Transcription:
Pulmonary Embolism

Amanda Wilde (Host): A pulmonary embolism is when a blood clot breaks free and lodges in your lungs. It can happen suddenly and it can be fatal. So today we'll talk about how to address the risk factors of pulmonary embolism with Dr. Aditya Mangla, Director of Cardiology at Jamaica Hospital Medical Center. This is Jamaica Hospital Med Talk, the podcast from Jamaica Hospital Medical Center. I'm your host, Amanda Wilde. Dr. Mangla, thank you so much for being here today and speaking to a condition we should all be aware of. Will you please describe exactly what a pulmonary embolism is?

Aditya Mangla, DO, FSCAI (Guest): Yeah. Thanks, Amanda. Thanks for having me on I'll be happy to talk about this. So, a pulmonary embolism is, as you described, a clot that lodges in the lungs and can be fatal. It's part of a broader group of diseases in what we call venous thromboembolism. The shorthand term is VTE.

Venous thromboembolism means there's a clot that forms in a vein, and then that clot embolizes, meaning it travels from a vein somewhere else. Now the place where we worry about it traveling to the most is actually the lungs, hence pulmonary embolism. So generally speaking, what happens is that a vein in the legs, forms a clot. Almost always, they come from the legs. Sometimes they'll come from the arms, but almost exclusively, they come from the legs just because of the gravity causes blood to pool in the legs, obviously. So a clot will form in the legs in one of the veins somewhere. And then, at some point, the clot can actually break off from where it originated from.

And then it travels through the vein system, through the heart on the right side, and then lodges inside the lungs. And that's basically what a pulmonary embolism is and can have multiple different clinical features after that.

Host: Well, what causes pulmonary embolisms and how common are they?

Dr. Mangla: Right. So this I think is a great reason why we should be having this conversation. There is a crisis of PE both nationally and internationally. And, one of the problems is that I think the public awareness of this particular disease is actually pretty low. If you compare it to awareness for let's say cancer or most people know about that. I mean, there's actually been studies on that. People are aware of the idea of breast cancer or colon cancer, but the concept of pulmonary embolism is, has much less public awareness. So in terms of that, I think it's important for us to talk about. Second, it's under-recognized and even undertreated by clinicians themselves.

In the United States, there's approximately two plus million of these clots, that form in the legs, what we call DVT, deep venous thrombosis. So about 2 million of those and out of those 2 million, there's going to be almost 600,000 pulmonary emboli. So that's a pretty big number. And one of the problems is that we don't even know the true numbers since many of them can go undiagnosed.

Then out of that 600,000, you're going to have at least a hundred thousand, if not more people who die from pulmonary embolism. And that's really why this is such a crisis. It's the third leading cause of cardiovascular death here in the United States and the number one preventable cause of death in the hospital.

Host: Wow. So what causes these to happen? Is it immobility and then blood pools and causes these clots?

Dr. Mangla: Yeah. Great question. So I think when people think of pulmonary embolism, immobility is one of the biggest causes. So classically you'll think of somebody who's been on a long flight, you know, the hospital where we're at Jamaica Hospital Medical Center here in Queens, we're right near the airport.

So I see a lot of these where, someone took a long flight, an international flight, usually more than four or five hours, they fell asleep on the plane. The blood is pooling in the legs. I like to describe blood as being almost like concrete, so it needs to be flowing all the time so that it doesn't harden. But if you're laying in a seat somewhere and the blood is pooling in a specific spot, it actually can cause a clot from immobility. So that's one of the main risk factors. Other things though can definitely lead us to worry about PE. We talked about immobility, so I, actually see this a lot in like long haul truck drivers, taxi drivers who sit in the car a lot, during the day the blood's pooling in the legs and, they can come in with a pulmonary embolism, but beyond that, there are a lot of different other clinical risks for PE. People with cancer. They have a very high risk of having clotting in the bloodstream. Any kind of cancer can really increase your risk of having both a clot in the legs and then therefore a clot in the lungs.

So that's one of the main risks. Things that people may not really think about, but especially for my younger, female patients who are on oral contraceptives, the use of oral contraceptives, has been linked to increase in DVT and pulmonary embolism, especially if those young women also smoke. So one of the things that you want to stay away from is both smoking, obviously for multiple reasons, but smoking and oral contraception together can lead to a PE. Then we have sort of more rare diseases, but things people often have heard about like rheumatoid arthritis, lupus, any inflammatory condition can increase your risk of having a clotting disorder in the body.

