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DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM

Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) are often underdiagnosed, but they are serious but preventable medical conditions.

Deep vein thrombosis (DVT) is a medical condition that occurs when a blood clot forms in a deep vein. These clots usually develop in the lower leg, thigh, or pelvis, even though they can also occur in the arm.

It is important to know about DVT because it can happen to anybody and can cause serious illness, disability, and in some cases, death. The good news is that DVT is preventable and treatable if discovered early.

  • DVT is a condition that happens when a blood clot forms in a deep vein, usually in the leg. A person can get DVT when sitting or lying down for long periods of time, such as during recovery from surgery or during a long airplane flight. When one does not move enough, the blood flow in the legs slows down and pools. Blood clots can form in the pooled blood.
  • PE happens if the clot breaks off and travels through the bloodstream to the lungs. The clot can block a blood vessel in the lungs and cause damage.

CAUSES

DVT is caused by blood clots. The clot blocks a vein, preventing blood from properly circulating in the person's body. Clotting may occur for several reasons.

These include:

  • Damage to a blood vessel's wall can narrow or block blood flow. A blood clot may form as a result.
  • Surgery. Blood vessels can be damaged during surgery, which can lead to the development of a blood clot.
  • Bed rest with little to no movement after surgery may also increase the risk for developing a blood clot.
  • Reduced mobility or inactivity. When a person is frequently immobile, blood can collect in the legs, especially the lower parts. If they're unable to move for extended periods of time, the blood flow in the legs can slow down. This can cause the development of clots.
  • Certain medications. Some medications might also increase the chances of blood forming a clot.

SYMPTOMS

Common symptoms include:

  • Swelling in the foot, ankle, or leg (usually on one side)
  • Cramping pain in the affected leg that usually begins in the calf
  • Severe, unexplained pain in the foot and ankle
  • An area of skin that feels warmer than the skin on the surrounding areas
  • Skin over the affected area turning pale or a reddish or bluish color

People with an upper extremity DVT (a blood clot in the arm), may also not experience symptoms. If they do, common symptoms include:

  • Weakness in the hand
  • Swelling in the arm or hand
  • Neck pain
  • Shoulder pain
  • Blue-tinted skin color
  • Pain that moves from the arm to the forearm

People may not find out that they have deep vein thrombosis until they've gone through emergency treatment for a blood clot in the lung (pulmonary embolism).

A pulmonary embolism happens when a DVT clot moves from the arm or leg into the lung. When an artery in the lung becomes blocked, it's a life-threatening condition and requires emergency care.

RISK FACTORS FOR DVT

Almost anyone can have a DVT. However, certain factors can increase the chance of having this condition. The chance increases even more for someone who has more than one of these factors at the same time.

Everyone Is at Risk. The following is a list of factors that increase the risk of developing DVT:

Injury to a vein, often caused by:

  • Fractures
  • Severe muscle injury
  • Major surgery (particularly involving the abdomen, pelvis, hip, or legs).

Slow blood flow, often caused by:

  • Confinement to bed (e.g. due to a medical condition or after surgery);
  • Limited movement (e.g., a cast on a leg to help heal an injured bone);
  • Sitting for a long time, especially with crossed legs or paralysis.

Increased estrogen, often caused by:

  • Hormone replacement therapy, sometimes used after menopause
  • Birth control pills

Certain chronic medical illnesses, such as:

  • Cancer and its treatment
  • Heart disease
  • Lung disease
  • Inflammatory bowel disease

Other factors that increase the risk of DVT include:

  • Previous DVT or PE
  • Family history of DVT or PE
  • Age (risk increases with age)
  • Obesity
  • A catheter located in a central vein
  • Inherited clotting disorders

COMPLICATIONS

Pulmonary embolism

A pulmonary embolism occurs when a blood vessel in the lungs becomes blocked by a blood clot (thrombus) that travels to the lung from another part of the body, usually the leg. A pulmonary embolism can be life-threatening. It's important for people to watch for signs and symptoms of a pulmonary embolism and seek medical attention if they occur. Signs and symptoms of a pulmonary embolism include:

  • Coughing up blood
  • Rapid pulse
  • Sudden shortness of breath
  • Chest pain or discomfort that worsens when a person takes a deep breath or when they cough
  • Feeling lightheaded or dizzy, or fainting

Postphlebitic syndrome

This is a common complication that can occur after deep vein thrombosis, it is also called post thrombotic syndrome. Damage to veins from the blood clot reduces blood flow in the affected areas, which can cause:

  • Edema (Persistent swelling of legs)
  • Skin sores
  • Leg pain
  • Skin discoloration

WARNING SIGNS AND WHEN TO SEE A DOCTOR

Contact a doctor if signs or symptoms of deep vein thrombosis develop. Seek immediate medical attention if signs or symptoms of a pulmonary embolism - a life-threatening complication of deep vein thrombosis develops.

