03-22-2024 Your Prescriptions

Blood Clots and How to Treat Them

Blood Clots and How to Treat Them | America’s Pharmacy

By Jillian Foglesong Stabile, MD

For many people, the idea of a blood clot is terrifying. When you hear blood clot, your mind may go to the worst-case scenario. Of the many types of blood clots, not all will need treatment with medication. Sometimes medication for more serious blood clots is only needed short-term, while other times, it may be needed for the rest of your life. How do you know when you need treatment?

Blood clots can be generally divided into two categories. Superficial blood clots and deep blood clots.

Superficial blood clots

Superficial blood clots are also called thrombophlebitis. Thrombophlebitis is a blood clot in the superficial veins that causes swelling and inflammation. The most common place for these blood clots to occur are in the arms or legs. In the past, healthcare providers were not concerned with long-term complications from superficial blood clots, but they are increasingly being viewed as a less benign condition.

Symptoms of superficial blood clots

Superficial blood clots are usually very painful. Symptoms include pain, warmth, a hard cord under the surface of the skin, swelling, and redness. Itching may also be present.

Who gets superficial blood clots?

Superficial blood clots may be the result of injury to the vein or the result of other underlying health problems. Some of the risk factors for superficial blood clots include:

  • Recent intravenous catheter or blood draw
  • Age greater than 60 years
  • Pregnant or recently giving birth
  • Recent surgery
  • Cancer
  • Heart failure
  • Respiratory failure
  • Obesity
  • Varicose veins or other venous problems
  • Smoking
  • Prolonged inactivity such as travel or being confined to bed
  • Family history of clotting disorders
  • Previous episode of blood clots
  • History of stroke

If you have these risk factors, it is reasonable to talk to your healthcare provider about ways to prevent blood clots.

Complications of superficial blood clots

One of the reasons that healthcare providers are more concerned about superficial blood clots is the potential complications. Deep blood clots are one of the more serious potential complications associated with superficial blood clots. Deep blood clots are seen in between 6 and 36% of people with superficial clots. Other complications include:

  • Hyperpigmentation of the skin over the affected area
  • Long-term firm nodule in the skin
  • Infection of the blood clot

If the blood clot becomes infected, it can lead to abscess formation, bloodstream infection, sepsis resulting in the failure of multiple body systems, and septic emboli (breaking off infected clots that move to other parts of the body).

Diagnosis of superficial blood clots

Generally, the diagnosis of superficial blood clots is made by history and physical exam. If there is no history of trauma or easily identifiable cause of the blood clots, then laboratory or imaging studies may be used to further evaluate for other causes. Some of the reasons that additional testing may be indicated include:

  • Unexplained clots in non-varicose veins
  • Progression of blood clots despite adequate treatment
  • Blood clots in people under 40-50 years of age
  • Recurrent clots
  • Clots in unusual sites
  • Unexplained clots in newborns
  • Breakdown of the skin associated with clots
  • Clots in arteries before 30 years of age
  • Having a family history of blood clots
  • Unexplained abnormalities in certain types of lab tests
  • Recurrent pregnancy loss
  • Lupus
  • Immune thrombocytopenic purpura

Lab tests may look for certain genetic conditions that can cause a hypercoagulable state. Some of these include factor V Leiden, prothrombin mutations, protein C and S deficiencies, anti-phospholipid antibody syndrome, and many more.

Imaging studies may include ultrasound. If there is a concern for deep blood clots, then ultrasound or a CT scan to evaluate the lungs for blood clots may be necessary.

Treatment of superficial blood clots

Whether or not to treat superficial blood clots depends on the cause of the clot, the extent of the clot, and the severity of the symptoms.

For small, superficial, mildly painful blood clots that occur in a varicose vein, mild pain relievers can be used. Medications such as ibuprofen or aspirin are frequently recommended. Generally, some type of gentle compression such as compression socks is recommended as well.

For larger or more painful clots, warm compresses may add additional benefit beyond the treatments used for smaller clots.

If the blood clots extend to the deep venous systems, or if other risk factors for progression to deep blood clots are present, then more aggressive treatment may be indicated. Low-dose molecular weight heparin such as enoxaparin or dalteparin are used in some cases to help treat the symptoms and decrease the risk of complications. Fondaparinux is another medication that has been shown to decrease the risk of progression to deep blood clots when superficial clots are present. Treatment is generally for 45 days.

