Although thrombosis or blood clot in the deep veins of the body is treatable, experts say it is the most common cause of preventable hospital deaths, reports Associate Editor ADEKUNLE YUSUF
THROUGHOUT her husband’s service years, which entailed active involvement in local and foreign military operations, Mrs Lizzy Payok admitted that the fear of losing her sweetheart constantly reduced her to an emotional wreck. “I was daily worried about dangers and hazards of warfare,” she said. But it was not an ambush bullet, bombing or landmine that took her husband’s life ten years ago. Rather, it was a blood clot in Mr. Payok’s leg that was left to fester, which ultimately travelled to his lungs and killed him and his blossoming military career.
Unlike the gallant soldier who succumbed to pulmonary embolism (a blood clot that breaks off and travels to the lungs), Eniola Adunni, a teacher, still lives to tell her story. In August 2016, Adunni, 35, was overjoyed after delivering a bouncing baby boy – her first. It was a pretty easy delivery, with everything appearing perfect until things almost turned haywire. As is the practice in the private hospital she patronized, she and the newborn were placed on observation for a few days before they were discharged. However, just before going home with her bundle of joy, she felt a Charley horse in her left leg and reported to the nurse on duty, who assured her that it was not a big deal.
To be doubly sure, a day after she was discharged, Adunni said she called her doctor to intimate him of her condition. Not a person that leaves things to chances, she reported for a medical check-up immediately. Like the nurse, the doctor also allayed her fears, assuring her all was well. Yet the pain progressed from minor to an excruciating level. Days after, when the pain refused to abate, she had to return to the hospital – this time a better one. Tests later showed that there was a blood clot in her leg. She was admitted to the hospital with a week-old baby in tow. In a nice twist of fate, she survived the treatment, having been diagnosed as suffering from a pulmonary embolism brought on by blood clot formations in the veins of her leg. Many are not that lucky, as haematologists insist a blood clot left untreated can lead to serious complications, including death.
Deep vein thrombosis explained
According to Prof. Sulaimon Akanmu of the Lagos University Teaching Hospital (LUTH), deep vein thrombosis (DVT) is a condition caused by the formation of potentially deadly clots or blood that has turned into solid form within the blood vessels. When the blood clot forms in the vein, part or whole of the clot can detach and travel in the circulation to lodge in the lungs, causing a condition referred to as pulmonary embolism (PE). Both DVT and PE are collectively referred to as venous thromboembolism (VTE). The risk factors for developing VTE are many and varied. High-risk factors include hospitalisation, with up to 60 per cent of all VTEs are hospital-associated. This also includes hip and knee surgery and estrogen-based therapy. While moderate risk factors are age (60+), personal or family history of blood clots, cancer/chemotherapy and estrogen-based therapy, its other factors include obesity, pregnancy or recent birth, smoking and alcohol consumption.
Arteries have thin muscles within their walls to be able to withstand the pressure of the heart pumping blood to the far reaches of the body. Veins don’t have a significant muscle lining, and there is nothing pumping blood back to the heart except physiology. Blood returns to the heart because the body’s large muscles squeeze the veins as they contract in their normal activity of moving the body. The normal activities of moving the body return the blood to the heart. Being mobile causes this blood return system to fail, and the resulting stagnated blood may clot.
There are two types of veins in the arm or leg; superficial veins and deep veins. Superficial veins lie just below the skin and are easily seen on the surface. Deep veins, as their name implies, are located deep within the muscles of the extremity. Blood flows from the superficial veins into the deep venous system through small perforator veins. Superficial and perforator veins have one-way valves within them that allow blood to flow only in the direction of the heart when the veins are squeezed.
There are both superficial and deep veins in the limbs or extremities (arms and legs). A blood clot in the deep veins is a concern because it can cause life-threatening complications. A blood clot (thrombus) in the deep venous system of the leg becomes dangerous if a piece of the blood clot breaks off or travels through the bloodstream, through the heart, and into the pulmonary arteries forming a pulmonary embolism. A person may not have signs or symptoms of a small pulmonary embolism (blood clot in the lungs), but a large embolism can be fatal. Risk factors for blood clot formation include immobility, a genetic tendency toward blood clotting, and injury to veins or adjacent tissues occurs. For DVT or blood clot in the leg, symptoms include pain, swelling, warmth, tenderness and redness of the leg or arm. Doctors diagnose the condition is with blood tests, and then is confirmed by ultrasound or other imaging tests.