And then other things that are more common like surgery. You had a hip surgery, you had a knee surgery, you're immobile, and those people are at higher risk of having clotting. Lastly, there are more rare genetic mutations that people can have, they're familial and many of those while rare they're enough that we do see them from time to time and they should be tested in families.

Host: Wow with all these sources from which you have increased risk of getting a pulmonary embolism, you would think it is better known than it is. And you said it was the third leading cause of cardiovascular death. So it's fairly common. Why do you think we don't hear about that?

Dr. Mangla: I actually even sent a letter to the FAA because one of the most preventable things that I see is people who have gone on a long flight and I, think people know that there's a recommendation to move around on the plane. Obviously that's hard now, if anyone's taken a flight recently, they sort of pack people in and, moving around on the plane has become more and more difficult.

But, it's surprising how little public awareness there is about a disorder that has such bad mortality.

Host: Yeah. And you mentioned a lot of factors, surgery, cancer, immobility, use of oral contraceptives, especially with smoking. I understand that COVID can also put someone at increased risk. Is there a connection there?

Dr. Mangla: Yes, there is, unfortunately with the COVID pandemic, there's multiple reasons why we have seen PEs. Number one is COVID itself causes some cascade of inflammation in the body that increases the risk of clotting. Now I think the public was very aware of that some of the vaccines may cause clotting, but what's much worse, which causes much more clotting is actually COVID, the disease itself.

So the disease of COVID, you can have clots, almost anywhere in the body. We saw many, many PEs in patients who had active COVID, strokes and other things that are related to clotting. So the disease itself, increases the risk of clotting. And then the other problem with COVID is that when people, let's say they're sick or they stay at home, they tend to be immobile.

Now they're laying in bed. They're not feeling well. So those two things together, you it sets you up for having these sorts of problems and having a clot in the legs that travels into the lungs.

Host: So given the fact that so many people die from pulmonary embolisms, what recommendations do you have on how to prevent one? Are there things you can do to address your risk factors? Well, what's the smoking part. Yes. They can control that. What other recommendations do you have on how to prevent pulmonary embolism? If there is any.

Dr. Mangla: First thing I would recommend for most people is please just see your regular doctor, go to see your doctor, to have your regular screening tests done, because they could talk to you about, what your basic risks are for any medical disorder, but certainly can talk to you about your lifestyle modifications.

Obviously, immobility we talked about is one of the major risks, but having a sedentary life and obesity are also risks. So, making sure you live an active lifestyle, working on either losing weight or being at a healthy weight are very important. Having your screening for cancers, there are certain recommendations, whether it's breast cancer, colon cancer, lung cancer, those things need to be addressed so that you can modify whatever risks factors that you have.

Additionally, your primary care doctor or whomever you see may ask the right questions. Maybe there was a clot in one of the family members. Maybe there's a history of clotting in multiple family members. And you wouldn't even know that until someone asks those questions. Right? So I think the best thing that one can do is A, try to lead a healthy lifestyle, be active, avoid having overweight and obesity in terms of your risk factors and having those screening tests done with your primary care physician. Additionally, the last thing I'd say is I always recommend to my own patients, that if they're taking a long flight, please make sure that you get up and move around on the plane every hour or two, even just flexing your calves, which can sort of drive the blood, through the legs is an important thing people do. Also what people can wear are those flight socks.

Host: I was just going to ask you about that.

Dr. Mangla: I wear them myself. And I consider myself a fairly active person. I exercise regularly, but when, I'm on a plane, I wear the flight socks because, they may feel uncomfortable at first, but you get used to them and actually they make your legs feel less tired when you get off the flight and, they can save your life, essentially.

Host: Well, that too is a good reason for compression sock apparel. You talked about how prolonged immobility can be a factor creating these pulmonary embolisms. What measures do you take at Jamaica Hospital then to prevent those patients that are immobilized from developing these pulmonary embolisms?

Dr. Mangla: So number one, there is pretty much a universal recommendation, whether you're immobile in the hospital or not, we have to give you a blood thinner on a daily basis, sometimes multiple times a day within the hospital, in order to, prevent these DVTs. So the first thing we do is make sure that we give you a heparin like blood thinner.

