Blood Clots Pose Threat to All of Us


If youre reading this story, youre at risk for developing a clot. Anyone with blood in their body is at risk of a clot, and while this may evoke one of those it-wouldnt-happen-to- me responses, in reality, thats not necessarily the case.

At 25, Traci Wilkes-Smith was tall, in shape and had just finished law school when she began experiencing a nagging and ultimately excruciating pain in her leg. Six months down the road, about 10 emergency room visits and a bunch of doctor appointments later, she landed in the hospital with a pulmonary embolism (PE), or blood clot in her lung, and a six-week hospital stay.

It was much the same scene with Beth Waldron. At 34, she too had a blood clot that started in her leg and traveled to her lung. I walked around with my leg hurting for several weeks and thought Id spent too much time on the treadmill, says Waldron, now program director at the University of North Carolina Blood Clot Outreach Program-Clot Connect

Eventually the chest symptoms hit Waldron, a script for antibiotics was written and the unbearable pain that prompted testing showed a bilateral pulmonary embolism--clotting in both lungs.

Both women suffered with a vascular condition called deep vein thrombosis (DVT), a blood clot typically found in the leg that can also, but more rarely, be found in the arm or abdomen. Overtime, the clot moves upward and finds its way to the lung creating a PE, which can be, and often is, life threatening.

In fact, sudden death is the first symptom in about one-quarter (25%) of people who have a PE, according to the Centers for Disease Control and Prevention (CDC).

[DVT/PE] is one that can manifest itself at any age and any stage of life, says Dr. Suresh Vedantham, interventional radiologist and professor of radiology and surgery at Washington University, who was instrumental in the creation of the 2008 Surgeon Generals Call to Action which works to overcome the human and economic cost of DVT/PEthe latter which is estimated to be as high as $10 billion, says Dr. Scott Grosse, a research economist and associate director for health services research and evaluation in the CDCs division of blood disorders.

Statistics demonstrate a need for action: estimates for new occurrences range from 300,000 to 600,000 (1 to 2 people per 1, 000,) each year in the United States; and 60,000-100,000 Americans die of DVT/PE also called venous thromboembolism (VTE), according to the CDC.

Lack of awareness

The medical community has come a long way recently with measures to diagnosis and prevent these dangers. According to Vedantham , in the past  we were doing a badat best, a mediocrejob. For example, of the patients undergoing major surgeries that put them at risk for clots, only 50% to 60% were getting appropriate prophylactic measures.

Clinicians and public health officials are still concerned about the disparity between incidences versus awareness. The general public, and even people who come to learn they are at risk, as well as physicians do not typically have DVT/PE at the top of their minds when evaluating symptoms that could signal an emergent condition.

Condition with many causes

Alan Brownstein, chief executive officer of the National Blood Clot Alliance, says the lack of awareness occurs because DVT/PE is not a discreet condition but often the result of or occurring because of something else.

Genetic components and gene abnormalities that increase a persons risk for DVT/PE put some people at higher risk. But other causes factor in:

1. People undergoing experiencing major surgery or trauma like a car accident with boney fractures after which the body overcorrects to clot and heal

2. Patients that have cancer cancer cells produce factors prone to clotting as do some chemotherapy drugs; also, under these circumstances, a patient is debilitated

3. Patients hospitalized or immobilized with a medical condition; in fact about 50% to 70% DVT/PEs are attributed to hospital stays, according to Brownstein

4. Patients taking hormonal treatments, supplements and birth control pillsa big category on which we can focus our prevention efforts, says Vedantham, who serves on the board of the Vascular Disease Foundation.

5. Pregnant and postpartum hormonal category bleeding response

The combination of a genetic risks with these external events puts people at more risk. So do more everyday activities like prolonged air travel or car rides, sitting at ones desk for long periods of time and birth control pills.

Both Wilkes-Smith  and Waldron were on the pill and it was subsequently discovered that both carried the genetic factor: Wilkes-Smith, Factor II Mutation, and a family history of clotting, and Waldron, Factor 5 Leiden. In Waldrons case, her condition was homozygous, meaning she carried two genes, one from her father and one from her mother.

Even considering these risk factors, experts say its not cost effective or totally prudent to perform widespread genetic testing. Consider the pathway of an alternate course, says Dr. Stephan Moll, associate professor in the department of medicine, division of hematology-oncology, at the University of North Carolina (UNC) School of Medicine and Medical Director of Clot Connect. A physician does the genetic testing, denies a woman the right to take the pill, she and her mate use a condom which can fail, she becomes pregnant and that pregnancy is unwanted and finally she suffers clotting as result of the pregnancy risk factor.

Its a case of graduated risk, Moll says.

Different risk factors stack up. The obese person who smokes and whose dad had a clot at age 40 is at a higher risk when taking birth control pills than someone whos of normal weight, doesnt smoke and whose family is devoid of genetic risk factors, he says.

Also, some oral contraceptives are less risky than others with third generation pills being two- to-three times higher risk than second generation. However, IUDs releasing progestins like Mirena do not appear to increase the risk for clotting, Moll says.

Physicians and community health departments must assess and discuss these cumulative risks with patients.

Post occurrence

Many people recover completely from DVT/PE.  However, among people who have had a DVT, about one-third will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb, according to the CDC. One-third (about 33%) of people with DVT/PE will have a recurrence within 10 years. A fraction will experience chronic lung damage, chest pain, heart failure and pulmonary hypertension, Moll says.

An unprovoked idiopathic clot with no trigger signals that a patient is at risk for another clot and, therefore a candidate for a blood thinner or anticoagulant. While lifesavers, these drugs come with their own risk factors.

Moll says that monitoring is required whenever someone is on long-term blood thinners with reevaluation taking place every six to 12 months by a physician with a thrombosis backgrounda hematologist, or vascular specialist.

New research data, new drugs, a patients tolerance of the blood thinner and the impact of the thinner on the patient's quality of life are all factors in mapping the course of treatment.

The good news is that most blood clots can be prevented with current technology and drugs. We just have to connect the dots for this to happen, says Brownstein, noting that physicians must look beyond their own specialties to be aware of and diagnose DVT/PE in situations in which clotting could occur.

Then theres the patient. Educate yourself about the signs and symptoms of blood clots, says Wilkes-Smith.

Adds Waldron: Dont be afraid to demand that your doctor look for a blood clot when symptoms require; also before undergoing surgery, becoming pregnant or going on birth control bills, push the discussion to assess your risk.