John Bartholomew, MD
John Bartholomew, MD

Marcelo Gomes, MD
Marcelo Gomes, MD

Thursday, September 15, 2016 - Noon


When you cut or injure yourself, your body stops the bleeding by forming a blood clot (coagulation). Normal coagulation is important during injury to help stop the bleeding and start the healing process. When your blood clots too much, it’s referred to as a hypercoagulable state which can be dangerous to your health. John Bartholomew, MD and Marcelo Gomes, MD answer your questions about blood clotting.

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Moderator: To begin, let's set the stage for today's chat: When you cut or injure yourself, your body stops the bleeding by forming a blood clot. Proteins and particles in your blood, called platelets, stick together to form the blood clot. The process of forming a clot is called coagulation. Normal coagulation is important during an injury, as it helps stop a cut from bleeding and starts the healing process. However, the blood shouldn’t clot when it’s just moving through the body. If blood tends to clot too much, it is referred to as a hypercoagulable state or thrombophilia.

Hypercoagulable states can be dangerous, especially when these conditions are not properly identified and treated. People with hypercoagulable states have an increased risk for blood clots developing in the arteries (blood vessels that carry blood away from the heart) and veins (blood vessels that carry blood to the heart). A clot inside a blood vessel is also called a thrombus or an embolus.

Blood clots in the veins or venous system can travel through the bloodstream and cause deep vein thrombosis (a blood clot in the veins of the pelvis, leg, arm, liver, intestines or kidneys) or a pulmonary embolus (blood clot in the lungs). Blood clots in the arteries can increase the risk for stroke, heart attack, severe leg pain, difficulty walking, or even the loss of a limb.

Symptoms of Blood Clots

whatsit: I have pain in one of my legs - it hurts in the calf area. How do you know if you have a blood clot?

John_Bartholomew,_MD: See a doctor, preferably vascular doctor if available. If this pain is of sudden onset, you should seek care immediately. If chronic, I would defer to your family doctor or vascular specialist. They will likely order an ultrasound to determine if you have a blood clot.

coco: I am a 25-year-old female who had a DVT a couple years ago. I was diagnosed with Factor V Leiden. My left leg seems swollen, discolored, and cold and can be sore at times. I try to walk and keep my leg elevated but I am nervous that I am not managing this correctly. Can you talk about how to treat or follow Factor V and also if you have any thoughts about my leg - I would appreciate any comment.

John_Bartholomew,_MD: I would recommend you see a vascular medicine specialist for your problem. It is possible that you have a condition called May-Thurner Syndrome that can lead to some of your symptoms. You do not mention if you had a blood clot previously, however, so this would be important to evaluate. I would recommend wearing a prescription strength support hose if you not done so already. I am not sure why your leg is cold but you should see a vascular medicine specialist because Factor V Leiden would not cause that without a clotting history.

Deep Vein Thrombosis (DVT)

35kathy: I had a DVT diagnosed a couple months ago - my doctor said it was related to a long car ride probably and I am on BC pills. I am on Coumadin. Does the clot go away or what happens to it? Wearing stockings to help with swelling and keeping leg up. That was about all the instruction I had - how long does it take for swelling to go away.

Marcelo_Gomes,_MD: The blood clot may go away over time. Complete resolution of the blood clot happens in about 50% of patients after a DVT. This healing process may take 1 or 2 years. Wearing compression stockings will help minimize your swelling, which may be present for a few years after a DVT. Most likely your blood clot was from your birth control pills; stopping them should enable you to come off blood thinners 3 - 6 months later.

vxrtl8: I had a DVT a long time ago. I am not on anything for it but I have a question. I am always worried when getting a massage if the therapist should massage my calves. Is there any relation to that and having a DVT or if you do have an old DVT the clot breaking off and moving?

John_Bartholomew,_MD: I see no reason not to have your calves massaged, especially since your blood clot was a long time ago. Now a days we encourage patients to stay active once we have started their blood thinners.

cyclerider: I had a broken leg from a bike accident in the spring and last month developed a blood clot in the left leg. I understand that orthopedic injury and surgery increases the risk of getting a blood clot but would it occur 5 months later. Once you have had clot I was told you at increased risk of getting another. Is there anything you can do to reduce the risk such as taking a daily aspirin (after I come off the warfarin)? Thank you.

Marcelo_Gomes,_MD: You are correct that trauma and surgery to the leg can increase the risk of a DVT but not 5 months later (unless you were immobilized or in a cast). So, it is possible that your blood clot may not have been related to that accident. Therefore, we recommend you consult with a vascular medicine specialist or hematologist to determine the ideal duration for your blood thinner therapy.

