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Thrombosis and Blood Clotting Disorders (Dr. Bartholomew 11/17/10)

Wednesday, November 17, 2010 - Noon

John Bartholomew, MD
Director of the Thrombosis Center at the Cleveland Clinic.

Description

Thrombosis and blood clotting disorders are essentially formations of blood clots that obstruct the flow of blood through the circulatory system. These conditions can be dangerous, especially when they are not identified and treated properly. Blood clots increase the risk for death from a pulmonary embolism, stroke or a heart attack. It is therefore critical for patients to become better educated on the condition in order to treat it before it’s too late. In this free online chat, Dr. Bartholomew, a Cleveland Clinic Staff Physician, will provide answers to your questions concerning the disease and its risk factors, as well as information on preventive measures you can apply to your daily life.

More Information

Cleveland_Clinic_Host: Welcome to our "Thrombosis and Blood Clotting Disorders" online health chat with John Bartholomew, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today!

Thank you for joining us Dr. Bartholomew, let's begin with the questions.

Dr__Bartholomew: Thank you for having me today.


Diagnostic Testing

Stewart_B: I've had bilateral pulmonary emboli in the past. I'm on coumadin and consistently in therapeutic range. How often should I get my legs checked for emboli or blockages? I get a contrasting cat scan of chest abdomen and pelvis annually.

Dr__Bartholomew: I usually don't repeat studies for the legs unless the patient has new symptoms. Especially if their blood or INR level has been therapeutic. I also do not order an annual CT of the chest and/or abdomen unless the patient has new symptoms to suggest a new pulmonary embolus.

codinqueen: Do you recommend home testing of INR? if so, are you experiencing any problems with the insurance companies funding them for pulmonary embolisms and DVT cases?

Dr__Bartholomew: Medicare now allows for home testing INRs. This is absolutely a great way for patients to monitor their Coumadin. Most insurance companies are on board now a days for home testing. A most recent New England Journal of Medicine article acronym THINRS was published in October touting the benefits of home testing. So - if you are a reliable patient I am all for home monitoring but you must check with your insurance company. There are special forms that need to be filled out.


Thrombosis (Blood Clots) - Risk Factors

CathyM: I have Hereditary Spherocytosis. My hemoglobin is 10 or 9. My bibirubin is between 4 and 5. I had a splenectomy in 1976 By the Dr. Gross, Dr. Izant team. My information on the latest studies Indicate I am at higher risk for Thrombosis. DVT. Please comment if this is covered by your chat. Thanks.

Dr__Bartholomew: There is some data to suggest that patients with an elevated platelet count (seen after splenectomy) may be at higher risk for thrombosis. However blood clots or thrombosis is generally multi-factorial meaning requires multiple causes. For example if you are over 40 or immobilized for any length of time, undergo recent surgery or trauma or put in a cast or hospitalized - all are reasons for a possible blood clot.

Generally speaking - just having your spleen out will not increase your risk without additional factors as listed above.

Marsha_M: I had bilateral pulmonary embolisms on Sept 23, 2010. Have a history of bilateral LE DVT's twice in the '70s. I was heparinized for 2 days for the PEs, and then Lovenoxed for 4 days while in the hospital. I am on Coumadin 5 mg twice a week on Monday and Friday and 2.5 mg qd, the other days of the week, and my INR at last check was 2.7, on Tuesday 11/9/10. What are the chances, in percentage, that I can get another DVT or PE while I am therapeutic on Coumadin? I do not take birth control or any hormones (other than thyroid), do not smoke, and have not recently had surgery, although I did fracture my ankle/foot on 9/1/10. The DVTs in the 70s were attributed to birth control and smoking, the PEs were attributed to immobility and being in a cast for the ankle/foot fractures. I am no longer in a cast, and only wear my CAM walker boot while out to grocery shop or go anywhere in public, to protect the foot/ankle as it continues to heal. Thank you.

Dr__Bartholomew: The great majority of patients will not develop another blood clot while on Coumadin as long as they keep their INR between 2 and 3. This is especially important for the first 6 weeks after the diagnosis. Most doctors will likely keep their patients on Coumadin for 6 months. You are at risk for future blood clots once off Coumadin however - should you be hospitalized, require surgery, immobilized, or placed in a cast again. In addition, long airplane or automobile trips place you at risk. Therefore you should let all of your physicians know of your history.