So heparin is one of the classic blood thinners. There are other ones, enoxaparin, but whichever one we use, or any hospital uses, but the ones that we use at Jamaica Hospital are generally heparin. And we give that a few times a day so that people are less likely to clot in the legs.

The second thing is we have made a concerted effort here, that any patient, regardless of the condition that they have medically, we try to move them around in the hospital. The last thing you want is having a patient who's essentially bedridden, that is a setup for one of these sorts of problems. And that's where it comes into this preventable, right? It's the number one preventable cause of hospital deaths. The patients who are most at risk are often the ones who can't really move that much. So we have to make sure that the nursing staff and other ancillary staff help the patients move in the bed or move them ourselves so that we can prevent these sort of things from happening.

Host: If someone does get a pulmonary embolism, are they more likely to get another one later on?

Dr. Mangla: Once someone has had a pulmonary embolism, they are unfortunately at increased risk, depending on what the cause was. So, if they had a pulmonary embolism, let's say from immobility during a flight, they have certain treatments, which, we'll talk about briefly, I guess, in a subsequent question, but once we treat them, we hope that those patients have less of a chance of having another one.

However, unfortunately, we found that patients who have one pulmonary embolism tend to have an increased risk for another. That puts you at a much higher risk category for other complications, like deaths, unfortunately.

Host: That was my next and last question, are what treatments are offered to prevent new clots from forming? If there are any.

Dr. Mangla: So, if you get diagnosed with a clot in the legs or a clot in the lungs, the mainstay of therapy has always been blood thinning medicines. There are various different ones that can be used. But generally speaking, you'll be on a blood thinner for about three to six months for a native clot, whether it's in the legs or the lungs.

Unfortunately, those sorts of things have been the mainstay of therapy for a long time. But recently we have had the ability to actually get the clots out of the body. There are some patients who, they'll have a pulmonary embolism and the signs and symptoms of a pulmonary embolism are usually shortness of breath, rapid beating of the heart, they may feel dizzy because blood is not flowing through the heart correctly. They may even faint, and the more symptoms you have, the more likely the patient is not to do well. And so we have different opportunities to intervene, in these higher risk patients.

So one of the things we do here at Jamaica Hospital Medical Center is that we have the ability to actually take the clot out of the lungs directly, basically suck it out almost like with a hose. And patients generally feel better almost immediately. And we're hoping that long-term, they have less sequelae of these problems long-term because not just the acute event. The pulmonary embolism caused the problem in the short term because they can lead to instability of the lungs and death. But unfortunately the clots that form in the lungs, don't always resolve and it can actually lead to longterm higher pressure inside the lungs, what we call pulmonary hypertension.

So there are both short and longterm sequalae of the disease. We're learning more as we go along on how to treat them.

Host: Well, we all have a chance of getting these. So it's good to know, that your awareness and techniques are up to date and hopefully the rest of us will come to increased knowledge as well. And meanwhile, I got some good tips, like stay mobile, keep active, keep that inflammation down. I guess, mostly through diet and exercise. It always comes back to those things, doesn't it?

Dr. Mangla: The chief stuff usually works the best. Right? I mean diet and exercise, can't say it enough honestly. Unfortunately some of these things make sense, but, we have to just really reinforce that. And I just wanted to add one more thing, if I could, if you don't mind, in terms of awareness, people don't often think about this, but there are very active people who have had PEs in recent memory. So Serena Williams, you may remember she had a problem with clotting, and there've been multiple athletes actually who've died of pulmonary embolisms.

This disease is near and dear to me, are, as my hospitals right next to the airport. And we tend to see this a lot. So I'm hoping that this information helps the public and they take better care of themselves.

Host: Yep. I think with conversations like this, we will get there. Thank you, Dr. Mangla.

Dr. Mangla: Thank you, Amanda. I really appreciate you having me on today. Thanks a lot.

Host: For more information or to make an appointment with a cardiologist at Jamaica Hospital, please call 718-206-7100. For more about all the services Jamaica Hospital offers, visit our website at Jamaicahospital.org/podcasts. This has been Jamaica Hospital Med Talk. I'm Amanda Wilde. Stay well.