Pulmonary Embolism

ll2569: I am a 30-year-old and developed a PE this past summer after having surgery. I have been on birth control for 10 years and never had a problem. My doctor told me not to go back on BC - what are your thoughts? If the PE was caused after having surgery - once I am healed - isn’t my risk back to what it was before? Wondering what my options are.

Marcelo_Gomes,_MD: Even though it seems like the surgery was the main risk factor for your PE (pulmonary embolism), women on birth control pills are at an increased risk of PE and deep vein thrombosis (DVT). Pills containing estrogen seem to be associated with a greater risk of DVT/PE. You should discuss your situation with a vascular medicine specialist, hematologist or your gynecologist because there are other options that can be used for contraception that will be safer than birth control pills that contain estrogen.

Factor V Leiden

JennyA: My husband needs bypass surgery and is positive for Factor V Leiden. Will that have an impact on his heart surgery?

John_Bartholomew,_MD: No. However, he should have appropriate DVT (deep vein thrombosis) prophylaxis after heart surgery to prevent blood clots.

rpeterson: Does any vitamin deficiencies have anything to do with Factor V and blood clots. My dad was diagnosed with a DVT and then found to have factor V but is also Vitamin D deficient - is that related?

Marcelo_Gomes,_MD: There is no relation between factor V and vitamin D deficiency.

winter99: Hi - I have factor V and also need a valve replacement. I also have atrial fibrillation and my one doctor said I better get this taken care of because I can have a stroke and/or be very sick - my other doctor said the factor V Leiden puts me at great risk for surgery? True? What to do?

John_Bartholomew,_MD: The factor V Leiden, assuming you are heterozygous (inherited from one parent), does not put you at great risk for surgery or a stroke. On the other hand, the atrial fibrillation, if not treated with blood thinners, could put you at risk for stroke.

liesel: I am a 77-year-old female with 5 stents in LAD and marginal. I was diagnosed with Factor V Leiden homozygote in October of 2006. In 2004 after an emergency heart catheterization and stent, I developed Deep Vein Thrombosis in my right leg due to the groin trauma. I was on Coumadin for about 9 months. Had a very difficult time with that medication. For years it has been suggested that I go on Warfarin or one of the newer drugs for life. I have resisted. I am doing all the right things, like eating right, exercising, taking 2000 mg of Fish Oil. Due to a new stent last November, at the moment I am on one full Aspirin a day; 10mg Effient, 25mg Metoprolol ER, 10mg Crestor and 50mg of Losartan. I also take Broad Spectrum Magnesium. My question: Is there anything else I can do to prevent future blood clots?

Marcelo_Gomes,_MD: It sounds like your deep vein thrombosis was provoked by the hospitalization after surgery. Current guidelines do not recommend lifelong anticoagulation after a provoked DVT. The homozygote Factor V Leiden may increase risk of DVT more than the general population but it’s debatable if long term blood thinners are necessary. Stay active, well hydrated, maintain an ideal body weight, exercise regularly and let all your physicians know of your clotting history. In addition, if you require surgery, suffer trauma or injury or are hospitalized, you are at risk for future blood clots. You should let all your physicians know of your clotting history and Factor V Leiden.

Homocysteine and blood clots

georgiageorge: My doctor told me I am at increased risk for blood clots due to elevated homocysteine levels. He told me to take aspirin and b vitamins. Is this true? What do you recommend for this and are there follow up tests to make sure I do not have any clots?

John_Bartholomew,_MD: We generally check vitamin B12, folate, and B6 levels to see if the homocysteine level is related to deficiency in any of these vitamins. Homocysteine can also be elevated if you have kidney disease. Depending on your age, taking aspirin would seem reasonable if you have other risk factors. We suggest you seek the advice of a vascular medicine specialist or hematologist.

bigax54: Thanks for your service! Brief history: DVT L calf 2011 (255 lbs); R calf 2015 (245 lbs), travel & surgery provoked. TIA Dec 2012; CABG April 2015. July 2016 on 7.5 mg Warfarin (INR good) unprovoked DVT-right distal popliteal - 6 cm. Moved to Lovenox injections 80 mg 2x day for 25-30 days, then to 100 mg due to wt. (215 lbs) for 4-5 days. Aug 8 doppler; DVT extended into right peroneal vein during the 5 wks. Genetic homozygous MTHFR & homocysteine (HC abbv.) level are players. PTS also seems to be happening? With MTHFR diagnosis, is it likely that other genetic disorders were tested? What are the names of blood tests to check disorders? (e.g CBC/Diff/Plt), specifically name for tests for elevated HC and to distinguish old/new clots? If MTHFR/HC is my only genetic disorder, what is a recommended medication plan? If other disorders were either not tested for or done inaccurately, what could be done? The latest on antidotes for newer oral meds since I may move off Lovenox in 6 mos?

