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Blood Clots, Hypercoagulable States, DVT - Dr. Bartholomew

May 7, 2008

John Bartholomew, MD
Miller Family Heart & Vascular Institute at Cleveland Clinic
Section Head of Vascular Medicine

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Cleveland_Clinic_Host: Welcome everyone, and thank you for being with us to discuss prevention, treatment and symptoms of Blood Clots, Hypercoagulable States, and DVT. We look forward to an interesting chat today. Let's begin with one of the questions!

Speaker_-_Dr__Bartholomew: Thank you for having me.


Blood Thinners and AntiPlatelet Medications

smithvolt3: I have a non metal replaced aortic valve and did have Atrial Fibrillation up to when My ICD kicked me into sinus rhythm. I have been in Sinus for the last 5 months. My INR is always 2.0 to 2.65. Do I need to stay on blood thinners permanently? Are there any side effects other than blood loss during an accident?

Speaker_-_Dr__Bartholomew: You should check in with your cardiologist regarding the need to stay on a blood thinner.

One can suffer blood loss other than with an accident - for example, blood in your urine and stool - if that were to develop - you need to contact your primary care physician immediately. Other less common side effects include hair loss and nausea or vomiting.

volvianacer: when somebody is taking aspirin and clopidogrel is saved to suffer any thrombosis????

Speaker_-_Dr__Bartholomew: Aspirin and clopidogrel or Plavix are generally taken to prevent arterial clots. This does not prevent venous blood clots - also known as deep vein thrombosis or pulmonary emboli.

marper: Thank you Dr. Bartholomew to take the time to answer our question. When I was 25 I had a shower of pulmonary emboli. I was given LMWH and coumadin. Both are not very nice drugs. I have heard of the newer drugs being developed, the antithrombotic agents. One of them is prasugrel, i belief this is the one furthest in development. I was told that it has a strong platelet inhibition. So my question is would this be a safe drug? If coumadin goes out of the INR region we have problems. Would this drug be he same?

Speaker_-_Dr__Bartholomew: The answer is no. This drug is obviously not yet available but is not the drug we would use for pulmonary emboli. We are currently looking at other oral agents - including direct thrombin inhibitors and oral factor Xa inhibitors. Some of these will be available we hope in the next few years.

Unfortunately only coumadin and LMWH and arixtra are available. Arixtra is also given subcutaneously but only once a day.

jack2005: Yesterday I had a TEE performed and the Dr said he saw a blood clot and then he put me on coumadin. Will that dissolve the clot or just prevent more clots from occurring?

Speaker_-_Dr__Bartholomew: Coumadin will not dissolve the clot but will prevent more blood clots from developing. You did not mention if you are on heparin or low molecular weight heparin while you are being given coumadin therapy.

Coumadin can take 5 or more days to become effective and generally I would use heparin or low molecular weight heparin in conjunction with coumadin until the coumadin has become therapeutic. This usually takes five or more days.

marper: Thank you. The PEs were due to the contraceptive pill. I have been wanting to get pregnant but know the risks involved. This year I had 2 bloodtest done to check for abnormalities in the clotting cascade. One test showed an increased level of plasminogen Act Inhibitor-1 (28 IU/mL) will the other one must have been normal (dr said all was fine). If this plasminogen is really elevated would that cause problems when I get pregnant?

Speaker_-_Dr__Bartholomew: Generally speaking ,patients with an identifiable hypercoagulable condition are put on prophylactic anticoagulation for their pregnancy. We use LMWH throughout the pregnancy and at least 6 weeks after delivery. I have treated many pregnant women in this manner successfully.

jeanie: I had a DVT a couple years ago. My doctor put me on coumadin for the rest of my life. Do I need to be on coumadin forever?

Speaker_-_Dr__Bartholomew: Current guidelines suggest long term anticoagulation for patients that develop a DVT for no good reason. This is termed idiopathic.

If there was a precipitating factor - such as birth control pills, pregnancy, hormone replacement therapy, surgery or trauma (or other identifying conditions) - treatment should only be 3 to 6 months. Some doctors are using a lower dose of coumadin to minimize new blood clots and prevent bleeding. This is based on a trial published in the New England Journal of Medicine 3 years ago (PREVENT). Again the length of therapy depends on what caused your blood clot.


