1 in 4 deaths worldwide from conditions caused by thrombosis
It is estimated that every 6 seconds a person dies from VTE globally
In England alone, 25,000 people die each year from venous thromboembolism (VTE) contracted in hospital
Thrombosis is often the underlying cause of heart attack, thromboembolic stroke and VTE, the top three cardiovascular killers
World Thrombosis Day aims to increase global awareness of the often overlooked and misunderstood condition of thrombosis
Many people know about the risks for breast cancer or heart disease, but most aren’t aware that 1 in 4 people worldwide die from conditions caused by thrombosis, more commonly known as blood clots.
Many, if not most, cases of thrombosis are preventable, and yet too many patients slip through the cracks. Approximately 60 percent of VTE cases happen to patients during or after being hospitalised or undergoing surgery. In the UK alone, up to 1 in every 1,000 are affected by venous thrombosis. This figure is higher than the combined total deaths of breast cancer, AIDS and traffic accidents, and costs the NHS an estimated £640 million annually.
Thrombosis is common, but general awareness about the condition is very low. In a 2014 global survey of nine countries conducted by the International Society on Thrombosis and Haemostasis (ISTH), only 68 percent of those surveyed were aware of blood clots, much lower than awareness of other potentially life-threatening health conditions such as hypertension.
Although thrombosis can affect anyone, those who are age 60 or older are at a higher risk, as are individuals undergoing surgery or cancer treatment, people who undergo long periods of immobility and women who are pregnant. That’s why it is so important for people to understand the risks factors, be able to recognise the signs & symptoms, and ask their doctors for a VTE risk assessment if they are hospitalised.
Because 1 in 4 people worldwide are dying from conditions caused by thrombosis, it will therefore be impossible to reach the World Health Assembly’s global target of reducing premature deaths from non-communicable disease by 25% by 2025 unless we address thrombosis.
This year, more than 550 medical and health organisations from every continent will participate in World Thrombosis Day, embracing thousands of educational events and bringing together in partnership patients, healthcare professionals, policy makers, research and industry supporters to place a global spotlight on thrombosis as an urgent and growing public health problem.
Thrombosis is the formation of potentially deadly blood clots. Blood clots can form in the artery (arterial thrombosis) or vein (venous thrombosis).
Deep vein thrombosis (DVT) is when blood clots in a deep vein (most often the leg)
Pulmonary embolism (PE) occurs when a blood clot breaks loose and travels to the lungs
Collectively, DVT and PE are known venous thromboembolism – VTE.
World Thrombosis Day (WTD) focuses attention on the often overlooked and misunderstood condition of thrombosis. It embraces thousands of educational events across the world, and brings together in partnership patients, healthcare professionals, policy makers, research and industry supporters to place a global spotlight on thrombosis as an urgent and growing public health problem
An air or gas embolism is a bubble that becomes trapped in a blood vessel and blocks it. This can lead to many different symptoms depending on where the blockage occurs. It’s one of the leading causes of death among divers.
An air or gas embolism can happen when a scuba diver surfaces too quickly from any depth. This can cause air to escape into the blood vessels from the lungs (pulmonary barotrauma) or bubbles of nitrogen to form in the blood vessels (decompression illness, or “the bends”).
An embolism can develop in an artery or vein. When an air bubble travels along an artery, it moves through a system of blood vessels that gradually become narrower. At some point, the bubble may block a small artery and cut off the blood supply to a particular area of the body.
Bubbles in the veins travel around the body and can cause breathing difficulties when they reach the lungs.
How serious is it?
The seriousness of the blockage depends on which part of the body the affected blood vessel supplies blood to and the size of the air bubble. For example, an air embolism in:
the arteries to the brain can cause immediate loss of consciousness and may lead to seizures (fits) or a stroke – it can also cause confusion, dizziness and slurred speech
the coronary arteries (which lead to the heart) may cause a heart attack or an abnormal heart rhythm
paralysis or weakness, possibly of one or more limbs
loss of consciousness
If a scuba diver develops these symptoms within 10 to 20 minutes of surfacing, they probably have an air embolism and should be given 100% oxygen and transferred to hospital as soon as possible, preferably one with a recompression chamber.