Marcelo_Gomes,_MD: Elevated homocysteine (HC) is a risk factor for DVT but the MTHFR mutation in itself is not. There are many other potential clotting disorders and testing for them should be decided in consultation with a vascular medicine specialist or hematologist. There are no antidotes for three of the four new blood thinners. The only one that has an antidote is pradaxa. Studies have shown that there is no need to monitor them with some exceptions.

Physicians who treat hypercoagulable states

JoyceG: General Question: Should a person with numerous blood clots in the leg following colon surgery see a vascular specialist or can an internist handle the problem? Right now he is taking xarelto. Will exercise cause the clots to break loose and travel? Will the body absorb the clots? Thank you!

Marcelo_Gomes,_MD: Ideally, we would suggest the opinion of a vascular medicine specialist in this situation unless your internist is well versed on blood clots. Exercise does not cause the clots to break loose. The body tends to absorb the clots about 50% of the time, but this healing process may take 1 - 2 years.

Unknown Cause of Blood Clots - Unprovoked

rmdlaw1: i am not a health care professional. I have an excellent MD cardiologist caring for me following a bilateral embolism about a month ago and I am on Elequise which I tolerate well and feel wonderful, however, I also have thalasemia minor and the cause of the clot was really undetermined. I have two concerns: first was the clot caused "possibly" by the thalasemia minor blood condition and second if I go off the thinner in six months should what precautions should we take to minimize the reoccurrence of another clot, i.e. vitamin E, monitoring the thalasemia to determine if I clot more than normal? Age 76 and in great shape otherwise.

John_Bartholomew,_MD: We don't think that thalasemia minor is the cause of your blood clot - I am assuming that you have not had blood clots in the past. If your blood clot was unprovoked (we don't know what caused it) there is a risk for recurrence that approaches 30-40% in the next 10 years if you are not on a blood thinner. Many would recommend staying on blood thinners long term but you need to discuss that with your physicians, as there are risks of bleeding on blood thinners that increase with age.

Medications for blood clotting disorders - anticoagulants

robbyl: I have been on Coumadin for two years due to a PE. Is there a time when you can come off of it?

Marcelo_Gomes,_MD: The duration of blood thinner therapy depends on what caused your PE. Some patients may be treated for just 3 months - others will require blood thinners indefinitely.

johnbart: I am on Coumadin. I have had DVTs twice now so my doctor wants to keep me on Coumadin but I wonder if I can take one of the newer meds that I would not have to be as careful with getting blood checked etc. My doctor wants me to stay on Coumadin. Your thoughts? With the newer meds, how do they know if your blood is actually thin enough to prevent blood clots without a blood test? And - one last question - if you do bleed on them, don't they have an anecdote now? Thanks for answering my questions.

John_Bartholomew,_MD: The newer blood thinners offer many advantages including very few drug interactions and no food interactions. They do not need to be monitored. However, these new blood thinners are not recommended for very obese patients or pregnant patients, severe kidney and/or liver disease, as well as the pediatric population. In addition they are not recommended for people with cancer and those that have hereditary clotting problems. There are no antidotes for three of the four blood thinners. The only one that has an antidote is pradaxa. Studies have shown that there is no need to monitor them with some exceptions.

miamickey: Good morning, I am F/62, was put on Coumadin for life about 2 years ago. I had pulmonary embolism of unknown origin. I do have familial hypercholesterolemia (total cholesterol of nearly 600,) repaired ASD, one bypass, AFIb that is controlled by meds, psoriasis and psoriatic arthritis with possible ankylosing spondilitis. Do these conditions alone warrant lifetime treatment? I did see a specialist and he made this decision. THANK YOU

Marcelo_Gomes,_MD: It sounds that the main reason for the indication of indefinite anticoagulation in your case is the fact that your pulmonary embolism happened out of the blue (unprovoked event). The other conditions that you mentioned in of themselves would not be a reason to keep you on long term blood thinners except for the atrial fibrillation. There is more and more data linking inflammatory diseases with blood clotting - such as you have. In addition, there is a link between cardiovascular disease risk factors and blood clotting, therefore we recommend you control of those risk factors.

IVC filter

mommaG: what is involved in IVC filter retrieval?

