blood clots

Monday, August 11, 2014

In August, a Philadelphia sports fan should be thinking about the Eagles and the Phillies but not necessarily the Flyers…okay, perhaps not the Phillies either, so it would have been easy to miss the news in the City of Brotherly Love, that Flyer defenseman, Kimmo Timonen, was hospitalized in Finland for blood clots in his leg and lung. The 39 year old was supposed to play an important role for the Flyers in the coming season, but team General Manager Ron Hextall was uncertain whether he could play: “This could be a long term thing…Could he play next season? I don’t have an answer to that.”

The answer begins with the treatment for DVT, deep venous thrombosis or blood clot in a vein, and PE, pulmonary embolism or blood clot in the lung. Anti-coagulation or blood thinning is the treatment of choice for both DVT and PE and while on that treatment, Mr. Timonen will not be playing hockey. By interfering with the body’s ability to clot blood, minor injuries can become major disasters, especially in hockey where falls and body contact are routine parts of the game. A minor bump to the head can cause lethal bleeding in the brain. A blow to the chest or abdomen can cause uncontrolled bleeding and shock if the body cannot mend itself. The big question to be asked is how long does he have to be on blood thinners? And that is where the science of medicine is not quite as precise as we have come to expect.

There are a few reasons why a blood clot or thrombus might form. The big three categories are vein injury from trauma, blood stasis and problems with the blood clotting mechanism. If the body is immobile, there is less muscle activity to squeeze blood back to the heart and stagnant blood tends to clot. Patients who are bedridden due to stroke or surgery (especially after pelvis, hip or leg operations) and those that have casts in place are at risk, as are people who sit in an airplane or car for hours. Decreased blood flow from the legs may also occur in obese people and can also be seen in pregnancy where the enlarged uterus compresses veins in the pelvis. Underlying medical problems can increase the risk of blood clot formation and range from genetic predisposition, to cancer, to smoking and the use of birth control pills.

DVTs are common but the big complication occurs when the thrombus breaks off and embolizes or travels through the heart and gets lodged in the lung arteries. More than 600,000 people are diagnosed with a PE every year in the US and the death rate is about 25%, but those numbers may significantly underestimate the problem. Based on death studies, there may be more than double that number and the diagnosis of pulmonary embolus often occurs autopsy. When a PE occurs, it affects the ability of the lung tissue to transfer oxygen from the air in to the blood stream and depending upon the amount of clot, the symptoms may be mild (sharp chest pain and mild shortness of breath) to collapse and sudden death.

The diagnosis is always in the back of the doctor’s mind to at least be considered when caring for people with shortness of breath. The diagnosis is entertained based upon history, physical examination, clinical suspicion and risk factors. It is confirmed in a variety of ways depending upon the clinical situation and the patient’s stability. Often, it may include, EKGs, blood tests, ultrasounds and CT scans.

For most people the treatment is anticoagulation, the use of medications to thin the blood. There are a variety of choices, depending upon the patient’s situation but most involve a combination of heparin injections to immediately thin the blood while also taking Coumadin by mouth. It takes a few days for Coumadin to reach effective blood levels, so dual therapy often occurs. Newer anti-coagulation drugs have been developed and in the past few months, Xarelto (rivaroxaban) has been approved as a single step oral treatment for PE. But in critical situations, emergency surgery may be required to remove or dissolve blood clots in the lung.

With that background, the question remains. How long should treatment last? For the first DVT or PE, anticoagulation is recommended for 3 months, as long as there is no underlying reason to consider longer therapy. Imagine a cancer patient or one who has an abnormal blood clotting disorder. For recurrent clot, the recommendations are less clear and consideration may be given to life-long treatment. The duration of therapy recommendations are more than a little vague for those patients.

This is the second time around for Mr. Timonen with clots. In 2008, he developed a DVT after being hit by a puck in the foot. Now the questions that face him and his doctors include whether that first DVT was due to trauma and does not count in deciding how long the anticoagulation should last. And they need to decide what caused this episode of DVT and PE and whether there should be a search for any underlying risk factor. And that leads to the question posed by the Philadelphia general manager as to whether Mr. Timonen will play in the coming NHL season that begins in about a month. And the answer is…not anytime soon.

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