Doctors Offer 1st Patient Care Guidelines for Challenging Blood Clots

Rochester expert gives advice to physicians caring for patients at high risk of death

March 21, 2011

Pulmonologists, hematologists, cardiologists and vascular surgeons have come together with the American Heart Association today to publish the first guidelines for treatment of unusual but life-threatening venous thromboembolism (blood clots) and the related complication of pulmonary hypertension. 

“These best practices will help doctors when they encounter patients with life-threatening ailments that account for more than a quarter-million hospitalizations each year,” according to   R. James White, M.D., Ph.D., pulmonary hypertension expert at the University of Rochester Medical Center and a contributing author of the guidelines. “Up until now, we haven’t had consensus recommendations for the treatment of some of these disorders and as a result, care has been highly controversial and probably sub-optimal for many patients.”

The AHA today issued a scientific statement for treatment of large pulmonary embolism, deep vein thrombosis, and chronic thromboembolic pulmonary hypertension. White serves on the AHA’s Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, one of two American Heart Association councils that wrote the recommendations after reviewing scientific data. The new guidelines are available on the AHA website and were featured today in its flagship journal, Circulation: Journal of the American Heart Association.

Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, sometimes deadly disorder that is often overlooked. Doctors treat the condition by using blood thinners, such as low molecular weight heparins.  However, in about 10 percent of the cases, blood thinners aren’t effective, usually because of the size of the clot. These cases of DVT and PE put patients at high risk for death and can result in long-term complications including post-thrombotic syndrome (a painful condition of the legs with chronic sores) and chronic thromboembolic pulmonary hypertension (a fatal condition of the lung blood vessels).

“We all agree on how to treat common clots that are small and the very large ones. It’s the ones in between, the medium-to large sized embolisms, over which pulmonary doctors lose much sleep,” White said. “These guidelines review the current data and offer support for clinicians to use clot-busting drugs, like alteplase, for patients who appear well at the moment but have a high risk of dying during their initial week in the hospital. Moreover, for about 5 percent of patients with PE, the initial clot progresses to cause widespread scarring in the lung blood vessels; one of our goals in writing these guidelines was to highlight the problem of chronic thromboembolic pulmonary hypertension and point frontline physicians to the national centers where patients could get the care they need.”

A patient with these medium-to-large clots typically gets the benefit of a multidisciplinary team of specialists in cardiology, pulmonology and hematology working together to develop the optimal treatment plan, weighing the risks and benefits of aggressive treatment with clot-busters. 

“In these cases, there are lots of cooks in the kitchen because, so far, we haven’t got the right recipe to care for these high-risk patients. This document provides the closest thing to a recipe that we will have until ongoing research is completed,” said White, assistant professor of Medicine.

White leads a specialized program for pulmonary hypertension at the University of Rochester Medical Center offering state-of-the-art care and opportunities to participate in clinical trials of new agents and therapies. The program serves people across Upstate New York and northern and western Pennsylvania.

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Leslie White
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