JenniferW: What risk factors lead to clotting issues other than clotting disorders and what can be done to lower one's risk?

Dr__Bartholomew: I look at clotting as hereditary or acquired. Hereditary risk factors include Factor V Leiden; prothrombin gene mutation; and protein C, S and antithrombin deficiencies.

Acquired risk factors include cancer, birth control pills, pregnancy, hormone replacement therapy, trauma to list just a few. There are many more. The best way to lower your risk is to ask questions about your risk factors should you be hospitalized, require surgery or suffer significant trauma.

Some patients are at risk if they travel extensively by airplane, automobile, bus or train. Generally for airplane trips, any flight over 8 hours is considered a risk. In that case, we advise avoiding alcohol while flying, keep well hydrated, wear support hose and get up and move about the cabin every hour. There are also exercises provided by the airlines to prevent blood clots. Some patients require an injection of a blood thinner for extended flights

roullac: My mother had emphysema for some time but had no side effects although she was complaining that she could not walk very much as she was getting breathless. Two weeks ago she had pulmonary embolism and she had to stay in the ICU for a couple of weeks The infection has cleared now but she has to have injections to thin her blood for the next 6 months. We do not know what really caused it, do you think that the cause of this would have been the emphysema?.

Dr__Bartholomew: There are many causes for blood clots including older individuals. In addition respiratory problems such as emphysema can put patients at higher risk for blood clots especially if they were immobilized or less active prior to the clot.

So - yes emphysema can be considered a risk factor however I always look for other causes. If nothing is obvious, I suggest age appropriate cancer screening. Assuming your mother is over 40 that would include a mammogram, pap and pelvic exam and if she is over 50, a colonoscopy.

dawnrag: Are blood clots and pulmonary embolisms hereditary, such that if someone in my family died from this post surgery, me or other members of the family are at higher risk for clots and PE's? would taking blood thinners post surgery be the best attempt at preventing a PE?

Dr__Bartholomew: Blood clots are hereditary but not always. Surgery is a strong risk factor for blood clots. Currently all patients admitted to the hospital in the US should be risk assessed for blood clots on admission. If you or any family members are over 40 years old, will be undergoing surgery, or have a family history of blood clots, or recently immobilized, you should receive appropriate prevention methods. This can include injections of heparin or low molecular weight heparin - or graduated compression stockings - or intermittent pneumatic compression devices, depending on your health.

It sounds as if your family member had the blood clot after surgery. It is possible they had a hereditary clotting problem, but more likely due to the surgery.


Medications: Heparin, Warfarin (Coumadin), Pradaxa

CONNIE: I recently read an article about Pradaxa and wondered if it is being used instead of Coumadin for atrial fibrillation and congestive heart failure. I have seen both pros and cons.

Dr__Bartholomew: This drug has just been approved for non-valvular atrial fibrillation. Its advantages are: no monitoring is required and it does not interact with other drugs and/or food like Warfarin or Coumadin does.

I suspect it will become much more popular but it is much more expensive. The down side is it is not reversible, meaning if the patient has bleeding, there is no antidote. I suggest you talk to your doctor about your particular case.

Susan_F: Average time on Warfarin to dissolve clots caused by portacath and chemo? Are aspirin and vitamin E helpful for this condition?

Dr__Bartholomew: Warfarin does not dissolve blood clots but your body may. Usually there are three things once a person develops a blood clot. It moves to your lungs (unlikely in your case because you are on Warfarin); It dissolves due to your own body's systems; or it stays in the vein but becomes attached to the wall and will not move. This can cause swelling in your arm and therefore you may need to wear a sleeve (a compression garment). Aspirin and vitamin E are not helpful.

codinqueen: If a patient has had 2 instances of DVT related to birth control in the 70's and then this year has a pulmonary embolism after breaking ankle/foot, would you consider that patient to need Warfarin the rest of his life?

