Posts Tagged ‘DVT’
Stephan Moll, MD writes…
An important study (AMPLIFY trial) was published today in the New England Journal of Medicine [ref 1]: In a large study of 5395 patients with acute DVT or PE, Eliquis (apixaban) was as effective as warfarin and caused less major bleeding. Read the rest of this entry »
Stephan Moll, MD writes…
Xarelto® is FDA approved for treatment of venous thromboembolism (VTE), prevention of VTE after hip and knee replacement surgery, and for atrial fibrillation. A number of practical management questions are encountered by physicians, pharmacists, and other health care professional taking care of patients on Xarelto®, such as (a) dosing in renal impairment, (b) conversion of a patient on warfarin to Xarelto®, (c) discontinuation of Xarelto® at times of surgery, dental procedures, colonoscopy, and other procedures, and (d) management of bleeding on Xarelto®. These issues may best be addressed in a health care system by the establishment of a structured treatment algorithm/guide/help for the entire hospital or physician practice. Read the rest of this entry »
Stephan Moll, MD writes… Well, it is not clear whether it does. A clinically relevant study (ASPIRE study) was published this week (Nov 22nd,2012) in the N Engl J Med [ref 1]. In patients who had a previous unprovoked (= idiopathic) DVT or PE and who had completed standard length (often considered to be 3-6 months) of warfarin therapy, aspirin did not prevent recurrent VTE. However aspirin was effective in preventing further thrombotic event (a conglomerate of arterial and venous events). Aspirin did not lead to an increase in risk of major bleeding. The findings are discrepant to the earlier WARFASA study, published in May 2012 in the N Engl J Med, which showed that Aspirin had efficacy in preventing recurrent VTE [ref 2]. The ASPIRE authors have also included a revealing, meta-analysis of this week’s study plus the previous WARFASA study [ref 2].
Beth Waldron, Program Director of Clot Connect, writes…
The claim: “Eating lunch at your desk could increase your risk of DVT”—was the dramatic headline from UK’s Marie Claire magazine which caught my attention. (1) The online story went on to say that “Almost 75 per cent of office staff aged 21-30 who work 10-hour days don’t get up to take a break. This could double chances of a fatal blood clot.” The story was light on citing scientific evidence to back up this claim, so, as someone interested in DVT education (and admittedly, who eats at her desk routinely), I decided to investigate if this assertion is true: Does eating lunch at your desk increase blood clot risk?
The answer: Yes. The act of eating lunch at your desk, in and of itself, does not increase blood clot risk; but the immobility associated with prolonged sitting at your desk, does.
The research facts: The association between immobility and venous thromboembolism (VTE) is well-accepted in the literature. The term VTE includes deep vein thrombosis (DVT; blood clots in the legs) and pulmonary embolism (PE; blood clots in the lungs) . Immobility associated with hospitalization, prolonged bedrest, cramped airline and long-distance travel increases VTE risk and has received notable attention from both the health care community and the media. The association between prolonged sitting at work and VTE risk has received much less acknowledgement, even thought the association between sitting and VTE was first reported in the New England Journal of Medicine in 1954.(2) The term “eThrombosis” was coined in a case report from 2003, in which occurrence of a DVT in a patient who sat prolonged periods at a computer was described.(3)
A 2010 study from New Zealand found that “prolonged work- and computer-related seated immobility was associated with a 2.8 fold increased risk of VTE.”(4) Additionally, the risk of VTE was found to increase by 10% for each additional hour seated.(4) The risk of VTE was significantly increased in persons who had their own desk at work and in those who usually ate lunch at their desk.(4)
A 2011 US study reporting results from the large and well-respected Nurses Health Study found that “the risk of pulmonary embolism was more than twofold in women who spent the most time sitting compared with those who spent the least time sitting”.(5)
Seated immobility, no matter the reason why one is seated—if from long-travel, desk work, computer use, video games or even watching television— slows blood flow in the legs, which may contribute to clot formation. After just 90 minutes of sitting, the flow of blood to the popliteal vein (behind the knee) is reduced by 40%.(6)
The practical implications:
1. Cause of VTE affects treatment decisions
Recognition that prolonged sitting at work can contribute to VTE has serious implications. Twenty-five percent of VTE cases are considered idiopathic, ie no clear risk factor precipitating the VTE event can be identified.(7) Given the sedentary nature of the modern office environment, could it be that occupational risks are a greater provoking factor in some VTE cases than is commonly realized? It is a question warranting further study and discussion since an accurate assessment of whether a VTE was provoked or idiopathic affects decisions related to the length of anticoagulant treatment.
