Aug 18, 2017
Dr. Richard N. Channick discusses the basics of blood clots and treatment options in Part 1 of 2 in his series on pulmonary embolism. He is the director of the Pulmonary Hypertension and Thromboendarterectomy Program at Massachusetts General Hospital in Boston. Dr. Channick diagnoses and treats patients who suffer from a variety of diseases of the pulmonary blood vessels, including PH and pulmonary embolism.
Hello, my name is Rich Channick. I'm a pulmonary critical care physician, Director of the Pulmonary Hypertension program at Massachusetts General Hospital in Boston.
Today, I'd like to talk to you about pulmonary embolisms.
Deep venous thrombosis and pulmonary embolism really can be considered as part of the same process. Clots can form, blood clots can form often in the deep veins of the legs, the arms sometimes, and these clots can form for a number of reasons.
When clots have been there for a little while and for reasons we don't fully know, some of them break off and travel. We call that an embolism. An embolism is a deep venous thrombosis that's broken off and will travel, and where they travel to is through the right side of the heart and into the lungs. When they get into the lungs, we call that a pulmonary embolism.
Pulmonary embolism is an extremely common condition, and it's actually a common cause of death, and many patients with pulmonary embolism who die of pulmonary embolism are never diagnosed. We do think that this is an under recognized condition. It's on a list of things that one needs to think about. Now, in some cases, it's very obvious and very large, life threatening, pulmonary embolism, but the thing is, it can happen to anybody. In fact, probably half a million people per year get pulmonary embolism. Some of these patients die before they get diagnosed.
The funny thing about pulmonary embolism is that many different kinds of specialists can diagnose and treat it, and that may be one of the problems is it kind of falls through the cracks, and there isn't one specific specialist. In fact, we've established a team approach to dealing with pulmonary embolism that's made up of many different doctors, but any physician, internist, cardiologist, pulmonary specialist should be able to diagnose and know the basics about pulmonary embolism.
The good thing about pulmonary embolism is that it's very treatable. It's treated on many different left, treatment anywhere from blood thinners like Coumadin, Aspirin, Heparin, one of the newer drugs that are available, newer oral anticoagulants, all the way up to very aggressive therapies, which can include clot-busting drugs, even surgery, certain procedures that are done by catheters to try to dissolve the clot or break it up. There are many different options.
Once a patient has had an acute pulmonary embolism, there's a few different things that can happen. One is that they fully recover and the majority of patients in six to eight weeks are back to pretty close to where they were before they had the embolism, but there is a significant percentage of patients who don't fully recover after an acute pulmonary embolism for reasons that we don't fully understand. But in some cases, these acute pulmonary embolism becomes chronic, and it starts to form scar tissue inside the arteries that can lead to elevation of the pressure inside the artery or what we call pulmonary hypertension. If that process occurs, this is a patient who can end up chronic thromboembolic pulmonary hypertension or what we like to call CTEPH.
We know that there are certain risk factors for pulmonary embolism and deep venous thrombosis, and these risk factors relate to “is the patient immobile, is an immobility patient at bedrest, recent surgery, orthopedic fracture,” those kind of things where a limb is immobilized, that's a risk factor. Patients who have, what we call, hypercoagulable state, so there's certain proteins in the blood that sometimes for genetic reasons are present either too much or too little and predispose the patient to clotting. Finally, if there are underlying diseases like cancer, they also make a patient prone to clotting.
We take all those things into consideration when we're determining whether somebody’s at risk for another clot, how long they should continue the blood thinners or anticoagulation, whether it's three months all the way to lifetime. Those are individual decisions we make.
Clots can disappear. The body typically can dissolve a clot, but sometimes it needs help, and the clot-busting drugs are used when we do use them because it'll dissolve a clot or at least partially dissolve a clot quicker than the body will. If somebody's really in trouble, and by that I mean the right side of the heart is not working well because it's pumping against the blockage in the lungs, that patient is in a life-threatening situation, and then we have to give the clot-busting drug to try to let a little more blood flow get through the lungs, but that doesn't necessarily mean the clot will completely dissolve. That's something that we determine, like I said, several weeks after the acute clot.
Every patient who's had a pulmonary embolism, there's a series of blood tests that we recommend looking for one of these, what we call hypercoagulable states. There's something in the bloodstream that predisposes them to getting another clot. That's an important component to it.
Then, usually at the end of three to six months of anticoagulation, the first clot they've had, then we may actually stop the blood thinner and draw we call a D-dimer test three weeks afterwards, and that test has been shown to help us predict the likelihood of having another clot in the future.
My name is Richard Channick, and I'm aware that I'm rare.
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