Question

Case Scenario: A 40 year old woman has been admitted with possible embolism. Her symptoms are chest pain, right leg temperature warmer than left, delivery of a baby by Csection 3 weeks ago, and fatigue and shortness of breath.

Question: What are the long term consequences of an untreated embolus? Include in your answer specific facts, data, examples, and other information drawn from your textbook and at least one other supplemental source.

Answer 1

A pulmonary embolism may dissolve on its own; it is seldom fatal when diagnosed and treated properly. However, if left untreated, it can be serious, leading to other medical complications, including death. A pulmonary embolism can: Cause heart damage.After the high-risk period has elapsed (roughly one week), blood clots in your lung will need months or years to completely resolve. You may develop pulmonary hypertension with life-long implications, including shortness of breath and exercise intolerance.Blood clots can wreak havoc on your veins, leading to symptoms that can last for years.

pulmonary embolism is a blood clot in the lung that occurs when a clot in another part of the body (often the leg or arm) moves through the bloodstream and becomes lodged in the blood vessels of the lung. This restricts blood flow to the lungs, lowers oxygen levels in the lungs and increases blood pressure in the pulmonary arteries.If a clot develops in a vein and it stays there, it’s called a thrombus. If the clot detaches from the wall of the vein and travels to another part of your body, it’s called an embolus.

People at risk for developing a blood clot are those who:

• Have been inactive or immobile for long periods of time due to bed rest or surgery.
• Have a personal or family history of a blood clotting disorder, such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Have a history of cancer or are receiving chemotherapy.
• Sit for prolonged periods.

People at risk for developing a pulmonary embolism include those who:

• Are inactive for long periods of time while traveling via motor vehicle, train or plane.
• Have a history of heart failure or stroke.
• Are overweight or obese.
• Have recently had trauma or injury to a vein, possibly after a recent surgery, fracture or due to varicose veins.
• Are pregnant or have given birth in the previous 6 weeks.
• Are taking birth control pills (oral contraceptives) or hormone replacement therapy.
• Placement of central venous catheters through the arm or leg If you have any of these risk factors and you have had a blood clot, please talk with your health care provider so steps can be taken to reduce your personal risk.

How serious is a pulmonary embolism

A pulmonary embolism may dissolve on its own; it is seldom fatal when diagnosed and treated properly. However, if left untreated, it can be serious, leading to other medical complications, including death. A pulmonary embolism can:

• Cause heart damage.
• Be life-threatening, depending on the size of the clot

What causes pulmonary embolism?

Pulmonary embolism may occur:

• When blood collects (or “pools”) in a certain part of the body (usually an arm or leg). Pooling of blood usually occurs after long periods of inactivity, such as after surgery or bed rest.
• When veins have been injured, such as from a fracture or surgery (especially in the pelvis, hip, knee or leg).
• As a result of another medical condition, such as cardiovascular disease (including congestive heart failure, atrial fibrillation and heart attack) or stroke.
• When clotting factors in the blood are increased, elevated, or in some cases, lowered. Elevated clotting factors can occur with some types of cancer or in some women taking hormone replacement therapy or birth control pills. Abnormal or low clotting factors may also occur as a result of hereditary conditions.

How is a pulmonary embolism detected?

Pulmonary embolism is commonly detected through the following tests:

• Computed tomography (CT) scan.
• Lung scan.
• Blood tests (including the D-dimer test).
• Pulmonary angiogram.
• Ultrasound of the leg -- helps to identify blood clots in patients who cannot have an X-ray due to dye allergies or who are too sick to leave their hospital room.
• Magnetic resonance imaging (MRI) of the legs or lungs.

How is pulmonary embolism treated?

Treatment for pulmonary embolism is typically provided in a hospital, where your condition can be closely monitored.

The length of your treatment and hospital stay will vary, depending on the severity of the clot.

Depending on your medical condition, treatment options may include anticoagulant (blood-thinner) medications, thrombolytic therapy, compression stockings, and sometimes surgery or interventional procedures to improve blood flow and reduce the risk of future blood clots.