Dr__Bartholomew: I would not - unless there were additional factors you have not mentioned. All your clots appear to be provoked and 3 - 6 months should be adequate therapy. I would avoid hormone replacement therapy and breaking ankles.

george1958: I am 53 year old and a Factor V Leiden homozygote recessive type. I do not show symptoms of clot formation (yet). My sister who is of the same type had a clot identified in her left thigh. She has been on Coumadin for years. My mother's side had a history of strokes. My mother had a cranial aneurysm that got repaired. Since I am at high risk of developing a clot, can I take any preventive measures like being on Coumadin or other drugs? Has there been a scientific correlation between Factor V Leiden and clots or strokes?

Dr__Bartholomew: If you have never had a blood clot , then there is no need for Coumadin. There is some older literature suggesting a link between factor v Leiden and stroke in women who smoke. I would not take any other medications unless you have high blood pressure, diabetes, high cholesterol or smoke.

Connie_J: My husband has end-stage Heart Failure and has had a quad bypass and has a pacemaker/defibrillator implanted post 5 years, he is also diabetic. He strives for an INR of 2.0. Would he be a candidate for Pradaxa and would there be any significant positives to change to his regimen to Pradaxa over Coumadin which he takes 5.0 x 6 days and 7.5 x 1 day?

Dr__Bartholomew: The advantage of Pradaxa is that it does not require monitoring as does Coumadin. This drug is much more expensive and is currently only approved for patients with non-valvular atrial fibrillation. It is easier to use because it doesn't interact with other drugs or food. The only contraindication revolves around your husband's renal function. If it is not normal, he may not be a candidate for this medication.

evillalo: How long can you be without a blood thinner before a blood clot forms?

Dr__Bartholomew: This is a general question and it depends on why you were on the blood thinner in the first place. If you had a blood clot develop after surgery or a hospitalization you are at lower risk to develop another blood clot when off blood thinners. However, if your doctor did not know what caused your blood clot you are at increased risk for future blood clots.

We predict that patients with an unprovoked blood clot (meaning we don't know what caused it) have a 30% risk to develop a new clot over the next 10 years. The risk is much less if we know what caused your blood clot (meaning it was provoked by one of the conditions above.)

cjcm: I am presently on lovenox injections, twice daily for blood clotting disorder, I was previously on Coumadin but clotted while on it. I hear there is a new type of Coumadin coming out, would I be a candidate for that even though the previous coumadin didn’t work?

Dr__Bartholomew: The new drug is Pradaxa. It was just recently approved for atrial fibrillation and has been tested extensively in patients with blood clots. However, it is not yet approved for this condition. You did not mention why you failed Coumadin so I can't be certain you would benefit from this new medication. However it is a completely different drug than coumadin and requires no monitoring. Again - I am not sure why you failed Coumadin and this makes it difficult whether you would respond to the new drug or not.

Squeak: Is it safe to use Warfarin (generic) or is it best to use name brand?

Dr__Bartholomew: We use both at Cleveland Clinic. There is a difference in price but both are approved by the FDA. It is important for your doctor or whoever is monitoring your coumadin which drug you are on and stick to one particular type.


Treatment of Blood Clots

David_H: I have been diagnosed with deep vein thrombosis in my left leg. I have been prescribed Warfarin. I have had a pulmonary embolism from clots from this leg in the past and was treated by Mercy Hospital in Folsom, California a couple years ago. My heart doctor says to forget vascular surgery. What do you suggest?

Dr__Bartholomew: The standard of care for DVT is to wear a below the knee compression stocking of 30 - 40 mm Hg. These stocking should be put on in the morning and worn throughout the day and changed frequently as they lose their elasticity. They should be worn for up to 1 to 2 years after the blood clot. A vascular surgeon cannot help you if your blood clot is older than 2 weeks.

cjcm: I know you spoke about this situation but I want to make sure I understood the answer, I had a DVT in my leg two years ago, ultrasound shows it is still there, has not been absorbed at all, since it has been 2 yrs it is possible the body may still absorb it or not?

Dr__Bartholomew: It is less likely, as most clots absorb in a year's time.