The warning signs and symptoms of a pulmonary embolism include:

  • Coughing up blood
  • Rapid pulse
  • Sudden shortness of breath
  • Chest pain or discomfort that worsens when patient takes a deep breath or when they cough
  • Feeling lightheaded or dizzy, or fainting

DIAGNOSIS

To diagnose DVT, the doctor will examine the patient's legs to check for swelling and tenderness. He or she will ask about symptoms and risk factors.

Based on the findings, the doctor may order a D-Dimer blood test or an ultrasound of the legs.

The blood test measures the level of a chemical called D-Dimer, which is almost always abnormally high when blood clots are actively forming in the body.

An ultrasound of the legs would also be done to look for blood flow problems in the veins. This procedure is called a lower extremity non-invasive test, or LENI. If the LENI shows evidence of a blood clot, the doctor will diagnose the individual for DVT.

If the initial LENI is negative, it does not mean that there is no clot. It may be too early to see the full effect of the clot. The doctor may for a repeat LENI in about a week.

If the doctor suspects a pulmonary embolism, they will first try to determine the presence of DVT. If the LENI shows one or more blood clots in the leg veins, and the patient has symptoms of a pulmonary embolism, an embolism is the most likely diagnosis.

Doctors may order a computed tomography (CT) of the chest. The test requires an IV injection of dye to look for blood clots in the pulmonary arteries. People that have impaired kidney function or an allergy to the dye might need a different type of lung scan called a V/Q scan to examine lung blood flow.

Expected Duration

If a person has DVT or pulmonary embolism, the symptoms should improve within a few days after beginning treatment with blood-thinning medication. The patient will need to take medication for at least three to six months to prevent more blood clots from forming.

Most people recover completely. But some people who had a very large pulmonary embolism or who already had lung disease will continue to have lung problems.

Some people who have had a DVT develop a long-term problem with swelling of their legs. This is called post-phlebitic syndrome. These people often need to wear special stockings that help squeeze blood back toward the heart.

TREATMENT

The initial treatment for a DVT or pulmonary embolism is Heparin or one of the new novel oral anti-coagulant drugs. Commonly known as blood thinners, these are medications that act on certain blood proteins to prevent new blood clot formation and therefore help unwanted clots get smaller.

There are two main types of Heparin. The oldest type of heparin is best administered by a constant intravenous infusion. Another type of heparin is called low-molecular-weight heparin. It is injected under the skin once or twice per day.

Some new anti-coagulant drugs have been approved for initial treatment of DVT and pulmonary embolism. These include rivaroxaban and apixaban.

A person with DVT but without a pulmonary embolism, may not need to be hospitalized. Such patient could be treated at home with injections of low-molecular-weight heparin or either rivaroxaban or apixaban.

Some people may need to begin therapy in the hospital. In this case, the type of heparin to be used is determined by factors including body weight, kidney function and other circumstances.

A pulmonary embolism patient however, will probably be hospitalized. They most likely will be treated with either type of heparin initially. But oral rivaroxaban or apixaban could be an option instead of heparin if the pulmonary embolism is small.

If the treatment begins on either IV heparin or low-molecular weight heparin shots under the skin, the doctor will transition the patient eventually to an oral drug. The traditional oral therapy for decades, has been Warfarin (Coumadin).

Warfarin takes a few days to start working and once a blood test shows that warfarin is effective, the patient will be made to stop taking Heparin.

During the first few weeks of taking warfarin, the patient will continue to need frequent blood tests to be sure that they are taking the right amount. Once blood test results consistently show that the right amount of medication is being taken, blood can be drawn every two to four weeks.

Some foods- especially green, leafy vegetables that contain large amounts of vitamin K- can modify the blood-thinning action of warfarin. The doctor or pharmacist can provide a list of these foods. One can continue to eat these foods as long as they eat approximately the same amount of them each day. That way, the effect on the medication will be consistently minimal.

The new novel oral anti-coagulants don't require regular blood testing. They are given in a fixed dose. The other advantage is not worrying about eating food with too much vitamin K.

Medications for DVT and PE

People with DVT and PE are often prescribed medication to stop the blood clot from getting bigger and to prevent more clots. There are a few different medications the doctors may prescribe.

Blood thinners (anticoagulants)

Blood thinners are medications that make blood less likely to clot. An anticoagulant is a type of blood thinner that slows blood clotting. Two types of anticoagulants are Warfarin (Coumadin) and Heparin.

Blood thinners can be taken as a pill by mouth, through an injection, or intravenously. Most people with DVT take these medications for three to six months. The doctors may want the patient to take them for a longer period if they have had blood clots before.

Blood thinners can make a person bleed too much when he/she gets a cut because they prevent the blood from clotting. Test results can help the doctor ensure the patient is getting enough medication to prevent blood clots, but not so much that would encourage excessive bleeding.

If warfarin and heparin does not help or if the patient can't take them for some reason, the doctors may prescribe a newer type of blood thinner called a thrombin inhibitor.