Anticoagulant medications

In most cases, treatment consists of anti- coagulant medications (also called blood thinners). Anticoagulants decrease the blood’s ability to clot and prevent future blood clots.

Anticoagulant medications include warfarin (Coumadin®), heparin, low-molecular weight heparin (such as Lovenox® or Dalteparin®) and fondaparinux (Arixtra®).

• Warfarin comes in tablet form and is taken orally (by mouth).
• Heparin is a liquid medication and is given either through an intravenous (IV) line that delivers medication directly into the vein, or by subcutaneous (under the skin) injections given in the hospital.
• Low molecular-weight heparin is injected beneath or under the skin (subcutaneously). It is given once or twice a day and can be taken at home.
• Fondaparinux (Arixtra) is a new medication that is injected subcutaneously, once a day.

You and your family will receive more information about how to take the anticoagulant medication that is prescribed. As with any medication, it’s important that you understand how and when to take your anticoagulant and to follow your doctor’s guidelines.

The type of medication you were prescribed, how long you need to take it, and the type of follow-up monitoring you’ll need depends on your diagnosis. Be sure to keep all scheduled follow-up appointments with your doctor and the laboratory so your response to the medication can be monitored closely.

While taking anticoagulants, your follow-up will include frequent blood tests, such as:

• PT-INR: The Prothrombin time (PT or protime)/ International Normalized Ratio (INR) test: Your INR will help your health care provider determine how fast your blood is clotting and whether your medication dose needs to be changed. This test is used to monitor your condition if you are taking Coumadin.
• Activated partial thromboplastin (aPTT): Measures the time it takes blood to clot. This test is used to monitor your condition if you are taking heparin.
• Anti-Xa or Heparin assay: Measures the level of low molecular-weight heparin in the blood. It is usually not necessary to use this test unless you are overweight, have kidney disease or are pregnant.

What are other treatment options?

Compression stockings

Compression stockings (support hose) aid blood flow in the legs and should be used as prescribed by your doctor. The stockings are usually knee- high length and compress your legs to prevent the pooling of blood.

Talk with your doctor about how to use your compression stockings, for how long, and how to care for them. It is important to launder compression stockings according to directions to prevent damaging them.

Procedures

If a pulmonary embolism is life-threatening, or if other treatments aren’t effective, your doctor may recommend:

• Surgery to remove the embolus from the pulmonary artery.
• An interventional procedure in which a filter is placed inside the body’s largest vein (vena cava filter) so clots can be trapped before they enter the lungs.

Thrombolytic therapy

Thrombolytic medications (“clot busters”), including tissue plasminogen activator (TPA), are used to dissolve the clot. Thrombolytics are always given in a hospital where the patient can be closely monitored. These medications are used in special situations, such as if the patient’s blood pressure is low or if the patient’s condition is unstable due to the pulmonary embolism.

Almost half of people who get a DVT may end up with post-thrombotic syndrome. That’s where swelling, pain, or skin color changes last much longer. You also may get sores called ulcers.About 4 in 100 people with a pulmonary embolism have long-term lung damage known as pulmonary hypertension. This means you have high blood pressure in your lungs, which can lead to issues like shortness of breath, tiredness, and chest pain.

Around 2% to 4% of patients with PE will have chronic damage to the lungs known as pulmonary hypertension (chronic thromboembolic pulmonary hypertension), which is characterized by shortness of breath and decreased exercise ability. Pulmonary hypertension can lead to heart failure if untreated.A pulmonary embolism can be life-threatening or cause permanent damage to the lungs. The severity of symptoms depends on the size of the embolism, number of emboli, and a person's baseline heart and lung function. Approximately half of patients who have a pulmonary embolism have no symptoms.

That's another term for high blood pressure in the arteries in your lungs. A PE also causes pressure in the right side of your heart to increase. This means your heart's right side works harder than it should. Over time, the result is heart failure, a weakening of the heart's pumping ability.

Pulmonary embolism has a higher mortality rate than deep venous thrombosis. Patients with pulmonary embolism have no higher risk of recurrence, but any recurrence is more likely to be a new pulmonary embolism than a deep venous thrombosis. A significant number of patients develop persistent perfusion defects after pulmonary embolism.