Monte_M: I had a DVT in my left leg 2 years ago; it was from my groin to bottom of my leg. I also ended up with a PE. I was first put on Coumadin then switched to arixtra injections, still got clots while on these two medications. I was then put on lovenox, twice daily injections, 120 mg each shot. I also had a vena cava filter put in. All medical testing done has shown no medical reason for my clotting disorder. This happened at the age of 29. My dosage of lovenox was recently changed to 100 mg, twice daily injections due to blood test showing my blood is too thin. I had an ultrasound of the leg and it shows the clot is still there, same as when I got it 2 yrs ago. I have two questions, one is why would my body not have absorbed the clot, now that it has been 2 yrs would this mean it will always remain there, my leg still has the swelling and discomfort and discoloration of the skin around the ankle and scaly skin. My second question is, why would my body not be responding to the lovenox, even with the lower dosage my range is not where it should be. Thank you for any information you can give me.

Dr__Bartholomew: Three things happen to blood clots - they either dissolve with time, move to the lungs, or stay in the leg and become fixed to the vein wall and will not move. When it becomes fixed to the vein wall, it leads to a condition known as the post thrombotic syndrome. Patients develop pain in their legs, swelling, dry and itchy skin. The treatment is to wear a 30 - 40 mm Hg below the knee compression stocking. Some patients find this too tight and then I recommend a 20 - 30 mm Hg below knee stocking. This is very important for your condition because you already have the post thrombotic syndrome per your description. You should also use a moisturizer daily on your skin for your dry scaly skin.

As far as the lovenox, it is generally dosed according to weight and kidney function. If you are requiring lower doses, it may reflect a change in your weight or kidneys. It is also important to have the test drawn at 4 hours after a dose.

codinqueen: Are below the knee compression stockings also recommended for patients who have had pulm embolism, of undetermined etiology? They are not sure where my bilateral PEs originated but they think in my casted leg. Should I be wearing them as well as taking Warfarin?

Dr__Bartholomew: I would advise stockings as it is possible your blood clots left your legs and went to your lungs and that is why they are no longer in your legs.


Types of Blood Clotting Disorders


Protein S and C Deficiency

Karen_LS: I was diagnosed with Type 1, Protein S Deficiency at 34 years old after having experienced severe headaches and a gran mal seizure followed by a coma. I was told I probably inherited it from my mother; she died of a blood clot in her lung at age 40. Does that mean my daughter is at risk of inheriting it from me? Should she be tested?

Dr__Bartholomew: Protein S deficiency can be inherited and usually is - but can also be low in patients with other acquired or non-hereditary diseases such as liver or kidney problems. As far as your daughter is concerned, it is possible that she has inherited this defect if it is genetic. As far as testing goes, it depends on her age and also I would discuss this with her family doctor. There are down sides to testing for example an inability to get health insurance. This might change with the new health care law however. If your daughter is quite young, I would not test her until she becomes an adolescent.

Ram: Ram asks: Last month Ochsner Hospital found Blood clots in rt lung. Cabbage 1999. When I get up become dizzy & can’t walk. I am69, healthy. On Coumadin & 81 mg aspirin. No clots in legs. Active & healthy. Diagnosis inherited problem. Protein s & C. Question: What I should be careful except Vitamin K items reduction in intake. Do my siblings will have same problem?

Dr__Bartholomew: It is hard to know whether your protein C and S abnormalities are due to Coumadin or are really a genetic defect. Coumadin does interact with lots of foods including vegetables and greens - and it is best to avoid foods rich in vitamin K. However, you can eat salads and other greens in moderation and as long as you are consistent in how much you take on a daily basis.

Your doctor can test your siblings for these deficiencies. If they are all normal, meaning they don't have protein C or S deficiencies, it is likely you don't have this either. Again - protein C and S can be low simply because of Coumadin. There is a doctor at Oschner who should be able to help you. He is in the Vascular Medicine Dept.

Antiphospholipid Syndrome

Kathy: Do you have any doctors that have experienced a patient who has antiphospholipid syndrome and a PFO? I have both and I am very frustrated with the lack of answers from the doctors in Chicago. I am 39 years old and I have been on Warfarin for 7 years, due to the APS. I just found out in May that I also have a PFO. Any help or direction would be greatly appreciated!! I am very disgusted and need help.

