John Bartholomew, MD
John Bartholomew, MD

Marcelo Gomes, MD
Marcelo Gomes, MD

Thursday, September 7, 2017 - Noon

Description

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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Antiphospholipid Syndrome

BlueViolet: I am a two year breast cancer survivor. I want to switch from an aramatase inhibitor to tamoxifen because of my bones. In 2004 I had two strokes, which followed a heart catheterization.  No known risk factors at that time. It was learned that I had a large PFO and that was closed with an Amplatzer-Occluder device. No stroke symptoms since. However, recently it was learned I have elevated beta-2 glycoprotein and intermittent slightly elevated IgM. So the question of anti-Phospholipid syndrome came up. A hematology consult said no tamoxifen. What other test can be done to determine if in fact I do have APS?

John Bartholomew, MD: The definition of antiphosolipid syndrome is made by the presence of a blood clot or thrombosis event plus laboratory studies.  The studies should be repeated twice at least 12 weeks apart to confirm the presence of this syndrome.  I suggest the test be treated as such and then discuss the results with your hematologist.


Prothrombin Gene Mutation

Saingcook: Should prothrombin gene mutation one copy and two copies MTHFR be treated for life with anticoagulants I already had one PE after surgery where they found out I was predisposed.

John Bartholomew, MD: The prothrombin gene mutation is considered a mild thrombophilia or hypercoagulable condition.  Generally speaking we do not get concerned about MTHFR unless you have an elevated homocysteine level.  For most patents with a blood clot after surgery, the treatment is 3 - 6 months.  I suggest you discuss this with your blood clotting doctor. 

sara88: I have prothrombin 20210 and have seen a hematologist.  This was diagnosed after a DVT in my leg.  I am wondering if I should see a vascular specialist too.

John Bartholomew, MD:  Prothrombin gene is a mild thrombophilia.  I imagine you had other risk factors for the blood clot and depending on the extent of your clot, you may be a candidate to see a vascular surgeon or interventionalist.  If the clot is not extensive you still may want to see a vascular medicine specialist or vascular surgeon for compression garments and treatment of leg swelling and pain


Factor V Leiden

Packerdad: Can you explain factor V Leiden.

John Bartholomew, MD: Factor V Leiden is one of the most common genetic known causes for blood clots. It is most commonly found in Caucasians and is rare in Asians and African Americans. It is a mild thrombophilia and if you have one gene normally not a reason for lifelong anticoagulation. The incidence in Caucasian population is about 5%. By itself, it is unlikely to cause blood clots in most patients.  Clotting is usually caused by multiple factors including recent surgery, trauma or injury. Hospitalization, older age and immobility. You should let all your doctors know that you have this condition especially before surgery or if hospitalized. They can take precautions to prevent blood clots.

Packerdad: I have Factor V Leiden- two genes and my sons have one. My brother has one gene and had two clots and is on blood thinners for life. Is there anything my sons and I can do to prevent clots?  I was told by one doctor to take daily aspirin and by another doctor that it would do no good. I am also diabetic and wonder if I am more at risk by this? Thanks.

John Bartholomew, MD: First of all, how were you diagnosed with Factor V Leiden? If you had a blood clot and have two genes, most physicians would recommend anticoagulation with a blood thinner stronger than aspirin. The best way to prevent blood clots whether you have one or two genes is to stay active, control your blood sugar, and weight, and diet and treat co-morbidities aggressively. That means maintain an ideal body weight, make sure blood pressure is in good control, control cholesterol and don't smoke. We now look at blood clotting in the veins or lungs as multi-factorial as mentioned before. Therefore control of your diabetes is important in reducing your risk for clots.

Packerdad: My brother got diagnosed after his second clot and we all got tested. My mom has one gene. I got diagnosed via genetic testing. My dad passed away from a pulmonary embolism while undergoing chemo so I am concerned about this. We are assuming he also had the gene.

John Bartholomew, MD: If you have never had a blood clot, we would not recommend putting you on a blood thinner. However, if you are hospitalized for any reason, suffer any injury or trauma, require surgery or mobilized for any extended timeframe, you should take precautions to prevent blood clots. Let all your doctors know of your genetic history. You may also want to take precautions on long automobile or airplane trips such as wearing support hose, move about the cabin frequently, get an aisle seat, and keep well hydrated.


