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Vascular Disease Patient Information Page: Venous Thromboembolism (deep vein thrombosis and pulmonary embolism) Natalie S Evans and Elizabeth V Ratchford Vasc Med 2014 19: 148 DOI: 10.1177/1358863X14529007 The online version of this article can be found at: http://vmj.sagepub.com/content/19/2/148
Published by: http://www.sagepublications.com
On behalf of:
Society for Vascular Medicine
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529007VMJ0010.1177/1358863X14529007Vascular MedicineEvans and Ratchford research-article2014
Vascular Disease Patient Information Page
Vascular Disease Patient Information Page: Venous Thromboembolism (deep vein thrombosis and pulmonary embolism)
Vascular Medicine 2014, Vol. 19(2) 148–150 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X14529007 vmj.sagepub.com
Natalie S Evans1 and Elizabeth V Ratchford2
Keywords deep vein thrombosis, pulmonary embolism, venous thromboembolism
What is venous thromboembolism? There are three types of blood vessels: arteries, veins, and lymphatics. Veins are the blood vessels that return blood from the arms, legs, and organs to the heart. Deep vein thrombosis (often called ‘DVT’) and pulmonary embolism (often called ‘PE’) are the most common types of venous thromboembolism. A thrombus is a blood clot and an embolism is a clot that has traveled through the bloodstream and has become stuck in another blood vessel. DVT occurs when blood clots form in the veins. Blood may form clots when blood flow is sluggish, when the walls of the veins are injured or damaged, or when the blood itself is more prone to clot due to inherited or other factors (known as ‘hypercoagulable states’). PE occurs when blood clots that form in the legs travel through the circulation and lodge in the blood vessels of the lungs. When this happens, the lungs are less effective at getting oxygen from the air into the bloodstream, which can lead to symptoms such as shortness of breath and, in severe cases, loss of consciousness or collapse.
Who is at risk? Venous thromboembolism is the third leading cause of cardiovascular death, behind heart attack and stroke, occurring in about one to two per 1000 people. Venous thromboembolism occurs most frequently in patients who have had recent surgery – especially orthopedic surgery such as hip or knee replacement – trauma, or medical illness that leads to hospitalization for more than 3 days. Other risk factors for venous thromboembolism include smoking, cancer, pregnancy, oral contraceptive or hormone replacement use, being overweight, and older age. Venous thromboembolism is uncommon in people younger than age 40 years, and it is much more frequent among people older than age 70. Among younger people, it is more common in women; among older people, it is more common in men. Some cases may be caused by acquired or inherited conditions that predispose people to blood clot formation (hypercoagulable states). In some patients, no
cause is ever identified, and these patients tend to be at much higher risk for having another venous thromboembolism if left untreated.
What are the signs and symptoms? The most common signs and symptoms of venous thromboembolism are shown in Table 1. In DVT, patients may notice that one leg becomes swollen, tight, and painful. The affected leg may be red and warm. DVT seldom occurs in the arm unless the patient has a central intravenous line such as those used for chemotherapy or antibiotics. In PE, most patients complain of shortness of breath, and they may have chest pain that is typically described as worse while taking a deep breath. Patients may have a rapid heartbeat and breathing rate, and in severe cases the blood pressure might be quite low. In the most severe cases, patients may lose consciousness and collapse. Occasionally, patients with DVT or PE have no symptoms, and the blood clot is identified when an imaging test is performed for another reason.
How is it diagnosed? DVT is usually diagnosed using vascular ultrasound, a noninvasive test that uses sound waves to look at the blood vessels in the leg. During the examination, an ultrasound technologist presses on the deep veins of the legs with the ultrasound probe to collapse or compress the veins, which 1Section 2Johns
of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA Hopkins Center for Vascular Medicine, Baltimore, MD, USA
Corresponding author: Natalie S Evans Section of Vascular Medicine Cleveland Clinic 9500 Euclid Ave. J3-5 Cleveland, OH 44195 USA Email: [email protected]
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
149
Evans and Ratchford are flexible, soft structures. Veins that are filled with clot do not collapse (Figure 1). Ultrasound is also used to evaluate the flow within the veins. In some cases, an invasive procedure called venography may be used to diagnose DVT. In this test, a catheter is inserted into the veins of the legs and contrast dye that can be seen with X-rays is injected to outline the vein. PE is most frequently diagnosed using computed tomography (CT) scanning. Contrast dye is injected into an arm vein through an intravenous (IV) line while images are obtained to outline the pulmonary (lung) blood vessels. Other techniques for diagnosing PE include ventilation/ perfusion scanning, which uses injected and inhaled material to look at the lung blood vessels, and pulmonary angiography, which is similar to venography.
