by Anjali Bhave, Lambert High School in Suwanee, GA
and Nimish Kadam, Riverwatch Middle School in Suwanee, Georgia
AB: Anjali Bhave
NK: Nimish Kadam
RK: Rashmi Kulkarni, MD
Greetings, Dr. Kulkarni:
(Anjali’s comment : Rashmi Kulkarni, MD, is a Board Certified Family Practitioner. RK has been in practice for the past several years, and has seen and treated patients with thrombosis in her practice).
AB : On behalf of the GTF, an affiliate of NATF, I want to thank you for your time given to us this morning.
I am AB, a Freshman at Lambert High School in Suwanee, GA
I am NK, an eighth grader at Riverwatch Middle School in Suwanee, Georgia
AB: Let us first tell you the purpose of this event. We started working in GTF some 5 years ago with the mission of spreading awareness of thrombosis in the Georgia community.
GTF has been conducting several projects to bring awareness in the community about various aspects of thrombosis (DVT, MI, PE, Stroke, etc.).
We would now like to get a perspective from an experienced physician, such as yourself, about what you see in your daily professional life, your challenges, questions from patients, and when you dispense medications for thrombosis to your patients.
We are privileged to be interviewing an expert, such as yourself, in Family Practice. We have made some notes in an attempt to let the flow of our interview go smoothly. We hope you would not mind.
So let us get started. First, we are going to ask you some general questions about the risk factors for VTE and your opinions.
What is thrombosis?
RK: Thrombosis is a condition where a clot is formed in blood
It could be arterial (MI, stroke), or venous (DVT, PE)
DVT is a condition where a clot is formed in the deep vein
NK: 1. Do you see patients with thrombosis in your practice?
RK: Yes, I do see them regularly. I see patients with DVT frequently, MI sometimes but stroke, I see it very rarely.
AB: 2. In your practice, what age group is affected the most?
RK: Depends on the type of thrombosis. For example, DVT / PE can happen at any age. MI / stroke: these generally tend to appear at an older age.
NK: 3. In your experience, what are the main causes of thrombosis?
RK: Main causes of DVT are grouped in Virchows triad- Stasis, endothelial injury and hypercoagulable state. In patients with MI / Stroke, age, obesity, hereditary conditions, comorbidities like diabetes, hypertension etc. play an important role.
AB: 4. Do factors such as ethnicity, family history, country of origin play a role in thrombosis in women?
RK: Yes, absolutely, these factors play a significant role in thrombosis in women
NK: 5. We know that pregnancy increase the risk of DVT. What is the incidence of DVT in pregnant women?
RK: From what I’ve read, pregnancy increases the risk of VTE from between 4-5 times.
AB: 6. Does Injury/surgery increase the risk of DVT?
RK: Yes, injury plays an important role in causing DVT, due to injury to the endothelium and immobility.
NK: 7. Do hormones or hormone based medications play a role in DVT?
RK: Yes, they do. Estrogen in oral contraceptives all can cause an increased risk of DVT.
AB: 8. In your opinion, do lack of physical activity, immobility play a role in VTE?
RK: Yes, they do, because they result in stasis of blood, and thus VTE.
NK: Obesity. Our research shows that people with a body mass index (BMI) of 30 or higher are two to three times more likely to have a blood clot. What has been your experience in your practice?
RK: Yes, obesity does increase the risk significantly. From what I have read, a BMI of 30 is a bit more conservative, risk really picks up for patients with BMI of 40 onwards.
AB: Active cancer. Cancer and cancer treatments double or triple clot risk. Do you agree?
RK: Yes. Cancer causes a state of hypercoagulability and thus increase the risk significantly.
NK: What about other health problems, certain acute infections, kidney disease, diabetes, long bone fractures, and neurological diseases that affect movement in your legs? Can all these add to the risk of DVT?
RK: Yes, these conditions also have a potential of increasing the risk of VTE.