2. Everyone should know the risk of VTE, including healthy office workers who do not perceive themselves at risk from simply sitting at their desk.
VTE is a common medical condition and preventing blood clots associated with immobility and venous stasis is simple: movement. In recent years, greater public emphasis has been placed on the negative health consequences (obesity, diabetes, heart disease, etc) of a sedentary lifestyle, but rarely is VTE mentioned in an appeal to increase physical activity. Greater public awareness is needed that immobility—in all its various forms—is a risk factor for potentially life-threatening blood clots.
3. Occupational strategies to reduce risk and prevent VTE
If you spend your work days sitting at a desk, there are things you can do to reduce your blood clot risk:
Get up every hour and stretch your legs. Take a short walk around the office. Get outside at lunch for a longer walk.
If you can’t get away from your desk, exercise your legs while you’re sitting. The CDC recommends(8):
- Raising and lowering your heels while keeping your toes on the floor.
- Raising and lowering your toes while keeping your heels on the floor.
- Tightening and releasing your leg muscles
- “Eating lunch at your desk could increase your risk of DVT” http://www.marieclaire.co.uk/news/health/538820/eating-lunch-at-your-desk-could-increase-your-risk-of-dvt.html
- “Thrombosis of the Deep Leg Veins Due to Prolonged Sitting” John Homans N Engl J Med 1954 Jan 250:148-149
- “eThrombosis: the 21st century variant of venous thromboembolism associated with immobility.” Beasley R, Raymond N, Hill S, Nowitz M, Hughes R. Eur Respir J. 2003 Feb;21(2):374-6.
- “Prolonged work- and computer-related seated immobility and risk of venous thromboembolism” Healy B, Levin E, Perrin K, Weatherall M, Beasley R. J R Soc Med. 2010 Nov;103(11):447-54.
- “Physical inactivity and idiopathic pulmonary embolism in women: prospective study” Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. BMJ. 2011 Jul 4;343.
- “Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis.” Hitos K, Cannon M, Cannon S, Garth S, Fletcher JP. J Thromb Haemost. 2007 Sep;5(9):1890-5.
- “Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study” Heit JA, O’Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, Melton LJ 3rd Arch Intern Med. 2002 Jun 10;162(11):1245-8.
- CDC DVT prevention recommendations: http://www.cdc.gov/ncbddd/dvt/documents/DVT-Tip-sheet.pdf
Stephan Moll, MD writes… Klippel-Trenaunay Syndrome (KTS) is a rare congenital disorder of capillary, venous and lymphatic malformations and a localized disturbed growth of bone and/or soft tissue (see photographs)[ref 1]. Patients with KTS are at significantly increased risk for DVT, PE and superficial thrombophlebitis. KTS affects only one side of the body, typically the leg or the arm, sometimes both. It can also involve the trunk and face and inner organs. Chronic pain and swelling of leg and arm can be a problem. The swelling may lead to skin breakdown (ulcers). A patient support group for KTS exists with an informative website.
DVT and PE in Patients with Klippel-Trenaunay Syndrome
Superficial thrombophlebitis, DVT and PE are not uncommon in patients with KTS: (a) a study of 49 patients with KTS showed that 11 (22.5 %) had DVT and PE problems [ref 2]; (b) a study of 47 children with KTS showed DVT or PE in 11 % and superficial thrombophlebitis in 53 % [ref 3]; and (c) a study of 68 patients reported a history of DVT or PE in 17 %, and of superficial thrombophlebitis in 48 % of patients [ref 4].
The recurrence rate of blood clots and the best treatment are not known. Open questions are:
- Do patients need to be on long-term warfarin after a first episode of DVT or PE?
- Should patients with DVT or PE be treated with warfarin or low molecular weight heparin rather than with warfarin?
- Would the new oral anticoagulants Pradaxa® (Dabigatran) or Xarelto® (Rivaroxaban) be effective choices?
- In the patient with DVT, should an IVC filter be placed to prevent PE?
- What is the risk of recurrence of DVT or PE during pregnancy and how should pregnant women with KTS be managed? [ref 5]
How are KTS patients best treated?