How is it treated? Anticoagulant medications (‘blood thinners’) are the mainstay of treatment for venous thromboembolism. Anticoagulants work to stabilize the blood clot and prevent it from growing and traveling while the body works to dissolve it over time. In many cases, patients are started on either heparin, an IV medication, or low-molecularweight heparin, which is injected under the skin. At the Table 1. Common signs and symptoms of venous thromboembolism. Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Leg pain Leg swelling Leg redness and warmth Leg tenderness to touch
Chest pain Shortness of breath Racing heartbeat Rapid breathing rate
same time, an oral medication (pill) such as warfarin (Coumadin) is started, overlapping the IV or injected medication for a minimum period of 5 days and until the warfarin blood level is appropriate. Warfarin requires periodic monitoring with a blood test to ensure that the dose is effective. Most patients with venous thromboembolism are treated for a minimum of 3 months, and possibly longer, especially in cases of unexplained venous thromboembolism. In some cases, the DVT may only be in the veins of the calf, which have a lower risk for traveling to the lungs. Some patients with calf vein blood clots may not be treated with anticoagulants at all, but may be observed with a series of ultrasound studies. A new oral anticoagulant which does not require overlap with heparin or blood test monitoring (rivaroxaban) has recently been approved for use in certain patients with venous thromboembolism. Other similar oral medications have been studied for the treatment of venous thromboembolism patients and are expected to be approved for use in the United States soon. In some cases of severe DVT or PE, patients may undergo a procedure to dissolve the thrombus using a ‘clot-busting’ or fibrinolytic drug, either injected into an IV in an arm vein or directly into the clot through a catheter that has been threaded into the affected veins. This clot-busting drug does not eliminate the need for anticoagulants. Occasionally, patients with venous thromboembolism who cannot take blood thinners may undergo a procedure to have a device known as a filter inserted into the inferior vena cava (IVC filter). The inferior vena cava is the large vein that travels through the abdomen and to the heart. The IVC filter traps blood clots from the legs and prevents them from traveling to the lungs.
Figure 1. Ultrasound showing deep vein thrombosis in a vein of the thigh (femoral vein). Arrows show thigh vein filled with thrombus that does not collapse when compressed by the ultrasound technologist (w/comp, with compression).
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
150
Vascular Medicine 19(2)
What are the long-term effects of venous thromboembolism? As many as 20–50% of patients with DVT in the veins at the level of the knee or above will go on to develop symptoms such as long-term swelling, pain, and redness that may wax and wane over time. Some patients may have skin changes that can include poorly healing ulcers or a discoloration of the skin of the lower legs. This condition is called the post-thrombotic syndrome. A large PE may cause sudden death because of the strain the clot puts on the pumping chambers of the heart. A small minority of patients with PE may go on to develop chronic shortness of breath and have trouble with exercise. These conditions can be challenging to treat. All anticoagulant medications increase the risk of bleeding and are managed under the care of a health care provider. The length of time for treatment with blood thinners depends on the type of blood clot and the patient’s risk factors. Most patients take anticoagulants for a minimum of 3 months.
How can I prevent venous thromboembolism? Prevention is important both before and after any event that increases the risk for venous thromboembolism. Being in bed in hospital makes you more prone to blood clots, so you should get up and move around as soon as you are able. Blood thinners may be prescribed to prevent venous thromboembolism in hospitalized patients and after certain surgical procedures. If you have ever had a blood clot before, you should let your doctor know before undergoing any procedures.
Sitting for extended periods, such as on a long plane or car trip, can also lead to blood clots, even in healthy people. You should walk around at least once per hour on long trips. You should avoid alcohol and caffeine, and stay hydrated by drinking extra fluids. In your seat, you can do simple exercises that use your calf muscles; these are often illustrated in the back of the in-flight magazine and consist of toe and heel raises. Your doctor may want you to take blood thinners or wear special socks called compression stockings if you are already at risk for venous thromboembolism. Everyone can reduce their risk for venous thromboembolism and other cardiovascular problems by not smoking, maintaining a healthy body weight, and getting regular exercise. You should aim for a total of at least 30 minutes per day of exercise on most days of the week.
Summary Venous thromboembolism is common, occurring in about one to two per 1000 people each year. DVT is typically diagnosed using ultrasound. PE is usually diagnosed using a CT scan. Anticoagulant medications are the mainstay of treatment; most patients take anticoagulants for a minimum of 3 months. Several important measures can help prevent venous thromboembolism. Declaration of conflicting interest The author declares that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
Vascular Disease Patient Information Page: Venous Thromboembolism (deep vein thrombosis and pulmonary embolism) Natalie S Evans and Elizabeth V Ratchford Vasc Med 2014 19: 148 DOI: 10.1177/1358863X14529007 The online version of this article can be found at: http://vmj.sagepub.com/content/19/2/148
Published by: http://www.sagepublications.com
On behalf of:
Society for Vascular Medicine
Additional services and information for Vascular Medicine can be found at: Email Alerts: http://vmj.sagepub.com/cgi/alerts Subscriptions: http://vmj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - May 14, 2014 What is This?
