Pulmonary Embolism

[Pluripotent]

OK, this came up recently. Generally, as I've said in other threads, the people I take care of are already -- sadly -- largely beyond much meaningful help. But every once and a while, I see someone who still might have a chance. These times are rare, and I'd like to be more prepared than I am.

I recently saw a rather young (mid thirties) male patient who is in pretty good shape, no real significant PMHx, and he apparently hits the gym regularly (I am now kicking myself because I didn't ask him what type of program he follows). Anyway, he suffered a sudden and unprovoked pulmonary embolism that may just have taken out one of my more regular patients. I see PE pretty regularly, but not some much in this patient population. It was medium in size (which means it was pretty big), and he had large amounts of clot in both legs with a saddle embolus. His right heart was very dilated on echo. So, this guy probably has some shitty genetics that make him clot prone, because there's really no other obvious explanation. We are looking into that. But in the meantime...he is asking me when he can get back to the gym. This kinda took me off guard, because no one ever asks me that. I mean, it's so rare, that I wasn't really prepared to answer him, and I probably should have been. Amazingly, he tolerated his clot burden very well and was not requiring O2 at discharge. I totally expected to send him home with O2 for a month or two. I told him that his shortness of breath would largely be his guide and he will get winded easily, especially early on. Take lots of breaks and don't push it, but as the shortness of breath decreases he can start to push harder and go longer. (This advise is already way more liberal than most of my colleagues would have told him. I asked someone else about it and they said he shouldn't do anything strenuous for 2 months minimum.) The real issue is the strain on his right heart, and his pulmonary artery pressure, which was very elevated just after the PE, but I'm not sure he should have to sit around doing nothing until his follow up echo in 8 weeks. So, any SS coaches on here have any experience in training someone post PE? Rip?

[Mark Rippetoe]

Over my pay grade. Sully? Will?

[Will Morris]

The big hanging chad here is the maturation of the clot. In the first few weeks after a PE/DVT the clot is more fragile and has a higher risk of breaking. I've dealt with many chronic PE/DVT patients and we've always started them back to training 4 weeks post discharge. The advice you gave him leaving the hospital sounds very reasonable to me, but then again, I am much more aggressive than others.

[Jonathon Sullivan]

He may have a previously subclinical genetic thrombophilia, like an antithrombin or Factor V issue. Certain neoplasms can also cause a prothrombotic state.

He needs to be under the care of a hematologist until such issue is specifically ruled out or treated.

With the information provided, I would proscribe heavy training at least until he was demonstrably clot-free (by both leg duplex and cardiac echo), had a hematology workup, and was under antithrombotic therapy if indicated. The guy has bigger problems than getting his squat up right now. My 2 cents.

[shombre]

The big hanging chad here is the maturation of the clot. In the first few weeks after a PE/DVT the clot is more fragile and has a higher risk of breaking. I've dealt with many chronic PE/DVT patients and we've always started them back to training 4 weeks post discharge. The advice you gave him leaving the hospital sounds very reasonable to me, but then again, I am much more aggressive than others.

Can you elaborate on why clot maturation is of concern when a patient with a PE, and quite a few with DVT, would be on full dose anticoagulation, with the express aim of clot dissolution? Is it more the case that you're waiting for anticoagulation to have been established to prevent further clots?

[Jonathon Sullivan]

Can you elaborate on why clot maturation is of concern when a patient with a PE, and quite a few with DVT, would be on full dose anticoagulation, with the express aim of clot dissolution? Is it more the case that you're waiting for anticoagulation to have been established to prevent further clots?

Anticoagulants like heparin, enoxaparin, and the new Factor X inhibitors like Xarelto do not dissolve thrombus. They prevent clot formation and propagation and give the body's intrinsic thrombolytic processes a chance to get ahead and dissolve the clot.

[Pluripotent]

Can you elaborate on why clot maturation is of concern when a patient with a PE, and quite a few with DVT, would be on full dose anticoagulation, with the express aim of clot dissolution? Is it more the case that you're waiting for anticoagulation to have been established to prevent further clots?

This is a common misconception about anti-coagulation therapy, and I'm constantly explaining it to PE/DVT patients. The aim is not to dissolve the clot. The aim is to prevent it from growing. What he means by clot maturation is the process by which your body essentially stabilizes the clot within the vein and then begins to resorb it. We can give "clot-busting" medications (tPA), but this is generally reserved for very severe PE when the patient is not hemodynamically stable on presentation (low O2 sat, low BP, etc.). But you don't take that stuff long term (it's IV and has a fairly short half-life, not to mention expensive). In such a situation, you can either give systemic (non-directed) tPA, or directed (meaning that a catheter is threaded to where the clot is in the lung and tPA is dripped right on top of it.)

Once a stable patient is on anticoagulation, then the body will stabilize and resorb the clot over 6-8 months or longer.

This guy is now following with heme/onc as outpatient. I'm the inpatient guy. I don't always get them involved in all PEs, but this guy just has no explanation as to why he suddenly got such a major clot. They are doing the genetic workup.

I should have pried more into what type of program he was doing, but he looked like a gym bro, so probably typical gym bro stuff. I think if he can get his pulmonary artery pressure down, he's probably going to be OK, although he may need lifelong anticoagulation. Kind of a shitty situation for the guy, his life just changed forever. With any luck, he'll be near normal in half a year and just on a few new meds.

[chaloney]

Anticoagulation is established in an hour to a few hours, depending on the anticoagulant used. As they mature, clots become less likely to break into pieces and float away. Without anticoagulation they tend to grow--clot adding on to what is already there. Anticoagulation stops new clot from forming while the body breaks down the clot that is there (slow--weeks to months) and compensates for whatever physiologic effects the clot is causing (faster--days to a week or two), depending on the location and size of the clot/clots.

Regarding the patient in question, I agree with sully that return to the gym probably should wait for demonstration of resolution of clot as well as resolution of the right heart strain. The ACCP has extensive guidelines on the diagnosis and treatment of thromboembolic disease and if data exists on return to activity and/or exercise after PE, it is probably addressed. I will try to look later tonight. I doubt there will be anything on strength training specifically.

[chaloney]

Looks like the ACCP guidelines focus on antithrombotic treatment. Nothing I could see about return to activity.

Antithrombotic Guideline | CHEST Journal | CHEST Publications
For anyone interested in some really dry reading

[Pluripotent]

Anticoagulation is established in an hour to a few hours, depending on the anticoagulant used. As they mature, clots become less likely to break into pieces and float away. Without anticoagulation they tend to grow--clot adding on to what is already there. Anticoagulation stops new clot from forming while the body breaks down the clot that is there (slow--weeks to months) and compensates for whatever physiologic effects the clot is causing (faster--days to a week or two), depending on the location and size of the clot/clots.

Regarding the patient in question, I agree with sully that return to the gym probably should wait for demonstration of resolution of clot as well as resolution of the right heart strain. The ACCP has extensive guidelines on the diagnosis and treatment of thromboembolic disease and if data exists on return to activity and/or exercise after PE, it is probably addressed. I will try to look later tonight. I doubt there will be anything on strength training specifically.

That last bit is why I posted this on the board. I have not done an exhaustive literature search, but I'm predisposed to believe that this is not addressed by "the literature." If someone wants to prove me wrong, I'm certainly willing to be wrong.