Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Expert

 

Ask the Expert Live Chat Transcript - Tuesday, December 7, 2010

Elizabeth Ratchford, MD


Assistant Professor, Department of Medicine, Division of Cardiology, Johns Hopkins Heart & Vascular Institute

 

 

Dr. Ratchford generously donated her time to answer our patients' general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as her answers.

Moderator- VDF: Welcome everyone! Thanks for joining us today, we're glad you're here! You may now go ahead and type your questions for Dr. Ratchford to answer. We appreciate everyone's patience as she works to answers everyone's questions.


Joe: How safe is the use of Cilostazol and how much does it help? I have PAD in my right calf and have had bypass surgery to alleviate, which it did some. Also, how does it work?

Speaker Dr. Ratchford: Cilostazol is relatively safe but cannot be taken if you have a history of heart failure. It increases your walking distance by about 50% (so if you could walk 2 blocks before, you would increase to 3 blocks), which is less than would be expected with a supervised exercise program. The exact mechanism of how it works to help the leg pain is unclear but it has a number of effects on the blood and the blood vessels including dilating them to some degree.

VDF Moderator: Joe, are you walking every day? I you would like we would be happy to send you a free walking brochure geared towards patients with PAD. It's free and all you need to do is send us an e-mail to info@vdf.org with your address.

Joe: Not every day. 4 days a week and arm cycle two days a week.

VDF Moderator: Oh cool Joe! Are you in the arm cycling study? Do you think it's helping you? That's great news!

Joe:  No I am not in the study. It is hard to tell if it is helping because of the other activities. But, if I had to say one way or the other, I would say yes.

VDF Moderator: Oh great Joe! I'm glad that you feel it’s helping. I take it you got the newsletter article with the instructions in it?

Joe:  Yes. But, I have not quite gotten to the level they desire. What tests can done to indicate if the blood is thinner than it should be?

Speaker Dr. Ratchford: With vascular disease, we are not typically worried that the blood is "too thin" but rather "too thick". Were you concerned about a bleeding problem?

Joe:  Vascular disease is not the only problem. I am on Plavix and aspirin for heart problems.

Speaker Dr. Ratchford: Plavix and aspirin both affect platelets which would prolong the bleeding time but this is expected.

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VDF Moderator: This question was e-mailed to us ahead of time: I have had acute DVT for 5 years now and it is in my entire left leg. I have been taken off anticoagulation meds several times but clots always come back and so I am on Lovenox for life. They do not fully understand why nothing works for me but Lovenox and what causes my clots. The question is based on data collected so far can you tell me what I should expect in the future for my leg?  I know poor circulation but are there other things I should be aware of? I have no idea what will happen to my leg since the entire leg is clotted.

Speaker Dr. Ratchford: The primary concern down the road will be "post-thrombotic syndrome" which is related to the damage to the valves in the veins from the prior clot. This can cause swelling and skin changes; compression stockings, elevation, maintaining a normal weight, and regular exercise like walking can help to alleviate it. It sounds like you will need life-long blood thinners.


Denise: Can an old DVT clot move? I had a DVT about 6 months ago and am on Coumadin. I worry about doing too much exercise or activity because it might break loose and go to my lung.

Speaker Dr. Ratchford: It is unlikely that the DVT would move at this point; often your body will dissolve the clot (though not always). You can see if there is any residual clot left on ultrasound. Exercise is very important to prevent vein (and artery) problems down the road so I would not avoid it unless your doctor has told you to do so.

Denise: How long is it typical to stay on Coumadin?

Speaker Dr. Ratchford: The duration of Coumadin depends on the suspected cause of the DVT. It can be as short as 3 months if it's just after surgery for example. I typically prescribe 6 to 12 months if the underlying risk factor has been fixed. It can be lifelong in some cases if the risk factor is not 'fix-able', for example if someone has metastatic cancer.

Denise: Can the coagulation test (INR) be used to see if someone has a clotting problem?

Speaker Dr. Ratchford: No, the INR is used to monitor whether the Coumadin is at the right level in the blood. There are several other blood tests which can be done to see if someone has a tendency to clot.

Denise: Are they with the drop of blood like for INR or do they have to draw a lot of blood?

Speaker Dr. Ratchford: It would be at least a few tubes of blood to do a complete evaluation. The exact tests depend somewhat on the clinical situation.

Denise: Another question. Since I am on Coumadin, the potential for bleeding is greater. Is there a way to stop it faster if I get a small cut? For example, a styptic?

Speaker Dr. Ratchford: Holding pressure is probably the best and safest way to stop the bleeding.