Blood Clots

karentk29: What exactly are the symptoms of a DVT? I have calf pain but not sure if I pulled a muscle or I should go to the doctor?

Speaker_-_Dr__Bartholomew: The most common symptoms are calf pain and swelling. Sometimes the foot or leg can appear to be discolored - may have either a reddish or bluish appearance.

georgejr: I have been on chemotherapy. Now I have blood clots in my lungs. Is that related? What is the treatment for this?

Speaker_-_Dr__Bartholomew: Most people develop blood clots for a reason - a long airplane or automobile trip; trauma to the leg; or recent surgery. Women are prone to blood clots if they are pregnant or on birth control pills or oral hormone replacement therapy.  

It is always safe to be sure - therefore I suggest you see your doctor or go to the emergency room.

The treatment for blood clots in your lungs is anticoagulation. We currently use low molecular weight heparin for patients with cancer.

Chemotherapy can precipitate blood clots in some patients depending on the agent used. I generally treat these blood clots with low molecular weight heparin for 3 to 6 months and then convert to coumadin long term.

rick: I am 40 years old. I was diagnosed with DVT in my calf. I am taking an injection of blood thinner twice a day. My pain is almost gone. Can I go back to running? My leg is still swollen. Will that go back to normal? Am I now prone to DVT?

Speaker_-_Dr__Bartholomew: You did not say what the cause of your DVT was. You did not mention how long ago you had the blood clot. Current guidelines state that you should be placed in a compression stocking of 20 to 30 mm HG and preferably 30 to 40 mm HG. This should be a below the knee compression stocking. You should wear this when your resume running and also on a daily basis. This will help prevent swelling and/or pain from your blood clot. I would ask your family physician if it is ok to resume running. Generally speaking, running is limited by the pain you have from your blood clot and the time since your event.

chevy5:I am in my 50s and have incompetent veins along with a blood clotting disorder. I have been having problems with clots for years. I have had them in my legs, arms, lungs, and heart. My legs hurt all the time. Can anything else be done? I am on lovenox and have had a filter placed.

Speaker_-_Dr__Bartholomew: I am assuming that you are on full-dose lovenox and not on a prevention dose. Patients with incompetent veins often can have surgical procedures. We would first evaluate you with a venous ultrasound to see if you have persistent deep vein thrombosis.

If your deep veins are intact, and your problem is superficial vein involvement, then there are several surgical procedures available. I suspect most surgeons would avoid operating on you due to your clotting history. This would need to be clarified.

The best treatment is compression stockings. These could be below the knee or even thigh high garments. Additional recommendations include:

  • Walking is an excellent exercise.
  • Maintaining a healthy body weight is important.
  • Elevating your legs when off of them.
  • There is an over the counter medication - herbal agent - horse chestnut - you should discuss the use of this medication with your doctor.

Speaker_-_Dr__Bartholomew: I do not always keep patients on lovenox long term - preferring to use Coumadin. Unless the patient has failed with this approach.

qween3: My husband is in the hospital. They said he has a blood clot in his heart. How is that treated? Is it dangerous? Can he get a stroke?

Speaker_-_Dr__Bartholomew: You did not mention whether or not he had a pulmonary embolism. However assuming this is only in his heart, then the standard treatment would be a blood thinner such as Heparin or low molecular weight heparin. Other options include surgical removal. It is also important to know whether this is on his right side or left side of his heart.

If it is on the right side of the heart, we generally worry about a pulmonary embolism. If it is on the left side, we are concerned with the possibility of stroke. Most patients respond to heparin or low molecular weight heparin. On occasion we will use a clot dissolving medication.


Raynaud’s

fred46: I have Raynaud's that is causing me to have ulcers on my fingers and toes. Dr. Bartholomew, I was given your name as a doctor to treat this. What can be done for me? I cannot take many medications without feeling sick.

Speaker_-_Dr__Bartholomew: There are two types of Raynaud's. Some people call them primary and secondary. Others use the terminology Raynaud's disease or Raynaud's phenomenon.

