the activity involved and avoiding risky behaviors like drinking and driving.

Preventing alcohol-related diseases can help prevent a significant cause of internal bleeding.

Individuals taking medication that predispose them to internal (and external) bleeding should take extra precautions to avoid any trauma; moreover, they should continue to get routine blood tests (INR, PT, CBC's) to see if they are appropriately medicated and assure they are not bleeding internally

Internal Bleeding At A Glance

  • Internal bleeding may occur in many areas of the body and may cause significant local pain. If enough bleeding occurs, signs of shock may be apparent.

  • Bleeding is a recognized complication of anti-coagulation medications such as aspirin, clopidogrel (Plavix), warfarin (Warfarin), and heparin. The benefits of these medications need to be balanced against the risk of bleeding.

  • Bleeding is never normal in pregnancy.

  • If internal bleeding is suspected, it is important to seek medical care