May Thurner

carol: Can you tell me what goes into the diagnosis of May Thurner? I recently had a blood clot in my leg and wonder how that is diagnosed.

John Bartholomew, MD: May Thurner Syndrome is defined by compression of the left iliac leg vein by your right iliac artery. The diagnosis is usually made after an extensive blood clot up the left leg. There may be a suggestion of May Thurner on ultrasound but not all technologists are able to image that part of your pelvic area. The best test is either a CT scan with venous imaging or MRI and at times, the use of IVUS (Intravascular ultrasound).


Deep Vein Thrombosis (DVT)

Bob73K: My wife is now being treated for a DVT the length of her thigh. In the hospital she had an IVC filter put in and they put in a clot buster medicine that decreased the clot some but not all. 1) What can I expect now for her treatment or questions to ask?  2) Why would this happen?

John Bartholomew, MD:  As far as the cause of her blood clot, age plays a factor as well as weight and other comorbidities such as diabetes, hypertension, or high cholesterol and even tobacco use. Most blood clots in the vein however arise from recent surgery, prolonged immobilization, trauma or injury, hormone therapy, pregnancy or hospitalization. As far as the incomplete procedure with residual blood clot, your wife may experience some leg swelling and pain especially if on her feet for prolonged periods of time. Your doctor may recommend wearing support hose for this. As far as why the clot was not completely dissolved, perhaps some of it was old clot. The blood clot busters work best if the clot is under two weeks old.


Pulmonary Embolism

golferguy: I had a PE a couple years ago and have been on a medication to prevent clots. I have read that you are at risk for PE in the future if you have one. My doctor wants to take me off my medication - he said I don't need it at this point. What is the length of time one should be on the meds after a PE and you are safe?

John Bartholomew, MD: The current American College of Chest Physician guidelines suggest all patients with a pulmonary embolism be treated a minimum of three months. This is if the blood clot was provoked (we know the cause of it, such as recent surgery, hospitalization, trauma, extended travel). If your clot was provoked then your doctor is correct if the underlying cause is removed. If the clot was unprovoked, meaning we do not know the cause or if you have ongoing risk for future clots, then we recommend staying on long term anticoagulation. Once you have a blood clot, statistically you are always at risk for future clotting.


Behcet’s Disease

jg053: I have had multiple DVTs in both legs beginning in 2010. I've been diagnosed with Behcet's Disease. Can you talk about treatment and prevention of future DVT?

Marcelo Gomes, MD: Behcet's Disease can be a risk factor for recurrent DVTs. You did not mention if you are still taking a blood thinner. In many circumstances, long term blood thinner therapy is the best way to prevent recurrent DVTs. If you have not been followed by a rheumatologist, it is important that you do so.


Medications: Blood Thinners

Isa:  On a previous chat, you responded to my question about new anticoagulants, specifically in my case (Factor V Leiden) +non symptomatic CLL (WBC now 27.2 - up from normal in 2 years) and that you did not recommend new anticoagulants. What is alternative?  I have been on ELIQUIS 7 months due to DVTs after car accident. DVTs resolved, but doctor reluctant to stop it, though chronic venous insufficiency, angry varicosities, red inflamed feet, swelling of tissues, spider veins ALL WORSE. What treatment would be your choice for a patient like me - a healthy 77 year old taking no other medications?Second question, please explain your protocol for getting off ELIQUIS, if DVTs stable, it is safe and risks for someone who has no heart conditions. My doctor says even for dental procedure, like root canal + bleeding not anticipated, I must stay on because risk too great if go off.What is your protocol for taking patient off it permanently? Taper vs. just stop? Your chats appreciated! ISA

John Bartholomew, MD:  For your varicosities, red inflamed feet, swelling and spider veins or as you state Chronic venous insufficiency, the best treatment is wearing support hose. Leg elevation helps when off your feet and there are two medications that are helpful in this condition including horse chestnut (an over the counter herbal medication) and a prescription drug known as vasculara. One must take precaution when using horse chestnut with blood thinners.