Dr__Bartholomew: We have several experts with patients who have a PFO including Dr. Tuzcu and Dr. Kapadia. However, in patients with the antiphospholipid syndrome, long term anticoagulation is generally recommended assuming you were diagnosed with this condition at the time of a blood clot. I am an expert on the antiphospholipid syndrome and work closely with the above doctors in patients such as you to determine if they need their PFO repaired or not.

zyphoid: Hello. Female, age 63. I have lupus, Sjogrens, with antiphospholipid antibodies. Placed on Coumadin and aspirin due to frequent amaurosis fugax and several TIAs. Recently discovered chronic subdural hematoma, taken off all blood thinners. Amaurosis has returned daily, just sitting here waiting to have a stroke! Differing opinions as to when/if can restart Coumadin. Is there a particular type of specialist whom I should try to see to coordinate care for these oppositional problems? Is there any other med that might handle the amaurosis and stroke risk while waiting for the CSH to resolve?

Dr__Bartholomew: You did not mention what your INR was when you had your subdural hematoma. If it was between 2 and 3, our normal therapeutic range, this makes your problem more difficult. On the other hand, if your INR was above 4 or higher, then it would be reasonable to resume Coumadin at some point when your neurosurgeon is in agreement. You don't mention if you fell or hit your head or if there were other risk factors for your subdural hematoma.

I am assuming that your antiphospholipid syndrome plays a role in your TIAs. If not, then other medications include aspirin or plavix. I also assume you had a carotid artery ultrasound to make sure there is nothing that can be surgically repaired that would help relieve your TIAs. You may wish to see a hematologist who should be able to help you in this situation.

Ada: We have an inherited clotting mutation in our family. My father died of multiple clots in his lungs, my brother has both had clots and my daughter also. Is it possible that I do not have the condition since I seem to be a bleeder? I can't even take baby aspirin without bruising and excessive bleeding when cut.

Dr__Bartholomew: It is possible you do not have the genetic defect. Blood clotting is due to multiple factors - the two most common genetic defects are Factor V Leiden and Prothrombin gene mutation. These conditions are more likely in the Caucasian population than African Americans or Asians. Just having these however is generally not enough to develop blood clots.


Symptoms

SusanM: Nov. 2007 - May 2008 I visited Cleveland Clinic for severe bilateral arm pain. I was diagnosed by Dr. Bartholomew with bilateral DVT's in my subclavien and axillary veins, bilateral thoracic outlet syndrome and Factor V Leiden. I was also diagnosed by Dr. Shook with (4) herniated cervical discs. The cause of the arm pain was never determined but Dr. Bartholomew did not think it was due to Chronic Venous Insufficiency and Dr. Shook did not feel it was due to a "pinched nerve" in my neck. Since that time, I have tried pain medication, physical therapy, activity limitations and exercise and the condition has improved in my right arm but my left arm and neck is still problematic (severe at times). Because the pain and the DVT's happened simultaneously, I feel they are related events and I am exhausted from seeing specialists who look only at the individual components of the thoracic region. My question is: Is there one type of Dr. specialty who will look at the thoracic region as a whole e.g. vascular, neurologic, and musculoskeletal to determine the cause of the pain? If so, what would that specialty be called and where might I find this person?

Dr__Bartholomew: I suggest you return and see me again but also one of our vascular surgeons by the name of Matthew Eagleton who specializes in these areas. I am sure Dr. Shook would be glad to see you back again. Generally speaking if it was a result of the blood clots in your arms, then wearing compression garments on your arms should help. These are known as sleeves and can be purchased at a surgical supply store.

cdjohns1: I have pulmonary sarcoidosis (diagnosed via lymph node biopsy 8/2009). Since 7/2010 I have had elevated heart rate - no resting rate less than 95. In 10/2010 during a "routine" CT in prep for seeing my pulm, right pulmonary emboli were discovered. I was hospitalized for five days and am now on a Coumadin maintenance of 5mg daily with INR in the mid 2 range. Ultrasound studies of both legs revealed two DVTs in right leg (one occlusive, one not). We have discontinued the Androgel 1% that I had been using for a number of years. We increased my Pred from 15mg daily to 40mg daily in mid-July but this was after we discovered the elevated heart rate but BEFORE the discovery of the clots / DVTs. My blood pressure is normal. I am concerned about the continued elevated heart rate. I am a 57 white male who was physically active until a few years ago. Opinion as to cause / treatment of elevated resting heart rate?

