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Scott Webb: In honor of World Thrombosis Day 2022, I'm joined today by vascular medicine physician, Dr. Andrew Dicks. We're going to discuss the signs, symptoms, and treatment options for thromboses and pulmonary embolisms.

This is Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about thrombosis and blood clots and all things related. So as we get rolling here, what is thrombosis and is there a difference between thrombosis and blood clots?

Dr. Andrew Dicks: The short answer is no. There is no difference between thrombosis and blood clot. A thrombosis is a blood clot. Thrombosis can occur in an artery or a vein, but we often think about thrombosis as occurring more in the veins than in the arteries. And it's essentially where a blood clot forms inside a vein when it shouldn't be there.

Scott Webb: Yeah. And I think most of us can agree including an expert like yourself, we don't want them there. So what causes thrombosis?

Dr. Andrew Dicks: That's a bit of a complicated answer because there's not usually one specific thing that does cause thrombosis or does cause a blood clot. It's often several different factors that weigh in and we kind of categorize those into different groups. One of the main groups is immobility. So we think about patients who have just had surgery, those who have been sick in a hospital bed, those who have been on long car or plane flights and not moving around for extended periods of time that that immobility allows the blood to stagnate, if you will, in the legs. And that can predispose people to get blood clots.

But outside of that, there are a bunch of other things that we know increase the risk of people having blood clots. That can be things such as hypercoaguable disorders, disorders that are often inherited that make the blood just a bit stickier than it should be. Other disorders like cancer, which also increases the stickiness of the blood that makes it more likely to clot. And often, it's a multitude of those different factors that lead to the development of a blood clot.

Scott Webb: What is a pulmonary embolism? I've heard that before, but I'm not sure what it is. And is that a form of thrombosis?

Dr. Andrew Dicks: it is a form of thrombosis and it's a form of thrombosis that we often worry the most about. So pulmonary embolism, if you look at those two words, pulmonary lung embolism meaning a clot that has moved essentially, and so it is a form of a blood clot that, for the vast majority of people, originates in the leg. So a blood clot that forms in the leg and pieces of that blood clot break off or break loose and travel up through the veins of the body, through the heart and land in the lungs. And so, that is something that we as vascular medicine physicians worry the most about when people have blood clots because that can at times be deadly, but for the vast majority of people is not.

Scott Webb: Yeah. And you mentioned some of the causes before, but what are the risk factors for developing thrombosis or a pulmonary embolism, those sorts of things?

Dr. Andrew Dicks: Main risk factors for developing thrombosis really are the kind of immobility category, So surgeries orthopedic injuries, times when you find yourself in a walking boot in a cast, having to use crutches, not being able to move around all that well. Infections can be risk factors. Cancers, as we mentioned before, can be risk factors. Underlying hypercoagulable disorders can be risk factors. There are certain medications that can increase your risk, including birth control medications, certain medications to treat cancer or prevent cancer can be risk factors, as well as one of the bigger risk factors is as a prior history of having a blood clot. If you've had a blood clot at some point in your past, then that sets you up to be at an increased risk of having another blood clot in the future.

Scott Webb: Yeah, I see what you mean. And wondering do you know? Do you feel something? What are the signs of thrombosis?

Dr. Andrew Dicks: Most deep vein thrombosis or DVTs typically begin in the legs. And so for the vast majority of people, they will notice some degree of leg swelling. The severity of the leg swelling depends on how large the clot is and where the clot is actually located in the leg. But often, patients will have some degree of leg swelling as well as some degree of leg discomfort. And that discomfort is often described as an achiness or a crampy kind of sensation or a charlie horse-like sensation. And then depending on where the clot is, if it's more superficial or closer to the skin, people can have some degree of redness or warmth of the skin. But that by no means is necessary for somebody to have a blood clot.

Now, if that clot has moved, if it's no longer in the leg, or if pieces of that blood clot have moved and traveled to the lungs and, again, that's what we call a pulmonary embolism. Those patients typically will have some degree of shortness of breath. And that's probably the most common symptom. And then others will describe some chest discomfort. I typically hear a sharp chest discomfort, typically that's worsened when people take a nice deep breath in or, in certain physicians, patients sometimes find it painful to lie flat or painful to sit upright. But that positional change is often associated with a pulmonary embolism pain.