Treating air embolisms
If a diver develops an air embolism, the only effective treatment is immediate recompression treatment in a special pressurised room called a hyperbaric chamber.
The diver should be given 100% oxygen and laid horizontally until they reach the hyperbaric chamber.
Recompression treatment involves lying in a hyperbaric chamber, usually for several hours, and breathing a mixture of gases and oxygen under pressure. The high pressure can restore normal blood flow and oxygen to the body’s tissues and reduce the size of the air bubbles in the body.
In cases of decompression sickness, the pressure forces the bubbles of nitrogen to dissolve back into the bloodstream.
After recompression, pressure is reduced gradually to allow the gases to leave the body without worsening the problem, similar to surfacing slowly from a dive. Treatment might be continued for several days depending on the severity of symptoms.
Preventing an air embolism while diving
The following advice can help reduce your risk of developing an air or gas embolism when diving.
Limit the depth and duration of your dives.
Come up to the surface slowly and always perform safety stops to allow any air in your tissues and blood vessels to escape safely. Use a dive computer or dive tables, and don’t dive again if you have broken these rules until you have had a suitable time at the surface.
Don’t dive with a cold, cough or chest infection.
Avoid rigorous exercise before, during and after a dive.
Make sure you’re well hydrated before diving.
If planning several dives, leave adequate surface intervals between dives to allow the nitrogen to leave your body.
After diving, wait for 24 hours before flying or going to a higher altitude.
If in doubt, contact a dive professional or doctor, who can provide further advice.
Other causes of air embolisms
Air embolisms also occur during surgery or other medical procedures, but this is rare.
In hospitals and health centres, care should be taken to prevent this. For example:
before injections, air should be removed from syringes and intravenous lines
catheters or other tubes inserted into the body should be inserted and removed using a technique that minimises the possibility of air getting into the blood vessels
patients should be closely monitored to help ensure air bubbles don’t form in blood vessels during surgery
Air embolisms resulting from surgery, anaesthesia or other medical procedures can be difficult to treat. Treatment is usually needed to support the heart, blood vessels and lungs.
For example, fluids may be used to treat a fall in blood pressure and oxygen may be given to reduce levels of other gases in the blood vessels
Last Monday 13th October saw World Thrombosis Day 2014. To mark the day we conducted an interview with Dr Hilary Jones on the subject of Thrombosis.
But did you you know this seven important facts about thrombosis?
1) Sitting at a desk, in a car, or a train for just a 90 minute period of time can reduce blood flow behind the knee by 50%, increasing the risk of thrombosis – a blood clot
2) Other risk factors: Major surgery, such as orthopaedic or surgery for cancer, or extended time in the hospital, heart diseases, pregnancy, smoking, hormone therapy, being overweight/obesity, dehydration, family history and cancer
3) Deep vein thrombosis (a blood clot in the leg) or a pulmonary embolism (a blood clot in the lung) kills one person every 37 seconds in the western world (1,2) – in England more than one in 1,000 adults could be affected by blood clots every year (3)
4) Blood clots can also travel to the brain causing strokes. These types of clots occur in people who have atrial fibrillation (an irregular heartbeat) – a condition which affects over one million people in England (4)
5) New data reveals that 75% of people in the UK wouldn’t know what to expect if they experienced a blood clot in the lungs (5) – highlighting the need to raise awareness of the signs and symptoms of thrombosis
6) itting at a desk, in a car, or a train for just a 90 minute period of time can increase the risk of thrombosis – a blood clot
7) There are a number of effective treatment options available to treat and prevent blood clots
The interview was conducted bu Antonia Lipinski on behalf of PatientTalk.Org.
Lipinski So what actually is DVT and why is it so dangerous?