Examples of thrombin inhibitors include:

  • Dabigatran
  • Lepirudin
  • Argatroban
  • Bivalirudin
  • Desirudin

DVT and PE can also be treated with direct oral anticoagulants (DOACs). These are a newer types of drugs that eliminates the need for routine blood test for monitoring. Another benefit of DOACs is that they may result in significantly fewer complications of bleeding. The thrombin inhibitor dabigatran is also a DOAC.

Other examples of DOACs include:

  • Apixaban
  • Edoxaban
  • Rivaroxaban

Thrombolytics

Pulmonary Embolism is an emergency situation because it can block the airflow through the lungs. Doctors may give patient drugs called thrombolytics to break up the clot very quickly. This type of medication can only be obtained often in an emergency room in a hospital.

The patient may be given thrombolytics through a catheter. This is threaded right to the clot to break it up.

PREVENTION

Venous thromboembolism (VTE) is an umbrella disease that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Though they're not the same thing, DVT and PE are both forms of VTE.

Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) are often underdiagnosed yet they are serious, but preventable medical conditions.

It is important to know about DVT because it can happen to anybody and can cause serious illness, disability, and in some cases, death. The good news is that DVT is preventable and treatable if discovered early. Maintaining ideal body weight with a healthy nutritional program and exercise regimen will generally reduce the likelihood of venous thrombosis.

Other specific measures are shown below:

  • To prevent venous thromboembolism VTE during a hospitalization precipitated by a medical condition: Discuss with the treating physician measures such as mechanical compression boots for the legs and/or blood thinners given either intravenously or as injections.
  • To quit cigarette smoking: Try using the prescription drug bupropion, nicotine patch, gum, or spray.
  • To prevent venous thromboembolism VTE during pregnancy: Patients should consider daily self-injected heparin if they are considered at high risk of VTE.
  • To prevent sedentary lifestyle: Walk, jog, ride bicycle, or swim.
  • To control hypertension: Check blood pressure, and report elevated readings to the doctors.
  • To prevent venous thromboembolism VTE after trauma or surgery: Discuss with the doctors how to implement measures such as mechanical compression boots for the legs and/or blood thinners that are given either intravenously or as injections.
  • To prevent obesity: Limit caloric intake, exercise, and avoid saturated fats.
  • To prevent venous thromboembolism VTE during air travel: Drink extra water, walk if feasible, wear vascular compression stockings, and avoid alcohol.
  • To deal with a known genetic predisposition to venous thromboembolism VTE: Alert the doctors about the family history and any abnormal blood tests related to a clotting tendency.

HOME REMEDIES

Once a DVT blood clot is diagnosed, the doctor will likely prescribe a medication to help thin the blood or break up the clot. The prescription medication, can be combined with the following home remedies to prevent other complications and reduce the risk of future blood clots.

Move around more

Shorter, frequent walks are better than one long walk. Take walks daily to improve blood flow.

Elevate the leg or arm

This is especially important for legs. Blood can pool if the feet are on the ground all day. Use a stool or chair to keep the legs elevated and close to level with the hips.

Use compression stockings

These are specially designed stockings that fit tightly around the feet and become gradually looser as they move up the leg to the knee. The compression helps prevent pooling and swelling, and it increases blood flow.

Most people don't need them, but people at high risk for DVT/PE may find them useful. Compression stockings may be beneficial during long distance travel.

DVT IN PREGNANCY

Being pregnant increases a person's risk of DVT. In fact, pregnant women are more likely to develop DVT than women who aren't pregnant.

The level of blood-clotting proteins increases while pregnant, and the level of anticlotting proteins falls. Again, there is increased hormone levels, and a slower blood flow as the uterus expands and restricts blood flowing back from the lower extremities, all these factors contribute to this risk.

The elevated risk continues until about six weeks after giving birth. Being on bed rest or having a cesarean delivery also increases the risk of having DVT.

Women must remain watchful for symptoms of DVT while they are pregnant.

DVT and flying

The risk of developing blood clots is higher when flying because one sits for long periods, and that increases the chances of DVT. The longer the flight, the greater the risk. It's especially significant for people whose flights that last more than eight hours. The risk actually increases the more if the one who is flying, already has other risk factors for DVT.

The following measures can help reduce the risk for blood clot while flying:

  • Wear compression stockings, which reduce blood pooling and help maintain blood flow.
  • Sit in an exit row or bulkhead seat so as to have more room to stretch and move the legs.
  • Take any prescription blood thinners or aspirin as prescribed by doctors.
  • Do exercises with the feet and legs to keep blood flowing.
  • Get up and walk around the cabin during the flight.

Note that the symptoms of a blood clot may not develop immediately after flying.

Diet and DVT

A healthy lifestyle is important for preventing DVT and helping to avoid life-threatening complications. Plus, a healthy lifestyle incorporates many of the changes that are necessary to prevent blood clots.

This includes; moving more, quitting smoking, and losing weight.

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