Scott Webb: Yeah. And it seems like a lot of the signs and symptoms could be one thing. It could be another thing. It could be a hundred things. And so, I'm wondering, do you find that folks put these things off? Like they maybe have some swelling or some of the signs and symptoms you've mentioned here, but they don't rush to see their provider. They don't go to the ER, urgent care. I guess my question, doctor, is when should we do that? When should we seek professional help?

Dr. Andrew Dicks: Yeah, no, it's exactly right. And it's tricky because a lot of the symptoms of a blood clot can mirror other more benign or more dangerous, I suppose, processes. And so, for the most part, I agree that people often put off going to urgent care, going to the ED, or coming to even see myself for several days after developing a blood clot in the leg. And it's tricky because a lot of the symptoms that people have can easily mirror that of a muscle strain or something like that. And I often think to myself, if I were to have these sort of symptoms, at what point would I be rushing off to go get an ultrasound to see if there's a blood clot? And I think it'd pretty reasonable to wait a few days to make sure that the symptoms are improving and, if they're not improving at that point, going to see additional care. Now, if you've had a blood clot before, I think that's threshold to say I should go get evaluated is a lot lower than if you've never had a blood clot. And so, I often tell my patients who have had blood clots before that, if you notice any signs or symptoms that are either similar to what you've experienced before or kind of fall into that category of the symptoms we just talked about, then you should give me a call or go to urgent care, go to the emergency department at a bit sooner than you would otherwise.

Scott Webb: Let's talk a little bit about diagnosis. I'm assuming, you know, being an expert like you are. I'm assuming that it's easier for you to diagnose and/or treat if we catch it while it's still a thrombosis and hasn't become a pulmonary embolism. But in general, how do you diagnose and how do you treat?

Dr. Andrew Dicks: Diagnosis as much as history and physical exam are important, we really need imaging to diagnose thrombosis. So as we discussed earlier, blood clots typically originate in the legs, and so the mainstay of diagnosing blood clots in the legs is with an ultrasound.

Now, if we do have concerns that clot has moved to the lungs, while ultrasound's not that great in the lungs, instead we typically will use CT scans, CAT scans, to diagnose the clot in the lungs. And you're right in the fact that, you know, the goal of treatment is to treat the clot and if we catch it early enough to prevent clot from moving to the lungs.

The good part is that, for the most part, despite where the clot is located, whether that's in the lungs or the leg, we treat it the same way, and that's with use of blood thinner. And for the vast majority of patients with the blood clot, all they need is blood thinner and the blood thinner will typically treat the clot on the order of weeks to months. There are other rare examples when people need something beyond just blood thinner, and that's where I can help guide the patients to figure out if that's something else they need, either stronger medications or procedure to go in and try to take out the clot. But for 95 plus percent of patients, blood thinner is the way to go.

Scott Webb: Wondering as we wrap up here, doctor, you've been really educational, I learned a lot today. I guess, I'm wondering, you know, after treatment, What are the outcomes? What can we expect?

Dr. Andrew Dicks: Yeah, I know, this is another really important question. So, I think there's two parts to this question. One is what do we expect to happen with the blood thinner? And then, the other part is what can we do to prevent more blood clots down the road? And so for the first part, what do we expect the blood thinner to do for the blood clot? The expectation is that with the blood thinner and with our body's own mechanisms, we would expect the blood clot to be slowly broken down over weeks to months, and sometimes that means that when we take another look with an ultrasound, after a few months, the clots completely gone. Sometimes that means that when we take a look with an ultrasound, the clot's been transformed into what we often describe as a scar, but that's what we expect over the treatment period when somebody has a new clot. The blood thinner will work to treat that clot.

And then, the question that often comes down the road is what can we do to prevent more blood clots from occurring? And that really kind of goes back to what risk factors were present when the clot first developed. And often that means that we keep people on some blood thinner at maybe a smaller dose, a low dose, with the goal of making sure that doesn't happen again. And so, it's a little bit of a complicated process of factoring in all the different risk factors that a patient might have and guessing what their risk of having another clot is. And often, you know, involves a nice little discussion with somebody like myself to make sure we have a good plan. But frequently, that does involve keeping people on a small amount of blood thinner long-term.

Scott Webb: Well, as I said, this has been really educational. You mentioned having conversations with patients, my experience with you, doctor, is that would probably go pretty well and be of a benefit to patients. So, thanks so much. You stay well.

Dr. Andrew Dicks: Thank you.

Scott Webb: For more information and other podcasts just like this one, head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Stay well.