 (DVT) and Pulmonary Embolism (PE)” in September 2008, blood clot has become a household term and public health efforts to increase DVT and PE awareness and prevention have increased. Still, more work needs to be done in raising awareness and engaging patients to adopt a philosophy of disease prevention.
Signs and Symptoms
In many instances, clinical presentation of clotting events occurs in the outpatient realm. With this in mind, it is important to identify the signs and symptoms. Notably, patient presentation can be highly variable and symptoms, such as headache, can be non-specific. Recent celebrity cases of VTE that have included Williams and Rivera have shaken the public’s perception that this disease only affects an older population. Patients who are young or middle-aged may experience stroke-like symptoms with or without neurological consequences, such as seizures, and/ or behavioral symptoms, such as delirium, amnesia, or worse—coma when presenting with sinus venous thrombosis.1
In some instances, diagnosis can take up to 1 week via magnetic resonance imaging (MRI) from the onset of symptoms. The most effective diagnostic evaluation may use MRI in combination with magnetic resonance venography. Patients typically respond positively to anticoagulation treatment with intravenous unfractionated heparin followed by management with oral vitamin K antagonists, such as warfarin.
The duration of anticoagulation management is highly dependent on the patient’s risk for recurrence versus the risk for bleeding. It has been shown that 40% of sinus thrombosis patients have the propensity to experience hemorrhagic infarcts. Furthermore, it is important to note that clots beget clots and patients having experienced primary VTE remain at risk for VTE recurrence. A long-term prospective study reported the cumulative incidence of VTE recurrence at 1 year, 5 years, and 10 years as 11%, 29%, and 40%, respectively.5
Clotting is not a disease that discriminates based on celebrity, but it deserves celebrity status. Pharmacists can continue to play a role in the prevention of VTE and its consequences by counseling patients on the conditions that may contribute to clot formation and helping to identify the signs and symptoms to aid patients who may need to seek preventive medical attention.
Dr. Stevens is an advanced practice anticoagulation pharmacist for the Partners Healthcare System and an adjunct clinical assistant professor of pharmacy at Northeastern University’s Bouvé College of Health Sciences in Boston, Massachusetts. This column’s information is based on current studies and references, but it may be updated without notice with newer studies or with different populations.
Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005;352:1791-1798.
Merli GJ. Pathophysiology of venous thrombosis, thrombophilia, and the diagnosis of deep vein thrombosis-pulmonary embolism in the elderly. Clin Geriatr Med. 2006;22(1):75-92, viii-ix.
Martinelli I, Sacchi E, Landi G, Taioli E, Duca F, Mannucci PM. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med. 1998;338:1793-1797.
de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP; the Cerebral Venous Sinus Thrombosis Study Group. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in [correction of who are] carriers of hereditary prothrombotic conditions [published correction appears in BMJ. 1998;316(7134):822]. BMJ. 1998;316(7131):589-592.
Prandoni P, Noventa F, Ghirarduzzi A, et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism: a prospective cohort study in 1,626 patients. Haematologica. 2007;92:199-205.