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
529007VMJ0010.1177/1358863X14529007Vascular MedicineEvans and Ratchford research-article2014
Vascular Disease Patient Information Page
Vascular Disease Patient Information Page: Venous Thromboembolism (deep vein thrombosis and pulmonary embolism)
Vascular Medicine 2014, Vol. 19(2) 148–150 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X14529007 vmj.sagepub.com
Natalie S Evans1 and Elizabeth V Ratchford2
Keywords deep vein thrombosis, pulmonary embolism, venous thromboembolism
What is venous thromboembolism? There are three types of blood vessels: arteries, veins, and lymphatics. Veins are the blood vessels that return blood from the arms, legs, and organs to the heart. Deep vein thrombosis (often called ‘DVT’) and pulmonary embolism (often called ‘PE’) are the most common types of venous thromboembolism. A thrombus is a blood clot and an embolism is a clot that has traveled through the bloodstream and has become stuck in another blood vessel. DVT occurs when blood clots form in the veins. Blood may form clots when blood flow is sluggish, when the walls of the veins are injured or damaged, or when the blood itself is more prone to clot due to inherited or other factors (known as ‘hypercoagulable states’). PE occurs when blood clots that form in the legs travel through the circulation and lodge in the blood vessels of the lungs. When this happens, the lungs are less effective at getting oxygen from the air into the bloodstream, which can lead to symptoms such as shortness of breath and, in severe cases, loss of consciousness or collapse.
Who is at risk? Venous thromboembolism is the third leading cause of cardiovascular death, behind heart attack and stroke, occurring in about one to two per 1000 people. Venous thromboembolism occurs most frequently in patients who have had recent surgery – especially orthopedic surgery such as hip or knee replacement – trauma, or medical illness that leads to hospitalization for more than 3 days. Other risk factors for venous thromboembolism include smoking, cancer, pregnancy, oral contraceptive or hormone replacement use, being overweight, and older age. Venous thromboembolism is uncommon in people younger than age 40 years, and it is much more frequent among people older than age 70. Among younger people, it is more common in women; among older people, it is more common in men. Some cases may be caused by acquired or inherited conditions that predispose people to blood clot formation (hypercoagulable states). In some patients, no
cause is ever identified, and these patients tend to be at much higher risk for having another venous thromboembolism if left untreated.
What are the signs and symptoms? The most common signs and symptoms of venous thromboembolism are shown in Table 1. In DVT, patients may notice that one leg becomes swollen, tight, and painful. The affected leg may be red and warm. DVT seldom occurs in the arm unless the patient has a central intravenous line such as those used for chemotherapy or antibiotics. In PE, most patients complain of shortness of breath, and they may have chest pain that is typically described as worse while taking a deep breath. Patients may have a rapid heartbeat and breathing rate, and in severe cases the blood pressure might be quite low. In the most severe cases, patients may lose consciousness and collapse. Occasionally, patients with DVT or PE have no symptoms, and the blood clot is identified when an imaging test is performed for another reason.
How is it diagnosed? DVT is usually diagnosed using vascular ultrasound, a noninvasive test that uses sound waves to look at the blood vessels in the leg. During the examination, an ultrasound technologist presses on the deep veins of the legs with the ultrasound probe to collapse or compress the veins, which 1Section 2Johns
of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA Hopkins Center for Vascular Medicine, Baltimore, MD, USA
Corresponding author: Natalie S Evans Section of Vascular Medicine Cleveland Clinic 9500 Euclid Ave. J3-5 Cleveland, OH 44195 USA Email: [email protected]
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
149
Evans and Ratchford are flexible, soft structures. Veins that are filled with clot do not collapse (Figure 1). Ultrasound is also used to evaluate the flow within the veins. In some cases, an invasive procedure called venography may be used to diagnose DVT. In this test, a catheter is inserted into the veins of the legs and contrast dye that can be seen with X-rays is injected to outline the vein. PE is most frequently diagnosed using computed tomography (CT) scanning. Contrast dye is injected into an arm vein through an intravenous (IV) line while images are obtained to outline the pulmonary (lung) blood vessels. Other techniques for diagnosing PE include ventilation/ perfusion scanning, which uses injected and inhaled material to look at the lung blood vessels, and pulmonary angiography, which is similar to venography.
