pulmonary embolus

Monday, February 23, 2015

If only patients would read the textbook and always have the same complaints and physical findings for an illness or disease. That would make diagnosis much easier. But real life is never easy when it comes to diagnosis and treatment. Consider the sad stories of Chris Bosh and Jerome Kersey.

Mr. Bosh, in the prime of his career as an NBA superstar notices some pain in his chest and for a few days doesn’t feel quite right. He sees his doctor and after a few tests, the diagnosis is made of pulmonary embolus, blood clots in his lungs. Mr. Kersey, at age 52 a retired basketball star, has one of the common presenting complaints for pulmonary embolus (PE). He dies suddenly with no warning and the diagnosis is made by the coroner. Mr. Kersey is not alone. Pulmonary embolus is the second only to cardiac arrest as the most common cause of sudden death.

There may be close to a million people each year in the US who suffer from PE, but it’s a hard diagnosis to make and the frequency may be even higher. Consider that autopsy studies of people who die in the hospital found that up to 60% had PEs and the diagnosis was missed 70% of the time. And for that reasons, doctors have a high worry factor when it comes to making the diagnosis. Patients show up complaining to their doctor about chest pain, worrying about their hearts, but as it turns out, lots more things cause chest pain that just heart disease.

Modern medicine hasn’t yet figured out how to help patients like Mr. Kersey who die without warning, but Mr. Bosh is a different story. His diagnosis is made and his doctors can high five themselves for not missing the potentially lethal disease. Now comes the tough decisions about treatment options. They all have to do with anticoagulation or thinning the blood. The blood clots in the lung, and there may be one or many, are actually located in the pulmonary arteries. Those are the large blood vessels where blood is pumped from the heart to the lungs, so that oxygen can be attached to red blood cells and then circulated to the rest of the body. Clots in the artery act like a dam and it makes it tough for the heart to pump against resistance. This can strain the heart muscle. If that isn’t enough of a problem, if enough clot is present, blood can’t get into the lung tissue and get loaded with oxygen. The potential exists for shock, hypotension (low blood pressure) and death.

pulmonary artery

The diagnosis is often made by CT and the amount of blood clot can be seen. The patient’s vital signs are monitored and their stability is assessed. The treatment for pulmonary embolus is anticoagulation or thinning the blood with medications. The first questions is whether the patient is so unstable that clotting busting drugs need to be used to dissolve the emboli that are already there. Usually, the answer is no and routine anticoagulation medication can be used. The second question to be answered is whether the patient can be treated at home. Many patients with PEs are stable and will need to be on blood thinning medication for a prolonged period of time. There are different medications available to use as an outpatient and the decision needs to be made whether to use a combination of enoxaparin (Lovenox) and warfarin (Coumadin) or the newer anticoagulants like apixaban (Eliquis) or rivaroxiban (Xarelto).

So how does one decide stability? It’s all about the vital signs. If the patient is tachycardic (rapid heart rate), tachypneic (rapid respiratory rate) and/or hypoxic (low blood oxygen), hospitalization and observation may be appropriate, even if the patient would get the same medications as they would if they were an outpatient. Abnormal vital signs presume that the heart and lungs are not working as well as they should and cannot deliver an adequate oxygen load to the body. Blood tests may be able to quantify how sick. Arterial blood gasses can measure how much oxygen is getting loaded into the blood stream and whether, the lungs are able to remove waste products from the blood. Troponin levels, normally a marker used to check for heart attack, can also help decide whether the heart muscle is being strained because it has to squeeze harder to push blood past the pulmonary artery clots. An echocardiogram, or ultrasound of the heart can also help assess heart strain.

Medications are also evolving and treatment strategies depend upon patient situation and physician comfort in using the newer anticoagulation medications like Eliquis and Xarelto. Classically, warfarin is used and blood levels have to be measured routinely to make certain the blood is adequately thinned. Warfarin dosing is adjusted based on those blood test results. That means patients have to go to the lab routinely, the doctors and nurses have to follow up on the tests and adjust medications. Studies suggest that patient blood is inadequately thinned more that 30% of the time. The new drugs do not need adjustment, blood tests or much follow up. Their downside: price is much more expensive than warfarin (but there is no need for blood tests or office visits) and…the anticoagulation cannot be emergently reversed in a bleeding emergency or if emergency surgery is required. Warfarin can be.

Finally, the question most basketball fans were asking: how long does a patient have to be anticoagulated, because on blood thinners, contact sports are out of the question because of the risk of fatal bleeding from trauma, especially to the head. The easy answer is at least three months. The real answer is…it depends. Questions that need to be asked have to do with the reason for the clot, the patients’ underlying risk of bleeding, if it is a recurrent clot and what other medical issues are present. The American College of Chest Physicians publishes guidelines for the diagnosis and treatment of blood clots and the summary is 47 pages long.

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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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