AB: Hospitalization. The risk of developing DVT in people who are hospitalized is several times higher than non-hospitalized patients. Has this been your experience?
RK: Yes, hospitalization, due to immobility and comorbid conditions can increase the risk of VTE many folds.
NK: Living in a nursing home. Residents have more than twice the risk of DVT. Any comments?
RK: Yes, absolutely. Again the reason are immobility. Nursing home patients are generally older and have certain conditions that keep them immobile.
AB: Do other health problems, such as diabetes, hypertension, kidney diseases, increase the risk of DVT?
RK: Yes, they play a significant role in causing DVT.
AB: We are now going to take the following conditions for discussion: DVT, PE, MI (Myocardial Infarction), and Stroke.
How do you define DVT?
RK: DVT is a condition in which a blood clot forms in one or more of the deep veins in the body, usually legs. DVT is a serious condition because if a blood clot in your vein breaks loose, it can travel through your bloodstream and block the blood flow to your lungs.
How many patients do you / did you see typically every month?
RK: Hard to say. I see patients with DVT and MI more, but stroke, I see rarely.
Symptoms: Some symptoms of DVT include leg pain or swelling, cramping or soreness.
RK: Yes, this is true. However, in some cases the patient will not show any specific symptoms that will help me in the diagnosis of DVT.
DVT is caused by formation of blood clots, in the deep vein due to injury, surgery, or immobility.
People with a family history of blood-clotting disorders and/or those suffering from obesity or heart failure, and/or taking birth control pills or any other oral contraceptives that may affect the natural processes of the body are at a higher risk of developing DVT.
What has been your experience?
RK: Yes, this is true.
Diagnosis: We understand that the physician will first ask the patient questions regarding what symptoms they may have been feeling, and a physical exam will be conducted so that the doctor can locate areas of swelling, pain and redness.
Next, the patient may undergo CT Scan, MRI, venography (dye injected into vein to produce image of veins and locate blockage), or ultrasound (wand-like device that sends sound waves to affected area which are reflected back and create a video image).
Which ones do you prescribe in your practice?
RK: I usually order Doppler ultrasound which is considered as a Gold standard.
Complication that could possibly follow DVT is PE because if the clot in the deep vein gets too big, it could break off and travel through the rest of the body and get stuck in arteries forming an embolus.
Another common complication that could follow DVT is postphlebitic syndrome, also known as post thrombotic syndrome.
Postphlebitic syndrome may be diagnosed through symptoms such as leg pain, often swelling of legs, skin discoloration, and skin sores.
Do you want to add anything to these?
RK: Not really.
Treatment: In most cases, the patient is given anticoagulants, such as oral coumadin, or different forms of injectable heparin.
However, depending on the severity of the case, a clot buster, such as tissue plasminogen activator (TPA) may be administered. If the patient is unable to take medications, a filter may be inserted into the large vein (vena-cava).
The patient may also be given compression stockings (socks that add pressure to prevent swelling and pooling or clotting of blood in the legs).
Do your thoughts concur with these methods of treatment?
RK: Yes. I do agree.
How do you define PE?
RK: The obstruction of pulmonary arteries by a clot that migrates from elsewhere in the body.
How many patients with PE do you see / did you see typically in a month?
RK: I see PE patients very rarely. Perhaps I have seen 2 cases in the last year.
From my research, common symptoms of PE include – labored breathing, chest pain, rapid pulse, coughing up blood, low fever, fluid buildup in the lungs, and in some cases there are no symptoms
RK: Absolutely, in some cases, there are no symptoms.
What are the risk factors of PE? We have read that prolonged bed rest, surgery, childbirth, heart attack, stroke, congestive heart failure, cancer, obesity, a broken hip or leg, oral contraceptives, sickle-cell anemia, congenital coagulation disorders, chest trauma, certain congenital heart defects, and old age can predispose to PE.
Has this been your experience also?