How is it treated? Anticoagulant medications (‘blood thinners’) are the mainstay of treatment for venous thromboembolism. Anticoagulants work to stabilize the blood clot and prevent it from growing and traveling while the body works to dissolve it over time. In many cases, patients are started on either heparin, an IV medication, or low-molecularweight heparin, which is injected under the skin. At the Table 1. Common signs and symptoms of venous thromboembolism. Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Leg pain Leg swelling Leg redness and warmth Leg tenderness to touch
Chest pain Shortness of breath Racing heartbeat Rapid breathing rate
same time, an oral medication (pill) such as warfarin (Coumadin) is started, overlapping the IV or injected medication for a minimum period of 5 days and until the warfarin blood level is appropriate. Warfarin requires periodic monitoring with a blood test to ensure that the dose is effective. Most patients with venous thromboembolism are treated for a minimum of 3 months, and possibly longer, especially in cases of unexplained venous thromboembolism. In some cases, the DVT may only be in the veins of the calf, which have a lower risk for traveling to the lungs. Some patients with calf vein blood clots may not be treated with anticoagulants at all, but may be observed with a series of ultrasound studies. A new oral anticoagulant which does not require overlap with heparin or blood test monitoring (rivaroxaban) has recently been approved for use in certain patients with venous thromboembolism. Other similar oral medications have been studied for the treatment of venous thromboembolism patients and are expected to be approved for use in the United States soon. In some cases of severe DVT or PE, patients may undergo a procedure to dissolve the thrombus using a ‘clot-busting’ or fibrinolytic drug, either injected into an IV in an arm vein or directly into the clot through a catheter that has been threaded into the affected veins. This clot-busting drug does not eliminate the need for anticoagulants. Occasionally, patients with venous thromboembolism who cannot take blood thinners may undergo a procedure to have a device known as a filter inserted into the inferior vena cava (IVC filter). The inferior vena cava is the large vein that travels through the abdomen and to the heart. The IVC filter traps blood clots from the legs and prevents them from traveling to the lungs.
Figure 1. Ultrasound showing deep vein thrombosis in a vein of the thigh (femoral vein). Arrows show thigh vein filled with thrombus that does not collapse when compressed by the ultrasound technologist (w/comp, with compression).
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
150
Vascular Medicine 19(2)
What are the long-term effects of venous thromboembolism? As many as 20–50% of patients with DVT in the veins at the level of the knee or above will go on to develop symptoms such as long-term swelling, pain, and redness that may wax and wane over time. Some patients may have skin changes that can include poorly healing ulcers or a discoloration of the skin of the lower legs. This condition is called the post-thrombotic syndrome. A large PE may cause sudden death because of the strain the clot puts on the pumping chambers of the heart. A small minority of patients with PE may go on to develop chronic shortness of breath and have trouble with exercise. These conditions can be challenging to treat. All anticoagulant medications increase the risk of bleeding and are managed under the care of a health care provider. The length of time for treatment with blood thinners depends on the type of blood clot and the patient’s risk factors. Most patients take anticoagulants for a minimum of 3 months.
How can I prevent venous thromboembolism? Prevention is important both before and after any event that increases the risk for venous thromboembolism. Being in bed in hospital makes you more prone to blood clots, so you should get up and move around as soon as you are able. Blood thinners may be prescribed to prevent venous thromboembolism in hospitalized patients and after certain surgical procedures. If you have ever had a blood clot before, you should let your doctor know before undergoing any procedures.
Sitting for extended periods, such as on a long plane or car trip, can also lead to blood clots, even in healthy people. You should walk around at least once per hour on long trips. You should avoid alcohol and caffeine, and stay hydrated by drinking extra fluids. In your seat, you can do simple exercises that use your calf muscles; these are often illustrated in the back of the in-flight magazine and consist of toe and heel raises. Your doctor may want you to take blood thinners or wear special socks called compression stockings if you are already at risk for venous thromboembolism. Everyone can reduce their risk for venous thromboembolism and other cardiovascular problems by not smoking, maintaining a healthy body weight, and getting regular exercise. You should aim for a total of at least 30 minutes per day of exercise on most days of the week.
Summary Venous thromboembolism is common, occurring in about one to two per 1000 people each year. DVT is typically diagnosed using ultrasound. PE is usually diagnosed using a CT scan. Anticoagulant medications are the mainstay of treatment; most patients take anticoagulants for a minimum of 3 months. Several important measures can help prevent venous thromboembolism. Declaration of conflicting interest The author declares that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vmj.sagepub.com at LAURENTIAN UNIV LIBRARY on October 14, 2014