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VDF Moderator: This next question was also e-mail to us ahead of time: My mother who has had a stroke and has been in bed for a month now has DVT in her arms, is this possible and can it be treated it? Could it be fatal? Thanks!

Speaker Dr. Ratchford: It is certainly possible to have a DVT in the arm, which we call an "upper extremity DVT"; it is less common than a leg DVT but it can still cause a pulmonary embolism (i.e. the blood clot can go to the lung, which can be potentially fatal unless it is treated). Blood thinners would be recommended.


VDF Moderator: If you would like more information about vascular disease, please visit our Web site: http://www.vdf.org
Beth: Is a strong family history of vascular disease a good enough reason to begin vascular testing on a non symptomatic patient?

Speaker Dr. Ratchford: Excellent question. This depends on the clinical situation. The field of 'Preventive Cardiology' is dedicated to answering this exact question. Some doctors feel that tests such as carotid IMT or coronary calcium scores can be useful in this case for what is called "risk-stratification".

Beth: I often receive information about screening test done at my senior center and church, do you recommend such testing? If so what should I look for in determining if it is a qualified operation?

Speaker Dr. Ratchford: Also a great question. I am thrilled when I hear that screenings are being offered, as I think it is good to 'raise the level of awareness' about vascular issues. But keep in mind that these are just screenings and not complete exams. It is critical to get a copy of the results to bring to your doctor and to determine if a more complete test is needed. Personally, I would do it if it was free but I'm not sure I would pay for it.


VDF Moderator: This next question was also e-mailed to us ahead of time: I am 44 and have a history of blood clots, high blood pressure, and high cholesterol and am pre-diabetic. I know I need to exercise to help with these conditions but the pain in my legs makes it very hard to walk very far. My legs ache constantly and when I'm sitting, my feet tingle so I'm wondering if I have PAD. When I get up in the morning it takes me a minute to get my legs working but there is not as much pain then. My doctor has prescribed medication for all my conditions and I have told her about my constant leg pain but she has never mentioned PAD. Since I'm already on medication for all these conditions, is there anything else that can be done or is there any point of me asking her to do tests?

Speaker Dr. Ratchford: Given your risk factors and symptoms, I think it would certainly be reasonable to check an ankle-brachial index (ABI) to see if you have PAD. The symptoms you describe do not sound like the "classic" PAD symptoms but sometimes people can have atypical symptoms. It would be worthwhile to check for PAD because it may change the medicines you would take.


VDF Moderator:  Hi Dr. Ratchford, what can you tell us about if the doctor where to hear a funny sound in their neck, what would that mean?

Speaker Dr. Ratchford: This is called a "carotid bruit" (pronounced BROO-EE). It is like a heart murmur but in the neck and it can be a sign of carotid artery disease (blocked neck arteries). The best way to evaluate this is through a carotid ultrasound.


Marilyn: I had a Femoral Cross By-Pass 19 years ago my vascular surgeon is amazed wondering if it "fails" what the symptoms will be that I should look for. I'm in Florida for the winter and I worry about not being in Toronto where my surgeon is. Thanks

Speaker Dr. Ratchford: What were your initial symptoms? I suspect that you had leg pain with walking?

Marilyn:  Yes, I had cramps in my calf when walking got so bad I could only walk about 5 steps without pain.

Speaker Dr. Ratchford: I suspect the symptoms would be similar if it were to close up again - pain in the leg, particularly with walking, relieved with rest, or occasionally a sore that will not heal.

Marilyn:  So if it occludes how long will I have to get back to Canada? Or will I have to go to emergency here to get help?

Speaker Dr. Ratchford: If it closes up all of a sudden (which is rare), this can be an emergency but this is highly unlikely and not a subtle thing (e.g. sudden onset of pain). If it is gradual, then it can usually wait till you get back to your regular surgeon. But there are also many vascular doctors in Florida!

Marilyn:  Thanks very much…maybe I won't worry as much now.


VDF Moderator: This next question was also e-mail to us ahead of time: A Stent was inserted in my left leg. A recent scan shows that the Stent is blocking up, can this stent be removed?

Speaker Dr. Ratchford: If the stent is in an artery and the artery has closed up again, then it would not typically be removed but rather it can sometimes be opened up by angioplasty and sometimes another stent may then be inserted.


VDF Moderator:  Thank you for joining us today! We appreciate your time and interest. Please join us for our next chat on 9/7 with Jean White. We thank Dr. Ratchford for her time today. Have a healthy day!


Disclaimer

The material provided on VDF's Web site and Live Ask the Expert chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.