DR JONES Well DVT stands for Deep Vein Thrombosis. This means that a blood clot forms in the veins which lie deep in the tissues of the body and this particularly affects the calf muscle veins. When people complain of pain and tenderness in the calf with swelling and redness it could be that they’ve got Deep Vein Thrombosis. The significance of Deep Vein Thrombosis is this that it is a very common disorder and it can have far reaching consequences. If a piece of the blood clot should break off into the circulation and be carried onwards towards the heart and lungs its means its can cause a pulmonary embolism. That is part of a clot that has broken off and has lodged in the lungs obstructing the oxygenising of blood and that can have very serious consequences and leads to a fair number of deaths every year.
Lipinski Who can get it?
DR JONES Well all most anybody can suffer from deep vein thrombosis. We know that it is more common with age but a young person who has had an injury, somebody who is having surgery, somebody is pregnant and somebody with a family history or a previous history of blood clots because some people have a genetic predisposition towards forming clots in the blood. All of these people, people who smoke even are more prone to blood clots so nobody is immune from blood clots and every 37 seconds one person in the Western world dies from a blood clot so that’s how significant it is.
Lipinski How is it treated?
DR JONES Well we know that we can to some extent we can prevent blood clots in people before it has actually happened. For example if somebody is having surgery we use compression stockings to increase the blood flow through the veins and prevent the stasis which occurs during the operation but more often then not somebody who has a deep vein thrombosis or pulmonary embolism we prevent further occurrences. We treat them. We anti coagulate them. PATIENTTALK.ORG Do flight socks actually work?
DR JONES Yes if they are up to the back of the knee and they are compressing the veins significantly. When someone is on a long haul flight, just as any kind of inactivity would do, it increases the blood flow through the veins and prevents the risk of blood clots so they really do help just as they do in a hospital setting or in anyone who is inactive and immobile for several hours at a time.
Lipinski How is PE different from DVT?
DR JONES Well a pulmonary embolism is where the blood clot breaks off from the leg and is carried up towards the lungs and blocks an artery which the feeds the lung with blood that is ready to be oxygenated. So somebody with a pulmonary embolism will be short of breath. They’ll have chest pain. They’ll have an increased heart rate. They might even cough up some blood and feel light headed. Also they might have no symptoms at all in the early stage as my brother didn’t when he had multiple pulmonary embolisms. Now he is a fit guy. He is an oarsman who rows to a very high standard and he had an abnormal collection of blood vessels in his thigh which he didn’t know about and he wondered why he was a bit more breathless when he was ain a rowing race. He saw a friend who happened to be a cardiologist who recognised the signs straight away. He was treated successfully and those abnormal blood vessels were removed. As I say anyone can be affected and the pulmonary embolism is much more serious because in many cases it can prove fatal if not treated quickly.
Lipinski What lifestyle changes can we make to prevent DVT?
DR JONES I think the first thing is to stop smoking because this thickens the blood and makes it stickier so blood clots are more likely to form. So giving up smoking is a really good step forward. Losing weight or normalising weight so you are not carrying too much weight is good. Reporting any kind of injury around the calf muscle particularly is important. Exercising on a regular basis because when you are using your leg muscles they are pumping and compressing in a rhythmically way the blood vessels underneath the muscle so the muscle pump is a good way of preventing blood clots and improving blood flow. So exercise, giving up smoking and just taking care of yourself are all important, normalising weight, these are all important. Probably nothing more so then recognising the signs and symptoms of DVT. It would be pain and tenderness in the calf, swelling of the ankle and foot, redness in this area, dilution of the surface veins so the veins look more prominent and an increased warmth compared to the other side. It always a good to compare the affected leg to the other side and if you have any doubts at all go and see your doctor and say could this be a DVT.
The NHS regulator NICE has today recommended that people taking a thinning agent can monitor their own blood levels at a time and place convenient to them. In the guidance, NICE recommends using the CoaguChek® XS self-monitoring device.
This means that more people taking a thinning agent should be able to self-monitor (or ‘SelfieChek’), rather than being tied to frequent (sometimes weekly) clinic or hospital visits to have their blood clotting levels measured. Self-monitoring allows people taking a thinning agent to enjoy a flexible lifestyle and reduces the risk of stroke for people with atrial fibrillation or a replacement heart valve.The guidance is also set to benefit the NHS by reducing the unnecessary burden that regular blood checks place on healthcare professionals’ time and resources.
