Deep Vein Thrombosis — Overlooked and Underrated
It Happened to Me
It was the early part of September, 2006, when after planting six Areca palms in my yard and tamping mounds of dirt forcefully with my right foot, I announced to my wife that I had likely torn a muscle or fractured a rib. I had, you see, developed the sudden onset of left-sided, focal, sharp chest pain. It was a particularly sultry late summer day in Florida and my landscaping labor had been extraordinarily strenuous and enervating. Therefore, it was easy for me to dismiss my symptoms and reject the all-too-obvious diagnosis of PE. I will spare you the humiliating details of the ensuing two days, during which I somehow miraculously convinced my wife, a physician, and my good friend and workout partner – a cardiologist – that I could not possibly have suffered a PE. After all, my chest was tender to palpation, a symptom that I had been taught could never occur from a pulmonary embolism. Wrong! Two days after the onset of my pain, I was rushed by ambulance from CT scan to the cath lab for an IVC filter, and finally to the ICU, where I spent the next nine days struggling to breathe and coughing up large amounts of blood from my necrosed lung.
Click on the images below for larger view. |
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CT Scans are courtesy of South Florida Medical Imaging. |
Why Me?
So why did I develop this PE and what could have been done to expedite the diagnosis and treatment? First of all, I neglected to mention that three weeks earlier, I had taken a long drive in order to deliver a lecture to the South Eastern Lipid Association. Those eight hours of driving had resulted in a large right lower extremity DVT. And, akin to 50% of DVT patients, I had absolutely no lower extremity symptoms or signs! The ensuing workup revealed that I am heterozygous for Factor 5 Leiden, a clotting abnormality (thrombophilia) in which the pro-thrombotic protein, Factor 5, inappropriately resists the anti-clotting effects of Protein C. Patients with this genetic disorder are prone to developing venous clots under the right circumstances. The more elements of Virchow's triad (stasis, vessel injury, and hypercoagulability), the more likely a clot will form. I had stasis — from driving — and hypercoagulability — from factor 5 Leiden. I may even have experienced an unrecognized injury during my landscaping debacle. Amazingly Factor 5 Leiden is quite prevalent — a full 5% of Caucasians carry this potentially deadly trait.
Testing the Gene Pool
Discovering this genetic flaw, I promptly tested all first degree relatives, discovering that my mother and younger son also carried the trait. Armed with their newfound knowledge they can now protect themselves from the experience that I had endured. For example, when they travel on an airplane for more than four hours, they should get out of their seats every hour to walk, stretch their legs repeatedly, drink plenty of water, avoid alcohol, and wear gradient compression stockings. These interventions are essential, as some studies have found the incidence of DVT to be as high as 10% in individuals traveling long distances by plane. Even the more mundane situations warrant special attention in people who carry Factor 5 Leiden. My son came very close to having his leg casted this past summer. Had the cast been required, he would have been given Lovenox injections to diminish his chance of developing a DVT.
Recognizing DVT When it Occurs
As my clot was asymptomatic, you may be wondering what you can do to recognize a DVT and begin appropriate treatment. Well, fortunately, not all DVTs are silent. Nearly half of them are associated with some symptom or sign. Calf pain, swelling, erythema, and occasionally a palpable or visible venous cord can alert you to the diagnosis. Understanding the physiology of the disease (Virchow’s Triad) will enable you to risk-stratify your patients. If your index of suspicion warrants, a lower extremity venous doppler ultrasound can clinch the diagnosis. Preemptive strategies are also beneficial. We must know who is at high risk: hospital or nursing home patients; those with malignant neoplasm, neurologic disease with paresis, varicose veins, and superficial vein thrombosis; patients with a recent history of surgery, trauma, chemotherapy, central venous catheter or pacemaker placement; anyone who is taking an oral birth control pill, as well as those who are sedentary or obese. Of course, knowing whether or not your patient carries the all-too-common genetic defect, Factor 5 Leiden, is also extraordinarily helpful. Given the prevalence of this disorder, it might even make sense to upgrade Factor 5 Leiden blood testing to a standard screening test for all patients.
The Bottom Line
The bottom line with DVT and PE is for health care practitioners to develop a sense of hyper-vigilance.These disorders are so common, so often overlooked, and result in such a high morbidity and mortality that the Surgeon General’s Office issued a call to action in September, 2008. The call was issued to raise the level of awareness among physicians and the lay public so that the purported 600,000 annual deaths from PE can be reined in. Podiatrists care for a huge number of at-risk patients and so your awareness and vigilance can most certainly help stave off the terrible outcomes associated with unrecognized DVT.
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