RK: I wouldn’t say it directly causes PE, these are the conditions that predispose you for DVT and then some will develop PE when the clot gets larger or the patient is under-anticoagulated.
What tests would you apply to diagnose PE? Our information says that PE can be diagnosed through a patient’s history, a physical examination, and diagnostic tests such as X-rays, lung scan, pulmonary angiography, electrocardiography, arterial blood gas measurements, and leg vein ultrasonography or venography.
RK: The main test used is a CTA scan of the chest. It replaced Lung scanning and pulmonary angiography.
Patients diagnosed with PE are generally hospitalized and treated with clot-dissolving or clot-preventing drugs, depending upon the severity of the PE. If severe, a clot-dissolving agent may be considered. The main goal is to maintain the patient’s cardiovascular and respiratory functions while the body naturally breaks down the clot and to prevent new clots.
Heparin is the injectable anticoagulant (clot-preventing) drug of choice for preventing formation of blood clots. Warfarin, an oral anticoagulant, is usually continued when the patient leaves the hospital and does not need heparin any longer.
Thrombolytic therapy (Streptokinase, urokinase, and recombinant tissue plasminogen activator, etc.) to dissolve blood clots is the aggressive treatment for very severe pulmonary embolism.
What has been your experience in experience in treating patients with PE?
RK: Generally, I don’t treat them in the clinic because we have to rush them to the hospital. Typical treatment includes injectable heparin or LMWH along with warfarin, or newer oral anticoagulants such as Xarelto or Eliquis which may be given for a longer period of time without monitoring the level. These new oral drugs have now replaced warfarin.
We understand that pulmonary embolism can be life-threatening.
About one-third of people with undiagnosed and untreated pulmonary embolism don’t survive.
When the condition is diagnosed and treated promptly, however, that number drops dramatically.
Pulmonary embolism can also lead to pulmonary hypertension, a condition in which the blood pressure in your lungs and in the right side of the heart is too high. When you have obstructions in the arteries inside your lungs, your heart must work harder to push blood through those vessels. This increases the blood pressure within these vessels and the right side of the heart, which can weaken your heart (a condition called cor-pulmonale).
In rare cases, small emboli occur frequently and develop over time, resulting in chronic pulmonary hypertension, also known as chronic thromboembolic pulmonary hypertension.
Dr. Kulkarni, would you like to add
RK: I think that covers all/ thanks.
Myocardial Infarction/Heart Attack (AB)
How do you define MI?
RK: The term “myocardial infarction” is defined as a condition in which the heart muscle shows death and the changes that occur due to the sudden deprivation of circulating blood.
How many patients of MI do you see / did you see typically each month?
RK: I see a fair number of patients with unstable angina, but less frequently typical MI.
Pressure on chest; pain in chest, back, upper body; shortness of breath; high heart rate; dizziness; caused due to blockage in coronary arteries or buildup of plaque.
Did we miss anything?
RK: Sometimes the patients exhibit atypical symptoms especially women-such as nausea, epigastric distress, upper abdominal pain, jaw pain, upper back pain, or pain in left arm.
We understand that patients are diagnosed based on the symptoms listed above and by physical examination.
Additionally, a stress test, electrocardiogram, MRI or CT scan, or angiogram are used to diagnose MI. Do you have anything to add to this list?
RK: A typical MI is diagnosed based on the symptoms, EKG changes, cardiac enzymes and sometimes upon coronary catheterization.
Complications: Some complications of MI may include heart failure, cardiogenic shock, and angina. Do you agree with this?
RK: I agree with this list. In addition, there could be pericarditis, cardiac arrhythmia, or death.
Treatment: The patient may be given blood thinners, such as heparin, to reduce the risk of blood clots forming in arteries. Pain relievers (morphine) and aspirin are also a common prescription. Drugs called beta blockers are also used. However, in many large centers, coronary artery by-pass grafting is performed as soon as possible. How do you treat your MI patients?