PatientTalk.Org spoke to Eve Knight of Anticoagulation Europe, about the background and implications of the new regulations. Cody conducted the interview on our behalf.
CODY– If you could just start by telling us a little bit about yourself, who you are, and what you do and what your role is?
EVE KNIGHT My name is Eve Knight and I’m co-founder and chief executive of the charity of the Anticoagulation Europe, chief executive basically means I’m responsible for everything although I do have a really great team who work with me and lots and lots of volunteers around the country.
CODY So what’s the cause of the Anticoagulation Europe, what are you guys trying to achieve?
EVE KNIGHT Anticoagulation Europe was founded 14 years ago, our aims are the prevention of thrombosis, the provision of information and support for health care professional and patients and their families and to make sure that the patient voice is at the centre of everything of the NHS does, particularly anyone who is designing anticoagulation services.
CODY Great, so were talking today about Atrial Fibrillation and some new NICE guidelines, so could you just explain to us why anyone would need to take a blood thinning agent? So what conditions require it and how does it work?
EVE KNIGHT There are a number of conditions that you would need to take an thinning agent, Atrial Fibrillation being one of them, replacements heart valves, deep vein thrombosis, Pulmonary embolism and genetic clotting conditions, the guidance that has been issued today is specifically for Atrial Fibrillation and replacement heart valves.
CODY So how does the blood thinning work?
EVE KNIGHT It doesn’t actually thin the blood, what warfarin does is to inhibit the production of Vitamin K in your liver, vitamin K is the vitamin that causes your blood to clot and we all need our blood to clot otherwise when we cut ourselves we would bleed to death. Warfarin inhibits the production so not so much Vitamin K is produced so your blood takes longer to clot.
CODY So who does Atrial Fibrillation affect because I was reading through this today and I was surprised to find out that it actually affects quite a few young people as well as old?
EVE KNIGHT It does affect young people , the major co halt of patients are older, 1 in 8 of us by the time we are 65 will have Atrial Fibrillation but it does affect younger people and what your trying to do with warfarin is to reduce the risks of strokes and young people regrettable do have strokes.
CODY Do you have any idea how many people this condition affects and how many people are treated with a thinning agent at the moment?
EVE KNIGHT In the UK about 1 million and a quarter of people are on warfarin, there’s about 800,000 people diagnosed with Atrial Fibrillation and approximately 40% of those are not on an Anticoagulant or they may be on aspirin and aspirin Nice have now said is no good for preventing strokes you have to be on an Anticoagulant, So there’s a huge co halt of patients who will now need to go onto an Anticoagulant.
CODY – And that was during this year?
EVE KNIGHT That was in June this year yes.
CODY – Do you know why they decided to make that recommendation?
EVE KNIGHT – Well this was a complete update of their 2006 guidance and they made several new points, it’s long been thought or known that aspirin is not as effective as warfarin as preventing strokes and yet it carries virtually the same bleeding risks. So finally the sway of opinion has come together on that and NICE have said that aspirin no longer be used as a mono therapy in preventing strokes for AF.
CODY – So someone on this kind of treatment, how often do they have to visit a clinic or a hospital for check-ups?
EVE KNIGHT That depends very much, everybody on thinning agent will be given a therapeutic range and that will differ depending on the condition for which you’re taking it. In the first few weeks when you go onto a thinning agent you are very likely to be very unstable so you may be going every 3 days/ twice a week, it will for most people eventually settle down and then for a lot of people it varies between once a week and once every six weeks.
CODY – So even when it settles down it’s a lot of visits?
EVE KNIGHT – It’s a lot of visits and it does very much depend, you know a thinning agent is quite an unstable product with a very narrow therapeutic window. So things you would normally do, things you would eat, things you drink, other things you take, all of these can have an effect on a thinning agent and make it go up or down and that would mean you go out of your range and if you go too high out of your range you’re at risk of a bleed and too low out of your range you at the risk of a clot and if your dose, if your range is varying, then you dose will need to be altered.