  • Primary Raynaud's is usually benign and does not cause ulcers.
  • Secondary Raynaud's can be a result of an underlying vasculitis, medication, and many other causes.

Speaker_-_Dr__Bartholomew: Doctors usually treat the underlying cause to treat the Raynaud's symptoms. Local treatment to the ulcers including topical antibiotics and keeping the hands warm at all times is imperative. We use a device called arterial flow system, which is applied to the arms 6 hours daily. This is a mechanical device that literally pumps more blood to the fingers to help the ulcers heal. This is not a medication and therefore can be a benefit to you.


Median Arcuate Ligament Syndrome

marybeth: About a year ago I was diagnosed with Median Arcuate Ligament Syndrome and ended up having to have aortic-celiac bypass surgery. Even after this surgery I continued to have some chronic steady abdominal pain. I am now experiencing a reoccurrence of the entire pain syndrome (intestinal ischemia) I had prior to surgery. Do you have any advice on how to alleviate this type of pain other than surgical intervention? Medications or ? I also feel I never completely or properly recovered from this surgery. Are there any guidelines, strategies to recovery/heal from abdominal vascular surgery?

Speaker_-_Dr__Bartholomew: Median Arcuate Ligament Syndrome is a rare disorder. Many patients have no symptoms as a result of this. As you are still having pain, I would want to make sure the bypass is open. I would also want to make certain your superior and inferior mesenteric arteries are also open. An ultrasound would be most helpful in this situation. Depending on the results of that test, then one would move forward with further recommendations.


Vascular Tumor

maryjo: just dx'd with vascular tumor of the spine. Don't understand what it is, tx or prognosis. pls help

Speaker_-_Dr__Bartholomew: There are many different types of tumors. I would really need to know more about which tumor type you have to answer that properly. You may be better served by contacting a neurosurgeon or an orthopedic surgeon who specializes in spines.


Lymphedema

julie: my bf has Primary lymphedema. What is the treatment for that?

Speaker_-_Dr__Bartholomew: Primary lymphedema is hereditary. It is diagnosed by a clinical evaluation or a nuclear scan. Unfortunately there is not one medication to treat this disorder. We usually refer patients to physical therapists who specialize in manual lymph drainage and compression garments. Patients must take meticulous care of their skin to avoid infections. And - maintaining an ideal body weight is important. Leg elevation when off the extremity is important as well. This is a chronic condition and the compression garments must be replaced frequently - often every three to four months. Again - a physical therapist that specializes in lymphedema treatment and/or a referral to a hospital with a lymphedema center is essential.


Poor Circulation

henry: I have gangrene in 2 fingers --one on each hand--due to poor blood circulation in hands. angiogram to upper extremities revealed OK blood flow in arms, but can't determine what is blocking blood flow in hands. diabetic, high blood pressure, poor circulation. Please advise if there is a way to determine what exactly could possibly be blocking circulation in hands

Speaker_-_Dr__Bartholomew: There are a number of possibilities for this condition. One is calciphylaxis but generally patients with diabetes who develop calciphylaxis also have renal failure. Another possibility is an embolic source - meaning a blood clot from your heart or even an artery in your arm. There are other possibilities including hypercoagulable conditions. We normally do a battery of tests to determine the cause. You did not mention whether you are a smoker or not - this too can cause gangrene.


Leg Ulcer

scared4me: I had a leg ulcer a few months ago and was treated. My leg healed and a couple days ago I bumped my leg on a door. The skin broke at the same spot as the ulcer. Will that turn into an ulcer? How should I treat it?

Speaker_-_Dr__Bartholomew: It is quite possible that this too could ulcerate. If your circulation (arterial circulation) is normal, then generally speaking patients should be wearing a compression garment. If not, you should discuss this with your family doctor.

  •  It is also imperative that you take meticulous care of your skin - meaning a good moisturizer applied daily to your legs but not between your toes to help keep the skin intact.
  •  Leg elevation is also important when you are off your leg.
  • You could put a dry dressing over the area and apply a support or compression hose over that.
  • In addition, you could put a topical antibiotic over the area.
  • If you have any fever or if the area looks infected, you should contact your doctor immediately.