According to experts, a blood clot (thrombus) in the deep venous system of the leg or arm, in itself, is not dangerous. However, it can become potentially life-threatening when a piece of the blood clot breaks off and embolises and travels through the circulation system through the heart, and enters into one of the pulmonary arteries and becomes lodged. This can prevent blood from flowing properly through the lung and decreasing the amount of oxygen absorbed and distributed back to the body.
Blood is supposed to be fluid. But if circulation becomes sluggish, which can happen to anybody after sitting for hours without moving, doctors explain that a gel-like clot can form inside the veins. If a blood clot develops in a deep vein, usually in the legs, it’s known in the medical parlance as DVT. If the DVT blood clot breaks off and travels up to the lungs, it becomes a pulmonary embolism (PE). While DVT and PE are the same diseases, their symptoms are different because the blood clots are in different locations in the body, explained Prof Akanmu. By itself, a DVT is not life-threatening. But a PE can be. It can clog an artery in the lung, robbing the body of much-needed oxygenated blood. Between 20 to 30 per cent of people with a DVT will develop a PE, he said, adding that most people with PE will survive if they access medical treatment immediately.
Why is VTE important
According to the Nigerian Society of Haematology and Blood Transfusion (NSHBT), VTE, which the body said its prevalence is increasing in Nigeria, is important because of its high rate of morbidity and mortality. It is also important to know about DVT because it can happen to anybody and can cause serious illness, disability, and in some cases, death. The good news is that DVT is preventable and treatable if discovered early.
In a communiqué signed by Prof Aisha Gwarzo and Dr. AbdulAzizz Hassan, president and secretary of NSHBT president, respectively, VTE is said to be sometimes “asymptomatic, misdiagnosed, unrecognized and untreated or undertreated.”
“VTE is a potentially deadly condition because the symptoms are not specific. Some of the symptoms, which include pain, leg swelling, warmth, discolouration of the leg for DVT and shortness of breath, chest pain, rapid breathing and lightheadedness for PE can be mimicked by several other medical conditions.
“It is relatively common with an incidence of one in one thousand in older adults. The prevalence has been reported to be increasing in Nigeria. Up to 14.9 per cent of patients admitted to medical service and up to 40 per cent admitted to surgical service will have VTE without appropriate prophylaxis. The danger of VTE lies in its silent nature and has been reported to be the most common cause of preventable hospital death. VTE is potentially fatal but highly preventable. The good news about VTE is that most of the cases are preventable,” NSHBT said.
Akanmu, a professor of haematology and blood transfusion and former president of NSHBT, said no fewer than 50 per cent of patients on admission in Nigerian hospitals may develop DVT. VTE kills mostly before needed specialised medical intervention is obtained, he said during a press conference organized by Sanofi, a multinational pharmaceutical company, to mark the 2019 World Thrombosis Day.
Although the actual statistics on DVT-induced deaths in Nigeria is not known, thrombosis is responsible for 370,000 deaths in Europe, far higher than the number of deaths from AIDS, breast cancer, prostate cancer and traffic accidents combined. It is estimated that thrombosis is responsible for 1 in 4 deaths worldwide and remains a leading cause of mortality in the world. Prof. Akanmu cited a research study in 32 countries showing that 50 per cent of patients admitted in surgical wards and 30 per cent of those admitted in medical wards had thrombosis risk.
A similar study conducted in 14 African countries, including Nigeria, also revealed the same result. However, less than 20 per cent of the African patients had a diagnosis of thrombosis risk while only a fraction of them received correct thrombosis prophylaxis. According to him, thrombosis is more common among patients in the hospital than individuals at home. Thus, if an individual in the hospital is evaluated and found to be at risk as high as 40 per cent, such a person is most “hundred per cent likely” to develop thrombosis before he leaves the hospital. “This is why we say when anyone is on admission bed, please let them be subjected to thrombosis risk,” he stressed.