CODY – Can you briefly just explain the role that NICE plays? Who they are to be issuing recommendations?
EVE KNIGHT NICE is the body that issues recommendations and regulations for what is used drugs or diagnostic tools within the NHS.
CODY So they have recommended that people can now monitor their blood levels at home. Can you explain a little bit about how the CoaguChek device works?
EVE KNIGHT NICE have recommended for people with AF and replacement heart valves that self-monitoring is clinically effective, it’s safe and it’s cost effective for the NHS. A CoaguChek XS is a hand held monitor that you place a little strip into. You prick your finger with a pen needle much the same as diabetics and you take the tiniest drop of blood and you drop that or swipe onto the strip. Within two minutes the monitor gives you your INR range. So it tells you if you’re within your therapeutic range.
CODY Is this quite new technology or is this recommendation coming in after it’s been proven over a period of time?
EVE KNIGHT This recommendation is coming a long time after the technology. In Europe it’s probably 28, 30 years. In this country it’s in excess of 20 years so it’s taken a long time to get to this point but we very much welcome NICE’s recommendation.
CODY Why do you think it’s taken so long for the recommendation to be made if it would seem to be obvious?
EVE KNIGHT To be honest I really don’t know why it’s taken so long. None of the companies have put into NICE for them to look at it. In fact NICE were actually asked by a patient to look at this and I believe that it’s the first time a patient has asked NICE to actually look at something and issue guidance.
CODY That’s interesting. In the same vein why do you think only 15% of GP’s in the UK currently offer self-monitoring to their patients?
EVE KNIGHT I think there are many reasons for that. Cost or the thought that it will cost too much is possibly one. I think a number of GP’s have not been convinced of its safety and now this guidance is out I am hoping that will change that. I think also we tend to take a longer time in this country to actually adopt new technology. I mean the Prime Minister David Cameron actually said in a speech in 2011, he used self-monitoring as an example of what was good about the NHS and what could be used in the NHS but he also recognised in that speech that we are not very good at bringing these things to the table and getting on with them. Now we’ve got the guidance I sincerely hope it’s about time we will get on with it.
CODY So you did mention cost briefly there. I suppose we have to treat it over a long time frame because if you are continuously visiting a GP there is a large cost involved in that as well. What sort of cost outlay is there for this sort of self-checking treatment?
EVE KNIGHT Well there are two sets of costs. Costs for the NHS which is the cost of taking the blood sample, sending it off to the lab, getting it back from the lab, contacting the patient and all that sort of thing. There’s also the cost of if you get it wrong; the cost of strokes. Strokes are extremely expensive things to treat in the NHS. For patients if they are going to clinics or their GP they have got the cost of getting there, the cost of taking time off work/ off school so there are lots of different costs involved. The long term cost savings for the NHS will be two fold. It will be that patients are self-monitoring at home frees up more time for the clinics to deal with people who don’t want too or for people it’s not clinically suitable. Also it has been proven in research that there are less strokes, less thrombotic events when people do self-monitor so the long term costs of saving life’s and saving money is there.
CODY I suppose you can avoid missed appointments and things like that?
EVE KNIGHT You avoid missed appointments and also when you self-monitor because you tend to self-monitor a little more frequently you don’t tend to make so many alterations to your dose so there are less chances of you being in and out of your range.
CODY Anticoagulation Europe are supporting and calling for more self-monitoring. What does success look like for you? 100% uptake?
EVE KNIGHT No there will never be 100% uptake. Some people will not want to self-monitor and that is quite right. No one is saying people have to self-monitor. It is a choice for patients and that’s the beauty of it. Its having a choice about what you want to do and how you want to live your life. Success for me would be getting an awareness of this out to patients and the general public so if they want to they can have these types of conversations with their GP or their anti coag nurse and then make a decision on the benefits of self-monitoring, would it be right for them. Success would also be and we will be campaigning for it, to get these monitors available on prescriptions alongside the strips that go with them so that people are not discriminated against by not being able to afford to purchase this monitoring equipment.