John_Bartholomew,_MD: It is an outpatient process by which the physician uses a wire starting from the neck vein to grab or attach the filter. Most of the temporary filters have a hook on the top of their filter and this wire is used to grab that hook. A sheath (similar to a straw) is placed over the wire and helps to collapse the filter so it can be removed. The process generally does not require hospitalization. The FDA has recommended all patients who have a temporary filter be evaluated for retrieval.

eddie7745: Doctor I have had DVTs over the years in spite of being on Coumadin. Does that mean that I am on the wrong dose - or why is that occurring? My doctor is suggesting an IVC filter along with the Coumadin? How does that work. I guess it captures clots but then how do you get the clots out? Will they just sit there? Can't it get clogged? I am confused about this filter, what it does, etc. Also my wife said there has been lots in the news about the filters being bad. Can you talk about 1) my clots while on Coumadin and 2) IVC filters - what they do and their safety and would you recommend this for someone like me?

Marcelo_Gomes,_MD: Blood clots may happen in patients taking Coumadin if the INR value is consistently below 2.0 (i.e. sub-therapeutic). There are some conditions that may cause blood clots despite the person taking Coumadin - you should consult with a vascular medicine specialist or hematologist to see if you need further tests. Because there are many other options for blood thinner therapy other than Coumadin, a specialist may decide if a different medicine is best for you. Typically IVC filters are not recommended in patients who develop blood clots in spite of Coumadin.

Bleeding Problems

sinaihospital: I have a bleeding problem and it takes time to stop it. Is borderline problem. What  can I do doctors for this? Thank you doctors.

Marcelo_Gomes,_MD: You should be seen by a hematologist in order to investigate what type of bleeding problem you have.

Vein Conditions

momof4: My daughter has been told the valves in her legs are damaged after a DVT three years ago. She has constant pain and swelling even with compression stockings and Coumadin. Any options for her? Thank you for any advice you can provide.

John_Bartholomew,_MD: There a number of options. We would recommend a follow up venous ultrasound to see if blood clots remain. In addition I would obtain a venous incompetency (special type of ultrasound) to determine where there is valve damage. There are herbal medications that may be helpful including horse chestnut. There is also a prescription medication vasculera. There are also interventional procedures that may be used to open up blockage if that persists. Lastly, exercise by walking, getting into a swimming pool and walking, maintain ideal body weight, and being sure to put the support stockings on first thing in the morning before the pain/swelling starts are important.

Isa: I am a 76 years old, pretty healthy woman who takes no medications. What is your opinion on the use of the medical food VASCULERA to improve the chronic vascular insufficiency symptoms of burning, inflamed veins in my legs, ankles and feet - worsening since my diagnosis of Factor V Leiden in 2008, and several laser ablations in superficial veins and two small DVTs in veins behind my knee 3/4 years ago and 6 months on Coumadin each time. I have been taking very expensive, not covered by my drug plan Vasculera per MD as RX for 6 weeks. Are there any other options to improve vascular insufficiency discomfort? Also, is it typical that continuous wearing of support hose for all these years has now caused thigh muscles to lose tone and be very flabby and fat and are they causing more harm than good? What are other current options for the treatment of chronic venous insufficiency? Are there any new trials / research to address this painful and likely potentially worsening condition? ISA

John_Bartholomew,_MD: Vasculera has been helpful in patients with chronic venous insufficiency. Another option is horse chestnut. This is less expensive and available over the counter. Vasculera requires a prescription and is not covered by all insurance plans. Horse chestnut's main side effect is stomach upset but tolerated by most patients. No data stating compression stockings affect muscle tone. Keeping your weight ideal, elevate your legs when off of them, and strengthen your legs by walking or getting into a swimming pool and walking would be our best advice.

zinnia: My profession is education. In 1994 I had a vein ligation after finding blood pooling in both legs. After 34 years of teaching mostly on terrazzo floors, I retired and in 2013 went through a vein ablation. The right leg is fine; my left, however, has superficial blood bumps on the inside up by the knee only. Is this a heart problem or a vein problem? Should I have ablation again? I wear Jobst panty hose or thigh high whenever we travel two hours or more or when I will be standing a long time. I am taking thyroxine 75 mg., Zocor 20 mg., and Effexor for sun deprivation. Otherwise, health is excellent.

Marcelo_Gomes,_MD: It seems that this is a vein problem and not a heart problem. You should see a vascular specialist and have an ultrasound to confirm if it is really a vein problem; and to determine the best treatment options. This may include ablation or other methods for treating veins. If the bumps are hard, red and inflamed you should be seen immediately as this could represent a superficial thrombophlebitis.

Reviewed: 09/16

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