RK: I do not treat MI in my outpatient clinic. I always call 911, but do give them sublingual nitroglycerin, oxygen, Aspirin and refer the patient to be taken to ER. Regarding beta blockers ER will use labetalol or agents such as metoprolol.
How do you define stroke?
RK: Stroke is when there is a lack of blood supply to the brain blocking cerebral vessels.
How many patients of stroke do you see / did you see typically every month?
RK: I rarely see stroke patients. In 10 years I may have seen may be about 4 to 5 patients. Typically time is of essence with these patients, so they are always advised to go to ER.
We are told that the symptoms of stroke include blurred or decreased vision, severe headache, weakness, numbness, paralysis, dizziness, and loss of coordination.
Do you typically see these symptoms, or anything else?
RK: What you have outlined basically covered everything.
Diagnosis is made by physical examination
A quick diagnosis and treatment gives the best chance of survival and recovery.
Patients with stroke should be immediately seen in the Emergency Room.
Diagnosis is made by physical examination
The physician may order brain computed tomography, MRI, CT arteriogram, carotid ultrasound, and/or carotid
Before sending them to the ER, generally a CT scan is done.
RK: Your list is complete.
Sudden death of brain cells caused by a ruptured artery in the brain or by a clot which blocks blood flow may cause damage to the affected brain tissue, or death of the patient.
Stroke is the leading cause of long-term disability
Did I miss anything?
Swift treatment followed by physical therapy can restore nearly all function in some cases. However, some individuals may experience damage severe enough that recovery is questionable and may be confined to a wheelchair or bed for the rest of their lives.
Vasodilators, neuroprotectors, and TPA (within 4-5 hours) are also being looked into as well as clot-preventive drugs
RK: The only thing I would like to add is “time”. With stroke, time is everything.
Have you seen patients with multiple thrombotic disorders?
RK: Yes, I do see patients with multiple thrombotic disorders.
Summary and conclusions
Thanks Dr. Kulkarni for your valuable time given to us in interviewing you on this very important subject. We have learned from this the following things:
1. That thrombotic conditions are serious, and an emergency for the patient and the family.
2. That thrombotic conditions need an immediate treatment to prevent any complications.
1. Deep vein thrombosis (DVT): http://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/basics/definition/con-20031922, 2016
2. Pulmonary embolism.World of Health. Gale, 2007.
3. Pulmonary embolism.Student Resources in Context. Web. 12 Feb. 2016
4. Acute Myocardial Infarction. Retrieved February 16, 2016, from http://www.healthline.com/health/acute-myocardial-infarction#Causes3
5. Complications of Acute Myocardial Infarction. Retrieved February 16, 2016, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/complications-of-acute-myocardial-infarction/
6. Heart attack. Retrieved February 16, 2016, from http://www.mayoclinic.org/diseases-conditions/heart-attack/basics/tests-diagnosis/con-20019520
7. How is a Stroke Diagnosed? Retrieved February 13, 2016, from https://www.nhlbi.nih.gov/health/health-topics/topics/stroke/diagnosis).
8. Blaser, Larry. “Stroke.”The Gale Encyclopedia of Science. Ed. K. Lee Lerner and Brenda Wilmoth Lerner. 5th ed. Farmington Hills, MI: Gale, 2014.
9. Student Resources in Context. Web. 13 Feb. 2016
10. Blaser, Larry. “Stroke.”The Gale Encyclopedia of Science. Ed. K. Lee Lerner and Brenda Wilmoth Lerner. 5th ed. Farmington Hills, MI: Gale, 2014.
11. Pulmonary embolism.World of Health. Gale, 2007.Student Resources in Context. Web. 12 Feb. 2016.
12. How is a Stroke Diagnosed? Retrieved February 13, 2016, from https://www.nhlbi.nih.gov/health/health-topics/topics/stroke/diagnosis).