Deep blood clots

Deep blood clots are also called venous thromboembolisms. The two most common forms of venous thromboembolism are deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT and PE are potentially dangerous conditions that can result in long-term health complications and sometimes even death. The risk of death is greatest in the first three to six months after the clot is diagnosed.

Symptoms of deep blood clots

Deep blood clots show symptoms based on where the clots are located. DVTs can occur in the upper or lower extremities. DVTs are associated with swelling in the affected extremity, usually only on one side because the clot is generally on only one side. The swelling causes pain and red discoloration skin. Leg DVTs are usually associated with a positive Homan’s sign, which is pain with dorsiflexion of the foot, or bending it back. PE can cause chest pain, shortness of breath, wheezing, and cough. DVT frequently occurs with PE, so symptoms of DVT may be present. In severe cases, PE can present with coughing up blood or sudden death.

Who gets deep blood clots?

The risk factors for deep blood clots are similar to the risk factors associated with superficial blood clots. Trauma (including surgery), pregnancy, cancer, certain medications, prolonged immobilization, kidney disease, cardiovascular disease, smoking, age, obesity, and genetic thromboembolic diseases are all risk factors for getting blood clots. Inflammatory bowel disease also increases the risk. The risk of deep blood clots is also associated with infection with the SARS-CoV-2 virus (aka COVID-19).

Diagnosis of deep blood clots

Several tests can evaluate for deep blood clots.

Labs for deep blood clots

d-dimer is a blood test that looks for a protein produced by blood clots. It can also be seen in other conditions, so it is more useful for ruling out blood clots than diagnosing them. It is very rare for the d-dimer to be negative in the presence of a DVT or pulmonary embolism.

Other blood tests are usually used to detect either the complications associated with blood clots or conditions that put you at increased risk of developing blood clots.

Imaging studies for deep blood clots

Duplex ultrasound is the most commonly used test for evaluating deep blood clots in the extremities. Magnetic resonance imaging (MRI) may be used to look for blood clots in the veins of the belly and pelvis. CT scans with dye are used to look for pulmonary embolism. In some situations, a test called a ventilation/perfusion scan, or VQ scan, may be used to evaluate for PE.

Complications of deep blood clots

Deep blood clots can lead to serious complications. Untreated, the clots can block blood flow to vital organs and cause damage to those organs or cell death. Pulmonary embolisms can result in strain on the right side of the heart due to increased pressure in the lungs. This can result in pulmonary hypertension. Post-thrombotic syndrome can cause chronic pain, heaviness of the extremity, cramping, hyperpigmentation, long-term swelling, and ulceration of the overlying skin.

Treatment of deep blood clots

Deep blood clots are generally treated with 2 classes of medications. Anticoagulants thin the blood, and thrombolytic agents work to try to dissolve the clot. Surgical procedures may also be used to remove the clots or prevent them from spreading to other areas.

Anticoagulation therapy

Anticoagulation therapy is used in about 90% of cases of DVT and PE because they have been shown to be very effective. Initially, therapy may be administered in a hospital setting if the blood clot burden is high enough or the symptoms are concerning enough. In some cases, anticoagulation therapy can be started as an outpatient. The medications mentioned above can be used for anticoagulation for deep clots as well as superficial clots. Heparin, rivaroxaban, apixaban, dabigatran, edoxaban, and warfarin are also used to treat these clots both in the short term and long term. Short-term treatment for blood clots is generally for 3-9 months depending on a number of factors. In the event of recurrent clots, or other risk factors that increase the risk of developing recurrent clots, life-long anticoagulation may be recommended.

Thrombolytic therapy

Thrombolytic therapy is generally used in severe cases of DVT or in PT when the patient is not stable. These agents are used in the hospital setting and are not used at home, so they are beyond the scope of this article.

Can you prevent blood clots?

Yes. In some cases, it is possible for you to prevent blood clots. You should never start or stop a medication without direction from your healthcare professional. Staying active and avoiding prolonged periods of immobility, discussing medications and lifestyle factors with your healthcare, maintaining a healthy weight, and stopping smoking may all help lower your risks. Your healthcare provider may also recommend medications depending on your risk factors.

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Dr. Foglesong Stabile is a board-certified Family Physician who enjoys full scope Family Medicine, including obstetrics, women’s health, and endoscopy, as well as caring for children and adults of all ages. She also teaches the family medicine clerkship for Pacific Northwest University of Health Sciences.