- Awareness, Prophylaxis: As quite a few patients with KTS develop superficial thrombophlebitis, DVT or PE, patients should know the symptoms and risk factors of blood clots, so they recognize them quickly and seek medical attention and rapidly get diagnosed and treated. They also need good DVT prophylaxis in risk situations, such as at times of surgery and hospitalization. Women need to know about their risk of VTE with contraceptives and pregnancy.
- Anticoagulant choice: A 2005 publication [ref 6] reviewed all published cases of PE in individuals with KTS (10 patients are listed in the analysis), summarizing that several patients had recurrent DVT or PE in spite of being on warfarin (Coumadin®, Jantoven®). The authors of the article, therefore, concluded that “if DVT or PE is diagnosed, then these patients should receive therapy with low molecular weight heparin”. However, it has not been studied whether low molecular weight heparin is truly more effective in preventing blood clots. At present, it appears fair to conclude, that there is some risk for recurrence of VTE, even while the patient is on adequate doses of warfarin. However, because of a lack of studies, publications and extensive experience, there are no established and accepted guidelines on treatment. Individual decisions need to be made
- IVC filter: It is not clear whether patients with KTS who have had a VTE may benefit from having an IVC filter placed. Individual decisions need to be made.
- Risk for bleeding: Lastly, since venous malformations may also be seen in the inner organs, such as the intestine, some patients with KTS have an increased risk for bleeding, putting the patient at increased risk for bleeding if long-term anticoagulants are used.
- Tian XL et al: Identification of an angiogenic factor that when mutated causes susceptibility to Klippel-Trenaunay syndrome. Nature 2004;427:640-645.
- Baskerville PA et al: Thromboembolic disease and congenital venous abnormalities. Phlebologie 1987;40:531-536.
- Samuel M et al: Klippel-Trenaunay syndrome: clinical features, complications and management in children. Br J Surg 1995:82:757-761.
- Douma RA et al. Chronic pulmonary embolism in Klippel-Trenaunay syndrome. J Am Acad Dermatol 2012;66:71-77.
- Güngor Gündoğan T et al. Klippel-Trenaunay syndrome and pregnancy. Obstet Gynecol Int 2010:706850. Epub 2010 Dec 19.
- Hiras, EE et al: Pulmonary thromboembolism associated with KTS. Pediatrics 2005;116:e596-e600.
Last updated: May 25th, 2012
Stephan Moll, MD writes… A clinically very relevant study (WARFASA) published today (May 24, 2012) in the New England Journal of Medicine [ref 1] shows that aspirin, 100 mg per day, reduces the risk of recurrent venous thromboembolism (VTE) in patients with unprovoked (= idiopathic) VTE, who have completed 6 to 18 months of anticoagulant therapy, without an apparent increase in risk of major bleeding Read the rest of this entry »
Stephan Moll, MD writes…..
When a young person is diagnosed with extensive pelvic DVT or inferior vena cava thrombosis, there may be an underlying and predisposing congenital abnormality of the IVC, such as a congenital absence (agenesis, aplasia) or narrowing (hypoplasia) of the IVC Read the rest of this entry »
Beth Waldron, Program Director of Clot Connect, writes…
The patient diagnosed with VTE (venous thromboembolism) may develop depression and anxiety, particularly if the clot was extensive and life-threatening. However, evaluation of the care and outcome of patients with VTE is often focused upon the visible short-term effects of a clot, such as: Has the acute clotting episode resolved? Are chronic pain, swelling, or other post-thrombotic issues well managed? Has there been any bleeding associated with anticoagulation? Has there been a VTE recurrence? However, a comprehensive evaluation should include a consideration of a patient’s emotional state and the impact of the VTE event on the patient’s quality of life. Emotional states (such as depression, anxiety, happiness and optimism) have been shown to influence health outcomes in many medical conditions, including cardiovascular disease.(,,) In respect to VTE, however, very little research has been done examining the psychological impact of VTE on a patient’s health outcome.
What is scientifically known about the psychological impact of VTE?
Stephan Moll, MD writes… This month the American College of Chest Physicians (ACCP) published its new (2012) guidelines regarding anticoagulation and management of various thrombotic disorders, replacing the 2008 edition. The details of the new guidelines can be found here Read the rest of this entry »
Xarelto (Rivaroxaban) was approved in Europe today (Dec 19th, 2011) for patients with acute DVT. This is good news Read the rest of this entry »