Dr__Bartholomew: I suggest that you get an echocardiogram or ultrasound of your heart. I am not sure a routine EKG will be of help. Patients who develop a pulmonary embolism can have an increased heart rate and if this persists, can lead to pulmonary hypertension.


Vena Cava Filters

Peter_R: I am a cardiologist in Nampa, ID. What percentage of vena cava filters are placed by cardiologists at Cleveland Clinic?

Dr__Bartholomew: Most of our filters are placed by interventional radiologists. Our radiologists are here practically 24/7 and appear to be more readily available, however we have some new younger cardiologists who are placing filters and I expect we will see more in the future. We also have vascular surgeons placing filters. I can't give you an exact percentage.

codinqueen: What criteria do you follow to know when a patient needs a vena cava filter?

Dr__Bartholomew: There are absolute indications for filter placement including a patient with a blood clot who cannot be anticoagulated. In addition, if someone has a blood clot and develops a complication from the blood thinner such as bleeding, a filter is indicated. If a patient requires surgery following a recent blood clot, a filter should be placed as well. There are now temporary as well as permanent filters. Filters can migrate so I like to take them out and prefer temporary filters.


Cholesterol and Blood Clots

SusanM: Question for Dr. Bartholomew: I am 56 year old female, have Factor V Leiden (from one parent) and have had a DVT's in both right and left subclavien and axillary veins. My primary care physician considers me at elevated risk for Cardiovascular disease due to family history. I have elevated LDL Cholesterol (120); my Triglycerides, HDL, and ratio are very good. My physician’s questions are: Given the Factor V, the DVT's and family history, what is the recommended threshold for LDL? My question is: if my LDL is too high, what are the best options for lowering it? I have been told it is genetic and the only option for lowering it is statins - is this accurate?

Dr__Bartholomew: There is new data suggesting a connection between risk factors for arterial disease and venous disease. Factor V Leiden, although a risk factor, is not associated with arterial disease such as heart attacks or strokes. An elevated LDL cholesterol is associated with arterial problems.

Two recent articles in Circulation reported conflicting data on LDL cholesterol and blood clots. The best options for lowering LDL cholesterol include diet and exercise. There is also new data on statins and blood clots. I suggest an aggressive approach of diet and exercise and then consideration of a statin medication if you have additional risk factors for heart disease or stroke.

susanem: Regarding the conflicting data on LDL cholesterol and blood clots: are you referring to arterial clots or venous clots? What is the conflicting data between LDL and blood clots?

Dr__Bartholomew: The conflicting data revolves around whether or not cholesterol is important to venous blood clots or not. An earlier article suggested cholesterol was important whereas a recent article implies it is less important for venous blood clots.


Abnormal Sed Rate

Paula_F: My sed rate has been fluctuating around 100 for the last 3 years. Last week it was 124. I have been seeing a D.O. for over 20 years and he is scratching his head .. suggested I contact you to find someone who can get me the special blood tests to see why I have this. I am a very UNUSUAL case. My C-reactive protein is normal and all my other blood work is very good. My doctor says he will mention my case anonymously at some medical convention. That doesn't make me feel very good if no one ... not even a researcher in this area ... will help ME. Please see if there is someone who is interested in my case and willing to help me. Thank you.

Dr__Bartholomew: I suggest you see a rheumatologist to begin with. You did not give me any other significant medical history to go on. An elevated sed rate can be abnormal because of infection, inflammation or other medical causes and should be checked out. I would start with a rheumatologist.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Bartholomew is now over. Thank you again Dr. Bartholomew for taking the time to answer our questions about thrombosis and blood clotting disorders.

Dr__Bartholomew: Thank you for having me.

Cleveland_Clinic_Host: Dr. Bartholomew is the Director of the Thrombosis Center at Cleveland Clinic.

Reviewed: 11/10


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