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Bill Klaproth (Host):  This is Bill Klaproth in for Melanie Cole.  A pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs. Could this happen to you? Dr. Aditya Sharma is the Director of the Vascular Medicine program at UVA Health Systems and is here to talk with us today. Dr. Sharma, thanks so much for joining us today. How does a pulmonary embolism develop?

Dr. Aditya Sharma (Guest):  Thank you very much. So, pulmonary embolism is basically a blockage of the blood vessels in the lungs where, typically, the blockage occurs from blood clots that usually form in the blood vessels in the legs and then go up to the lungs. So, how does it occur? Through many different means. One of the things is that it typically occurs after surgery or in someone that has been immobilized for a long period of time and that immobilization can be because they just drove 6-8 hours straight in the car or because they broke their ankle and now they cannot move for some reason or the other. When these things happen, usually, the blood tends to be stagnant for a long period of time in the legs and that causes a clot to form there which then breaks off and goes to the lung. The other ways it can happen is that some people just have some kind of blood clotting disorder which can be genetic and, in some situations, if somebody has cancer, cancer can make the blood a lot more clottable or hypercoagulable and these people also can develop blood clots. Those are the more common ways of getting blood clots.

Bill:  So, a pulmonary embolism isn’t necessarily age-specific. This can happen to young people and old people alike?

Dr. Sharma:  That’s a good question. Very interesting question. No, actually there is a difference and typically pulmonary embolism is more likely to occur in older people than younger people. If it happens in a young person, we will look for blood-clotting disorders more frequently. One of the reasons behind why older people are more likely to get pulmonary embolism more is from the fact that the inside of the blood vessels, which is the [inaudible 02:43] after years and years of being exposed to irritants such as smoke and so on, can actually become damaged. I think that’s one of the reasons why they are more at risk of getting blood clots.

Bill:  When you say “inactivity”, it’s basically sitting, right? It’s sitting for long periods of time. We hear about people on airplanes and really long flights of this happening, too. So, it’s basically in a sitting position? Not laying down?

Dr. Sharma:  Yes. So, it can be either way. It can be in a sitting position or lying down also. It’s any position in which you’re not using your calf muscles for a long duration of time. This typically tends to be 6 hours or greater, although sometimes people can have it sooner also. Typically, it’s 6 hours or so. Often you’ll hear the case of pulmonary embolisms typically occurring in somebody who takes a trans-Atlantic flight and immediately after the flight is over, their legs are swollen and then they may break a blood clot from their legs which goes into their lungs and causes the pulmonary embolism. But, often, it could be also somebody who has broken their ankle or just had a major surgery and has been lying in bed for hours and hours. Typically, they tend to get blood clots in the legs which can break off and go to the lungs, too.

Bill:  So, how do you know if you have one? Do you get like a pain in the chest or do you feel the blood clot traveling? Are their common symptoms that somebody should be watching out for?

Dr. Sharma:  Yes. Typical symptoms that help people recognize that they may have a blood clot in the lung are:  chest pain which will be, usually, sudden onset of chest pain; sometimes it might just be severe chest heaviness; it could be shortness of breath. A lot of times, it’s just severe palpitations. Those would be the typical symptoms. Another thing to look out for is a lot of these people will have sudden onset of swelling in the legs as the blood clot will typically form varicose before it goes to the lungs.

Bill:  Would there be any pain at all in the legs if a blood clot was forming?

Dr. Sharma:  Yes. If the swelling is severe, a lot of times people will have pain in the legs, too, but it’s not there always. So, the absence of it does not always rule out pulmonary embolism or a blood clot in the leg.

Bill:  So, this is a serious thing. You can die from this, right?

Dr. Sharma:  Yes, it’s true. In fact, it’s considered to be, actually, the 4^th leading cause of cardiovascular death in most developed nations and, in fact, pulmonary embolism is thought to be the most leading cause of death in the hospital. So, certainly, it’s a major big problem. It’s a major concern worldwide right now.

Bill:  Wow. I did not know that. Is there any way to prevent this at all? Exercise as you grow older? Exercise? Diet? Does anything help prevent this from happening?

