Features July 2017 Issue

Know the Risk Factors, Symptoms, and Treatment of a Pulmonary Embolism

This potentially fatal blood clot usually starts in the leg as a deep vein thrombosis. Avoiding obesity, smoking, and a sedentary lifestyle may help lower your risk.

A blood clot that gets lodged in your lungs—a condition known as a pulmonary embolism—typically starts out in your leg before traveling up into your heart and then your lungs. In the legs, this clot is called a deep vein thrombosis, and it can develop quickly.

The complications that can stem from a pulmonary embolism (PE) include damage to the affected lung, low oxygen levels in the blood, and damage to other organs that don’t receive enough oxygen.

“Pulmonary embolism is a very serious condition,” says ­Gustavo ­Heresi, MD, medical director of the Pulmonary Thromboendarterectomy Program at Cleveland Clinic. “It’s very common, but it can be fatal.”

Pulmonary Embolism

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A pulmonary embolism occurs when a blood clot travels from the leg and gets lodged in a lung. It damages lung tissue by blocking circulation to that part of the lung.

PE is the third-leading cause of cardiovascular death behind heart attack and stroke. A quarter of the patients who present with pulmonary embolism experience sudden death.

Symptoms and Diagnosis

Dr. Heresi notes that even though approximately 600,000 cases of PE are diagnosed in the U.S. each year, the condition can easily be misdiagnosed. That’s partly due to the non-specific nature of PE symptoms. They can include:
- Shortness of breath
- Chest pain
- Rapid breathing
- Wet cough, often with blood sputum
- Swelling in the legs

In many cases of PE, a patient has no obvious symptoms at first. Once signs begin to appear, you may be initially diagnosed with pneumonia or asthma. If you have those symptoms and you’re at a higher risk for PE, your doctor should consider PE as a possibility if other obvious causes can be ruled out.

Dr. Heresi says that a standard chest X-ray won’t detect a PE. However, if your doctor determines that the likelihood of a PE is high, a computed tomography (CT) scan with intravenous (IV) contrast may be ordered. IV contrast is an injected substance that helps make the lungs clearer during the scan. CT scans are special X-rays that use computer technology to create multi-layered and detailed images of internal organs.

Treating a Pulmonary Embolism

The standard treatment of a PE is anticoagulation therapy. Taking a blood-thinning agent such as warfarin (Coumadin) is usually very effective in most people with a PE, Dr. Heresi says. “Even if we’re not sure but we’re suspicious that a pulmonary embolism is present, we’ll start patients on anticoagulation therapy,” he adds.

Another anticoagulant drug that is commonly used to treat PE is heparain. It can be delivered with an IV or with an injection. “The main goal of anticoagulation therapy is to prevent new clots from forming and to prevent an existing clot from growing in size,” Dr. Heresi explains.

A PE often dissolves within a few months. With prompt treatment, there may be no serious complications. The time it takes for a PE to dissolve depends on the treatment and the size of the clot.

For large clots, a stronger type of medication, called a thrombolytic, may be needed. These “clot-busting” drugs can often dissolve a clot quickly. However, thrombolytics are associated with higher rates of bleeding complications, Dr. Heresi says. “The complications can be quite serious,” he says. “You can have bleeding inside the brain.”

Standard anticoagulants also carry a bleeding risk, but it is lower than with thrombolytics. The length of time you should remain on a blood thinner depends on several factors, including how the clot developed in the first place.

If the clot was probably triggered by a risk factor, such as obesity or a sedentary lifestyle, you can expect to stay on blood thinners for three to six months. “If there isn’t an obvious cause, you could be on a blood thinner for life,” Dr. Heresi says. “That’s not set in stone. Each case is different. But if pulmonary embolism is recurrent, then lifelong anticoagulation therapy is mandatory.”

If Symptoms Don’t Improve

With proper care, symptoms such as shortness of breath should be gone within six months. “If symptoms continue, we need to look out for long-term pulmonary hypertension,” Dr. Heresi says.

Pulmonary hypertension is high blood pressure in the arteries of the lungs. It can lead to heart failure.

The important thing is to be aware of your symptoms and report them to your doctor. The solution may be simply extending the time you’re on a blood thinner. There may be other lung conditions to investigate and treat if possible.

Prevention at Home and Abroad

Preventing a PE actually starts by preventing the formation of a clot in your legs. A PE can begin in your arms or, more rarely, in your pelvic region. But it’s much more likely to form in a vein in the lower leg. Arteries carry blood away from the heart to the rest of the body, while veins bring blood back to the heart. So a clot in a vein is more likely to return to the heart, and then the lungs. Once blood returns to the heart, it is pumped into the lungs to be replenished with oxygen.

Certain circumstances can increase your risk of developing a leg clot, Dr. Heresi says. They include a long car or airplane trips and major surgical procedures that leave you bedridden for hours.

“As much as possible, you should stand up and walk around,” Dr. Heresi advises. “If that’s not possible, contract the muscles in your the legs periodically. We think that helps prevent venous thrombosis.”

Hospital Safety

If you’re hospitalized for any reason, and you’re spending a lot of time lying down, you should take special precautions to prevent DVT. Lying down in the same position for an extended time reduces blood flow in the legs, increasing the likelihood of a blood clot forming.

“Pulmonary embolism is the most common preventable cause of death among hospitalized patients,” Dr. Heresi notes. “Most hospitals have protocols in place for DVT prophylaxis (disease prevention). But it doesn’t hurt to be aware of this in case you’re in a place without these protocols. Talk with your doctor about steps you can take to prevent blood clots.”

Lifestyle Changes

Of course, the best way to avoid DVT, PE and any number of other cardiovascular complications is to adopt a heart-healthy lifestyle. This means following a Mediterranean-style diet, doing aerobic and strength training exercises throughout the week, and quitting cigarettes. You should also be sure to keep up with your doctor appointments and take your medications as prescribed. If you’re on a blood thinner and you notice bleeding problems, tell your doctor immediately or call 911. Some of the signs of major bleeding problems in your digestive tract or brain include:
- Bleeding from a cut that doesn’t stop within 10 minutes if pressure is applied
- Black and tarry stool, with or without blood
- Abdominal pain
- Severe head pain
- Confusion
- Sudden change in vision
- Sudden loss of movement in your limbs.

If you have any questions about your risk for PE or about how your PE treatment is going, ask your doctor.

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