You apparently decided to go on one of the oral anticoagulants for your blood clots and appears you are doing well from that perspective. Many dentists will clean your teeth on Eliquis but if necessary we would recommend stopping the medication 24 hours before a dental procedure. You should resume it as soon as possible after the procedure. For patients undergoing surgical procedures such as heart surgery or resection of your colon you should be off the drug for 48 hours at least. In some situations we stop the drug for 4 or 5 days before surgery and convert you to a low molecular weight heparin preparation such as lovenox. The lovenox is generally stopped 24 hours before surgery. You should discuss these options with your primary doctor

Begam: Hello doc, my father has 80% heart blockage in his aortic valve... his doc prescribed blood thinning medicines till he gets ready for his bypass surgery... taking it past 10 days. Now, past two days he's getting bleeding stools. Now doc asking for colonoscopy. Any complications?

John Bartholomew, MD: Blood thinners can lead to bleeding. Some physicians will blame the bleeding on the blood thinner but normally bleeding on a blood thinner implies an underlying disease process. Therefore I would recommend investigating if further with a colonoscopy or other testing if his heart doctor clears him for the procedure.

KennyB:  I have been on Coumadin for some time for blood clots. What do you think of the home INR testing instead of going to the lab?

John Bartholomew, MD: Depending on the reason for your blood clots, the home monitor INR is a great and convenient way of monitoring your blood. The exceptions are if you have antiphospholipid syndrome (with a lupus anticoagulant) some monitors may not be accurate. Otherwise they are very convenient for patients.

deedee:  My doctor told me to stay on Eliquis for three months following my procedure. Do you just stop - do you wean - are there effects I would notice from stopping?

John Bartholomew, MD: Eliquis can simply be stopped in most situations. Depending on the cause of your blood clot, you may be at risk for future blood clots and you should discuss this with your doctor regarding how to prevent another event.

shawna65:  I was put on Coumadin for a blood clot a couple years ago. This past year for some reason my doctor has been unable to maintain me in a good therapeutic range so he put me on Eliquis. Last week i was having pain in my leg and was then diagnosed with another clot. I am wondering what my options are at this point. Also - the question on my mind with the Eliquis is - with no testing - how do you know if it is working?

John Bartholomew, MD: I am uncertain why you would get another blood clot on Eliquis. In most of the trials comparing Eliquis to warfarin, the Eliquis was as effective as warfarin and in some cases better. If you failed Eliquis once, I would not resume this medication unless you missed doses or if there was an explainable reason for failure. Other options include the injectable anticoagulants such as lovenox or arixtra. Of course you can always go back on warfarin assuming you did not have a blood clot on that drug. If you look at 100 patients taking warfarin at any one time, only about 60-70% will be in the therapeutic range of 2-3 at any one time. Some of those patient's blood will be too thick and others too thin. If your doctor decides to put you back on warfarin you can ask about a home monitoring device. As far as Eliquis goes in regards to it working - part of the advantage of this drug is that it does not need to be monitored. However, there are lab tests that can be used to monitor that medication. Ask your doctor if that is available in your area.

nelsonl:  My wife was on Xarelto when they found a DVT in her leg. The vessel was too small to stint and the doctor put her on warfarin. She has been doing good but difficult to stick for blood work so they want to put her back on Xarelto which did not seem to work the first time if she had a DVT. The other med is Eliquis but that is really expensive. Your thoughts?

Marcelo Gomes, MD: The best suggestion would be for your wife to ask her doctor for a referral to an anticoagulation (Coumadin) clinic where the INR tests can be done by finger prick as opposed to blood draw. There are three other oral blood thinner medications that are FDA approved but we would have to know the specifics of your wife's DVT.

candyman2:  Do the new drugs like Xarelto have an anecdote yet?

John Bartholomew, MD: Edoxidan, apixaban, and rivaroxaban do not yet have an anecdote. The only new drug with an anecdote is pradaxa, also known as dabigatran. The three listed above should have an anecdote by late winter or early spring in 2018.