Methylenetetrahydrofolate reductase (MTHFR)

tina: I have MTHFR. I am going to go to school in Colorado, which is at high altitude. Will that affect my getting blood clots?

Speaker_-_Dr__Bartholomew: MTHFR is a very common disorder. Many specialists feel that this is not a condition that leads to blood clots. There are different genetic varieties for this disorder - the most common being C677T. It is important to know what your fasting plasma homocysteine is. If abnormal, then I often check the patient's B6, B12 and folic acid levels. I do not see any problem going to Denver.


Antiphospholipid antibody syndrome

justin: Can you tell me about Antiphospholipid antibody syndrome? My mom has this – recently diagnosed. How is it treated?

Speaker_-_Dr__Bartholomew: Patients with the antiphospholipid syndrome are prone to blood clots in either the venous or arterial system. To confirm the diagnosis, one must have a battery of blood tests performed on two different occasions. These blood tests should be drawn at 10 to 12 weeks apart to make sure they remain abnormal. If the blood tests are abnormal on two different occasions and the patient has had a blood clot (deep vein thrombosis, pulmonary embolism, stroke or obstetrical complication) this can be classified as the antiphospholipid syndrome.

The treatment is anticoagulation with heparin or low molecular weight heparin and long term with coumadin. In addition control of one's blood pressure, cholesterol and diabetes is important.


Subclavian Steal Syndrome

hillary: My sister has subclavian steal syndrome. Can that be treated without surgery?

Speaker_-_Dr__Bartholomew: Patients with subclavian steal syndrome can be treated conservatively depending on their symptoms. Most patients will have arm pain with walking with this condition but they may also have episodes of lightheadedness or dizziness. It is also important that a person with this syndrome should have their blood pressure monitored in both arms because there can be a discrepancy in the readings. It is possible to miss high blood pressure if only the affected arm is measured. There may also be an interventional (stenting) option for some patients as opposed to surgery.


TIA

szujanek: My question is I've had several TIAs-I also had a PFO repaired at your facility-I've found that I have other issues-obesity and leg pain. Is it possible that meds could b a part of the problem?

Speaker_-_Dr__Bartholomew: You did not mention what medications you are taking but leg pains can result from statin therapy. If you are on this medication, you should contact your doctor to determine if this is a contributing cause. Some patients with leg pain can have a blood clot which could have contributed to your TIAs before your PFO was repaired. Most TIAs are treated with antiplatelet agents. It might be important for someone to look at your carotid arteries with an ultrasound if you are still having TIAs.


Calciphylaxis

MaryAnn: What is Calciphylaxis? I have a friend who has this and is in extreme pain. What is the treatment?

Speaker_-_Dr__Bartholomew: Calciphylaxis is a very uncommon disorder that is usually seen in patients with renal failure. It is generally diagnosed by a biopsy. The specific treatment is to undergo removal of one's parathyroid glands surgically. Some patients have benefited from hyperbaric oxygen treatment as well. There are other causes of calciphylaxis and there are a number of other disorders that can mimic this including Brown recluse spider bites, the antiphospholipid syndrome, vasculitis, atheroembolism, and coumadin skin necrosis.

Other treatment recommendations include pain control and possibly a plastic surgery consultation.


Factor V Leiden

jackie: I was recently diagnosed blood clots in my lungs. I found out 2 years ago that I have FactorFactor ix complex V leiden. My question is How can I have this when neither of my parents have it?

Speaker_-_Dr__Bartholomew: Laboratories can make mistakes therefore I suggest you have this test repeated. In addition you may want to have your parents blood tests repeated. Factor V Leiden is a genetic condition and inherited from one of your parents. So - again I would repeat the tests.


Wegener's Granulomatosis

sheri88: My wife has wegener's granulomatosis. I am very worried about her. Do you treat that? What exactly can I expect?

Speaker_-_Dr__Bartholomew: I do not treat Wegener's Granulomatosis. However, we have many experts in the department of rheumatology that do. Some patients however, are at risk for blood clots - and in that situation - I do treat that complication.

Cleveland_Clinic_Host: Thanks for joining us everyone! If you would like more information regarding the Miller Family Heart & Vascular Institute at the Cleveland Clinic, please see:

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 06/08


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