Blood clots are a serious issue, as they can be life-threatening. According to the Centers for Disease Control and Prevention (CDC), estimates that 60,000 to 100,000 people die from this condition annually. When a blood clot occurs in one of your veins, it’s called a venous thromboembolism (VTE). If you’re even slightly concerned you might have one, call your doctor right away. Symptoms of blood clots can vary. It’s also possible to have a blood clot with no symptoms.
Thrombosis, or blood clotting, is usually associated with the “coronaries”, that is the heart. However, thrombosis or blood clots can form in the deep vein of the legs, where it called deep vein thrombosis (DVT). These clots can break from the leg veins and travel to the lung blood vessels, where this pulmonary embolism (PE) can cause fatal outcomes and can cause immediate death. After heart attack and stroke, PE is the third most common cardiovascular killer. General knowledge about PE is scant. The clinical presentation can often be silent, and the diagnosis missed by ace clinicians. It continues to be one of the commonest causes of deaths in hospitalized patients.
Sreerupa Patranabish caught up with Dr. Sunil Kumar, an orthopaedic surgeon turned primary care specialist currently practising in Neshoba County General Hospital in rural Mississippi, who is widely respected for his pioneering contributions in diagnosing pulmonary embolism and creating public awareness about this killer health condition.
SP: Welcome Dr. Kumar. Normally, do blood clots form inside our circulation?
SK: Yes, very much so. That’s why one has heart attack!
SP: Do blood clots form even without the blood vessel being injured?
SK: Yes. Blood clots do form within the blood vessels due to changes in properties of the blood and/or changes in the inner lining of the blood vessel.
SP: Please elaborate…
SK: Normally, blood is brought back to the heart after circulating through various parts of the body. This flow is not passive. For example, blood from the legs must work against gravity to come back to the heart. This is facilitated by the muscles of the leg, especially through the calf muscles, which acts as peripheral pump or a peripheral heart. At other times, the properties of the blood may also change. The blood cells may become sticky. A common condition which makes the blood cells sticky is diabetes. So imagine a person who is both overweight/obese and diabetic and one who does not move around a lot will have clots formed within the blood vessel, despite no injury in the wall of the blood vessel.
SP: This is alarming then…
SK: Sure It is.
SP: How big is the clot?
SK: Clot can be pretty small like the size of a nail bed or it can be long and form a cast within the blood vessel.
SP: What is the fate of the clot?
SK: The clot can stay local; it can cause pain in the legs, swell up the legs and increase warmth on the skin. However, the clots can break from the primary site of formation and migrate elsewhere, mainly to the lungs.
SP: Can this be fatal?
SK: Sure it can be. It can instantaneously kill the person. The blood clot will prevent normal oxygenation. This is called pulmonary embolism.
SP: How common is pulmonary embolism?
SK: It is the third commonest hospital related deaths in the United States. Half a million people are affected every year. It is very common in India as well. In the United States, nearly 13.4 million hospitalized patients are at risk from VTE (venous thromboembolism, the combined name for DVT and PE).
SP: What are the risk factors?
SK: Most of the risk factors are external and iatrogenic. Prolonged immobilization is the single most critical risk factor. The long-haul air travel, immobilization after surgery, for example, like fracture repair and joint replacements, advancing age and other rheumatoid or neurologic diseases (after stroke) are the commonest factors. Autoimmune conditions like antiphospholipid syndrome (APLA), detects in blood clotting and anticlotting factors, and cancers are common medical conditions that predispose to DVT. Pregnancy, oral contraceptive pills (OCP) and post-menopausal hormone replacement are also important risk factors.
SP: How is Pulmonary Embolism diagnosed?
SK: A blood test called D-dimer assay is used as a primary screening. The Gold Standard for diagnosis of PE is computerized tomographic (CT) pulmonary angiography (CTPA), also called CECT (contrast enhanced CT scan).
SP: So, do we perform CTPA in all patients?
SK: No, here is the catch. In an original investigation, I, with my colleagues, have demonstrated that not all patients require CTPA. It is the onus of the clinician to clinically pinpoint who the high-risk patient is. CTPA using contrast agents can be harmful to the patients with consequent kidney damage. We need to remember that patients have multiple medical issues and are elderly and can have damaged kidneys from high blood pressure and diabetes. The X-rays for CT scan can be carcinogenic.
SP: Is CTPA expensive?
SK: Oh, yes. The symptoms of pulmonary embolism (PE) are often vague. The chest pain in PE may mimic heart attack. Given the non-specific nature of the symptoms, the busy clinician is inclined to rule out PE upfront. Missing the diagnosis of PE is not an option, as it is associated with very high mortality. At the same time, not all patients really need to be imaged. I was among the first to identify this issue and point out to the medical community.
SP: What is the treatment of PE?
SK: Medications, chemical clot busters, are needed to dissolve the clot. Sometime, this needs to be done by ultrasonic probe or complex cardiopulmonary surgery may be needed.
SP: Can PE be prevented?
SK: Yes, prevention is a major deal. This include reduction of body weight and efficient control of diabetes. Most importantly, body parts need to be moved.
SP: What is ShakeIT?
SK: ShakeIT is a free mobile health related Application and can be freely download from Google Play Store: https://play.google.com/store/apps/details?id=com.Shake.It. I am trying to motivate people to move around even if they are challenged to remain immobilized for relatively long periods of time. Patients with stroke needs regular physiotherapy. Patients on wheel chair as well needs assisted movement to prevent the fatal clots.
SP: How did you obtain this insight?
SK: In pursuance of my MRCS in Orthopaedics, I was regularly interacting with these patients, who were at high-risk for developing PE. However, I soon realized that smaller clots are also likely benign and may be physiologic. Then I started realizing that we should triage these patients and not all patients need to be imaged.
SP: How did you conclude?
SK: In a collaborative study, in our original analysis in 185 hospitalized patients who underwent CTPA based on clinical suspicion, our analysis showed that triaging the patients can reduce unnecessary radiology examinations. This work was published in the Journal of Community Hospital Internal Medicine Perspective in 2013.
SP: Are your recommendations currently being used?
SK: Fortunately, yes. There are few other groups from around the country which have taken cognizance of this work. Soon after our work was published, independent groups from Boston University published similar findings. These now form practice-changing guidelines adopted by the American College of Physicians (ACP) as well as by Choosing Wisely, an American Board of Internal Medicine (ABIM) Foundation initiative.
SP: This discussion is an eye opener Dr. Kumar.
SK: I am glad, thank you. People should be aware that moderate exercising and movement is a necessity, even in the face of physical disability. This shall help maintain the fluidity of blood and prevent clots from blocking the lung circulation and causing sudden death.
Blood Clots Are potentially deadly. Symptoms of Blood Clots Can Be Subtle. You can, and should ask for a Blood Clot risk assessment. Be persistent and advocate for yourself. You can help yourself on Blood Clots. It is really encouraging to make a difference. When people are not much aware and not appreciating that the condition is preventable. If you are well informed you can impact on their care.