Even in the United States, the precise number of people affected by DVT/PE is said to be unknown, although as many as 900,000 people could be affected, resulting in about 100,000 premature deaths every year. This translates into 1 to 2 per 1,000 each year in the US. Available estimates suggest that as high as 60,000-100,000 Americans die of DVT/PE yearly, with reports suggesting that 10 to 30 per cent of people will die within one month of diagnosis. Sudden death is the first symptom in about one-quarter of people who have a PE, with experts predicting that one-half of people who have has a DVT will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discolouration, and scaling in the affected limb.
DVT management and treatment
DVT can cause pain, swelling, and redness or purple discolouration of the skin in an armour, most commonly, the legs. PE can cause chest pain and shortness of breath, which may lead to coughing up blood or fainting. Doctors said the risk of DVT and PE increases in people who sit for long periods without moving, such as on lengthy car trips or long-haul flights. To prevent a first or subsequent DVT and PE experience, wearing compression stockings on long car rides and flights are advised. If possible, alcohol consumption should be avoided, while drinking plenty of fluids, such as water, can play the role of dehydration in travel-related DVT events. During long-hour flights, travellers are also enjoined get up from their seat as much as possible or make frequent stops if driving on a long journey, at least every two to three hours.
If detected and reported early, DVT can be easily managed or treated, haematologists said. Essentially, its treatment is aimed at disallowing the clot from getting bigger and preventing it from breaking loose, thus stopping DVT from snowballing into a pulmonary embolism, which is more life-threatening. The most common treatment employs the use of blood thinners or anticoagulants. Either when injected or taken as pills, these are drugs that reduce a person’s blood’s ability to clot. Although anticoagulants don’t break up existing blood clots, they can prevent clots from getting bigger, thus lowering a person’s risk of developing more clots.
In cases involving a more serious DVT or pulmonary embolism, clot busters or thrombolytics are also used because they break up the clots quickly. Clot busters are either administered intravenously to break up blood clots or through a catheter placed directly into the clot, but they are generally reserved for severe cases of blood clots because of side effects. For those not willing to take medicines to thin their blood, hope lies in the use of a filter, which can be inserted into the vena cava or a large vein in the abdomen. With the help of a vena cava filter, clots that break loose can be prevented from lodging in the lungs.
Dearth of haematological experts
As preventable VTE is, it is not easily recognizable by non-specialist doctors. This why Prof. Akanmu lamented that the dearth of specialists and equipment for the management of thrombosis in Nigeria is contributing to the crisis. According to him, most cases of thrombosis in Nigeria are often detected during post-mortem. To buttress this, he revealed that the few available figures on thrombosis in the country are obtained through post mortem studies.
However, Sanofi, a multinational pharmaceutical company, has stepped into the fray by raising awareness campaigns and training all categories of medical personnel so that all hospital workers in the country are skilled in the diagnosis and management of VTE. According to Folake Odediran, general manager, Nigeria-Ghana Sanofi, the company has embarked on a massive awareness campaign to address VTE challenge as part of the company’s community social responsibility (CSR). She disclosed that the process has been integrated into the company’s business strategy to better meet patients’ needs. The company, she further said, is focusing on capacity building and partnership with healthcare associations to drive awareness on VTE.
She added that Sanofi was launching its ‘VTE Safe Zone programme’ in major health institutions across the country to help improve the care of hospitalised patients and reduce their risk of a VTE.
“The programme is focused on educational programmes for doctors, pharmacists and nurses, development of VTE risk assessment tools and setting up of institutional thrombosis committees. This project has been successfully implemented in UCH Ibadan and is in the pilot phases in UNTH Enugu, UBTH Benin and AKTH, Kano. We have also partnered with healthcare associations like the NSHBT to disseminate the first-ever VTE guidelines to guide healthcare practitioners on management and prevention of VTE,” Odediran said.
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