Heparin-induced thrombocytopenia (HIT)

adourian:  I lost an associate who had an adverse reaction to heparin after heart surgery (HIT). I understand that there is a 2% chance that such an adverse reaction might occur. I am facing similar surgery. Can I be tested prior to surgery to make sure I am not part of the 2% who are susceptible to an adverse reaction? If so, what is the name of that test? Is there a better anticoagulant than heparin now on the market for use after open-heart surgery that eliminates this exposure?

John Bartholomew, MD: The name of the test is a platelet factor 4 heparin antibody test. It is a blood test and you can be tested before surgery and normally it would only be necessary if you had heparin or low molecular weight heparin recently. There is no better anticoagulation for heart surgery itself but there are alternatives after surgery including the new oral anticoagulants such as Xarelto or Eliquis. These are not used for surgery itself and only heparin is used for the surgery itself.


IVC Filters

ksa410:  I have a venous/Greenfield filter and I am on warfarin for the rest of my life. The filter was put in when i had surgery for ovarian cancer which was 3 years ago. I feel my filter should be removed. Are there risks to having it removed? What are the long term effects of keeping the filter in? Can it be there for the rest of my life...or for 30 more years?

John Bartholomew, MD: All filters are placed with the intention that they may be permanent. More recently we have temporary filters and they are the most common filter placed. They can be permanent however. The FDA has recommended on two occasions (2010 and 2014) that all temporary filters be evaluated for retrieval; Complications of filters include fracture, migration or penetration of another organ. If you are on lifelong coagulation, it would seem unnecessary to have your filter. Therefore I suggest you check with the doctor who placed the filter about having it retrievedand the blood specialist who is monitoring your warfarin to seek out his opinion.

ksa410:  Thank you Dr. Bartholomew. Three years ago, a few months after my surgery, I went in to the hospital to have it removed by the surgeon who put it in. In the prep room he decided all of the sudden that it shouldn't be removed and called my hematologist and basically bullied him to back off of his request to have it removed. Three years later I am concerned that it should be removed. I am only 49 and concerned that there will be issues down the road with the filter especially with my lifestyle....skiing, mountain biking, etc. Thanks for the advice.

John Bartholomew, MD: My suggestion would be to look for an IVC filter retrieval clinic in your area (or we would be happy to see you here in our filter clinic. The longer the filter is in place, the harder it is to retrieve. Your surgeon may not have wanted to retrieve it because it was a permanent filter. We have retrieved a few permanent filters but normally shy away from this. Be sure to find out if your filter was permanent or temporary.

ellie5:  Please discuss the issues with IVC filters. My mother has just had one placed and I am nervous about the complications and issues surrounding this treatment.

John Bartholomew, MD: There are some complications from filters including migration, fracture of a strut or leg of the filter and penetration into other organs. The filter itself can also clot off causing swelling of the legs. However, the great majority of filters do not cause these problems and they are important to prevent blood clots from going to your mother's lungs. If the filter is a temporary filter, you should discuss with her doctors about when it should be removed.


Symptoms

pqrst87:  Sometimes I get a pain in my hand, fingers, foot, ankle and it looks like a small blood clot has burst or maybe it is a small clot. What causes that - do I need to see someone?

John Bartholomew, MD:  It sounds as if you have a spontaneous venous hemorrhage. This is a small bleed from a blood vessel generally not too painful or not painful at all, but can discolor the finger. If it were painful, it would suggest another mechanism and I would suggest you see the doctor in this regards.


Factor X1

libmsj:  Do you think we'll ever have a factor X1 concentrate ever approved for use in the United States?

John Bartholomew, MD: This is a question for a hematologist who specializes in bleeding disorders. Sorry.


Coronary Artery Disease

yds888:  Hi. I had a myocardial perfusion exercise stress test and received printout of the report. It included these Scinigraphic findings: LVEF of 47%; TID of 1.03 and LHR of 0.27  Would these findings merit my being directed to receive a balloon angioplasty and stent insertion?

John Bartholomew, MD:  I am not a cardiologist and this needs to be answered by your heart doctor.

Reviewed: 09/17

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