Dr. Sharma:  Certainly, so one of the things, in talking about prevention, that the patient can do for themselves or we can do for ourselves is to make sure that we delay the damage within the blood vessels, the endothelial damage. That, typically, can be delayed by not smoking. Smoking, typically, tends to cause that damage and I think, overall, puts people at risk of getting pulmonary embolism in the long run. The other thing that we always advise is that if you are taking a long flight or if you’re driving a long distance, always stop every couple of hours, get out, walk a little bit, flex your calves and then sit back and continue with your flight or your drive. Those are the things we typically suggest. During surgery, now most major centers have standard protocols where we have devices called “sequential compression devices” which constantly pump blood in the leg immediately after surgery and even sometimes during surgery. We tend to give them low-dose blood thinners while they are in the hospital to help them avoid getting blood clots, too.

Bill:  If you do develop a pulmonary embolism, what is the treatment for it if it’s caught in time?

Dr. Sharma:  If a pulmonary embolism is caught in time, the most commonly used treatment is blood thinners. We used to have just one blood thinner for many years—almost for the last 50 years, we had only one blood thinner called Warfarin but now, we actually have 4 new blood thinners on the market that we can use, all of which are FDA approved for the treatment of pulmonary embolisms. So, it’s definitely that we have a lot of advances when it comes to that. Beyond that, it depends upon how bad the pulmonary embolism is but, often, at a big center as the University of Virginia, when we have somebody with sort of a high-risk pulmonary embolism as in the blood clot burden is so much that it’s causing stress on the heart and we are worried that this could cause death in the near time, we often will have a multidisciplinary discussion of such patients between the cardiovascular medicine group, interventional radiology group as well as the cardiovascular surgery group and discuss what would be the best option, whether just treating them with blood thinners is fine or should we go in and suck the clot out—a thrombectomy—or break down the clot with lytic agents or actually to open surgery and remove the clots. Often, it’s a fairly complicated solution for the patient and that is something we achieve through more of a multi-disciplinary approach.

Bill:  So, with treatment you’re generally able to get rid of the clot?

Dr. Sharma:  If we just use the standard treatment which is blood thinner therapy, over 30% of the time the clot will go away. About 30% of the time, half of the clot goes away. The role of blood thinners is not to take the clot out, but just to keep the blood thin enough so new clots don’t form and, in that period of time, the body actually takes down the clots on its’ own. That’s one of the reasons why, when we have patients with too much blood clot that’s causing stress on their heart, we will often think about going in and actually sucking the clot out with sort of devices or actually doing open surgery and removing the clot.

Bill:  What is the general prognosis, then, for recurrence if you are unfortunate enough to develop one of these?

Dr. Sharma:  The likelihood of recurrence depends a lot on under what conditions a person gets a blood clot. If there’s somebody who had a blood clot after major surgery or had a severe  fracture and they couldn’t move their leg for a long period of time and then they get those blood clots, their chances of having another blood clot is very low in the long term. It could be less than 10% in their entire lifetime because people usually have a reason why they developed the blood clot. Clearly, they couldn’t move their leg for a long period of time and ended up getting a blood clot in the leg which went to the lung. On the other hand, we will have people who just suddenly get a blood clot because they may have a genetically predisposed condition to get blood clots or it could be that we don’t even find anything genetic and then they just suddenly got a blood clot for no clear reason at all. In those people, the risk of getting another blood clot is very high and it can be, sometimes, up to 30% in the next 10 years of their life. So, typically, for those people, we tend to keep them on blood thinners for the rest of their lives to avoid getting another blood clot.

Bill:  Why should patients come to UVA for their vascular health needs?

Dr. Sharma:  One of the things that we do at UVA in a very nice way is we have a very collaborative environment when it comes to vascular care. Vascular care can be provided by vascular surgery; it can be provided by cardiovascular medicine; it can be provided by even vascular interventional radiologists. Often, all of these groups provide a certain amount of care. At UVA, we all actually work together to provide what could be possibly the best care that we could give for our patients with vascular disease. That’s what I think is one of the positive things about being at UVA because you have the top level surgeons; you have the best interventional radiologists you could potentially find in the country. So, we have all the skill sets, all the techniques and all of us actually come together and decide what would be optimal and treat patients that way. So, that’s why I think it’s one of the best places to get vascular care in the country.

Bill:  Well, Dr. Sharma, thank you so much for your wonderful work and thanks for being on with us today. For more information, you can go to UVAHealth.com. That’s UVAHealth.com. This is UVA Health Systems Radio. Thanks for listening.