Covid-19 hikes risk of deadly yet preventable condition

The Health Service Executive has contacted advocates again about the possibility of establishing a national venous thromboembolism clinical program seven months after the pandemic halted initial discussions. Peter Doyle Reports

When a clot develops in a vein in the lower body, it is called a deep vein thrombosis (DVT). and when this clot migrates into the lungs it is called pulmonary embolism (PE).

On the occasion of World Thrombosis Day (WTD) on October 13, the activists focused on the "often overlooked and misunderstood condition of thrombosis". WTD fell every year on the occasion of the birthday (October 13th) of the German pioneer physician Rudolf Virchow, who first introduced the concept of thrombosis into medicine in order to “raise global awareness of thrombosis including its causes, risk factors, signs / symptoms and evidence – based prevention and treatment ”.

"Ultimately, we strive to reduce the death and disability caused by the disease," states the WTD website (worldthrombosisday.org).

VTE death rates
DVT and PE were collectively known as venous thromboembolism (VTE), and this condition is responsible for nearly 150,000 deaths each year in Europe. In Ireland, VTE was estimated to be responsible for 4,000 deaths each year.

Irish doctors estimated that around 1,900 of these deaths were preventable, according to patient-run charity Thrombosis Ireland (TI). The work of the entire volunteer organization aiming to raise awareness of thrombosis among patients, healthcare workers and the general public across the country can be found at https://thrombosis.ie/. Mortality rates, the campaign group said, would improve with better management of the disease and an increase in patients' knowledge and awareness of the signs and symptoms of blood clots. The most effective way to achieve this is with the Consultant Physician in the Acute Medicine Department (AMU) at Limerick University Hospital (UHL). Prof. Michael Watts said the Irish Medical Times (IMT) would follow through on a national thrombosis clinical program that would establish standards of care for clinicians across Ireland.

An "orphan" disease
Prof. Watts said that VTE had been an “orphaned” disease “far too long” without a real home and remained in the shadow of morbidities with larger public profiles. Speaking to IMT before WTD, Prof. Watts added that the third largest cause of cardiovascular death in Europe is VTE. Prof. Watts, who is also co-chair of the VTE Ireland clinic group, said: “Number one and two are strokes and heart attacks. Both conditions have a lot of airtime, in part due to the number of interest groups representing the interests of people diagnosed with associated conditions. "

"Unfortunately number three on the list, Vein Thrombosis Embolism, does not have the same airtime. It does not make the same amount of investment – and there is certainly no national organization or body in Ireland," he continued. "It has no natural one At home, although it is responsible for so many deaths, it is one of the main reasons, especially on World Thrombosis Day, which we consider an orphan field in medicine. "

Prof. Michael Watts

Speaks recovery
Prof. Watts, Fellow of the Royal College of Physicians Ireland (RCPI) and National Clinical Director for Applications to the Registry's Specialist Department (SDR), also described how discussions are being held with the Health Service Executive (HSE) to set up a national clinic Leadership for VTE recently restarted more than seven months after the arrival of Covid-19, which put them on hiatus.

When the pandemic first hit Ireland, senior health officials were diverted to work on the nation's response to the pandemic and were too busy to continue their talks with VTE Ireland and TI. Studies have shown that hospitalized patients diagnosed with the highly contagious disease, which has been linked to more than 1,800 deaths in Ireland since the country was first diagnosed in March, have also been at high risk of developing thrombosis, the HSE and its Dr. Colm Henry, Chief Clinical Officer (CCO), had contacted Prof. Watts and his colleagues to continue the talks, which were suspended in February of this year due to Covid-19.

Stickier blood
"What we know about this particular virus is that it makes your blood extra sticky, perhaps more so than the usual viral infections that occur like influenza," said Prof. Watts.

"Based on the data we have, Covid-19 appears to increase the risk of thrombosis three times as much as influenza – this is not uncommon and we see this in other types of infections," he continued.

“The reason for this is that infections trigger an immune response, and that response is inherently linked to the way our blood clot proteins work.

"So it's not uncommon to get an infection where your blood is stickier than normal. What is very interesting about Covid-19, however, is that it's stickier than average."

He emphasized how "in the Covid environment" the risk of increased morbidity and mortality from blood clots has been exacerbated, saying these clots are "potentially preventable" – as are around half of the 150,000 clots that kill people across Europe each year . "They can be prevented by good medical care, which includes risk assessment for thrombosis and the prescription of preventive thrombotic drugs," said Prof. Watts.

A clinical home
Prof. Watts said, "Unfortunately, there is no national oversight over the prevention or treatment of VTE as there is no natural home for VTE." It's an orphaned specialty, unfortunately. What Covid is doing now more than ever is to bring this situation to the surface. "

Now it is time for Ireland to "take the lead on thrombosis". "We at VTE Ireland decided that since VTE is orphaned, we need a national clinical program with the appointment of a national clinical director," stated Prof. Watts.

"It's the third largest cardiovascular killer in Europe and yet it doesn't have a clinical home (in Ireland). It takes leadership and a national clinical program, and I think HSE gets that idea.

“We have worked with the HSE, specifically with the HSE Quality Improvement Department headed by (the National Director of Quality Improvement). Dr. Philip Crowley and (the department for clinical lead drug safety, quality improvement) Mrs. Ciara Kirketo promote the development of a clinical program in VTE. "

But the Covid-19 pandemic hit before the talks were final, and making arrangements for a crucial meeting with the CCO, Dr. Henry, were pushed into the background. Until now.

"It is somewhat ironic that Covid and thrombosis are linked, and because of the high risk of thrombosis from Covid, we are now in contact with the HSE Clinical Risk Forum and with Dr. Henry on developing a national strategy and appointing a lead clinic for thrombosis in Ireland, ”said Prof. Watts.

Hospital acquired thrombosis
Thirty years after the first evidence of hospital-acquired thrombosis (HAT) was published, the case of clinical VTE lead was just as compelling and backed up by recent data, added the adjunct professor of clinical medicine at Limerick University's Graduate Entry Medical School (GEMS).

For example, an audit conducted in October 2017 – three years before a new respiratory disease broke out in China, the World Health Organization (WHO) declaring the global Covid-19 pandemic – found that there is a significant risk of VTE with hospital admissions.

As a result of research carried out by VTE Ireland in partnership with HSE, there is now a clinical risk indicator for HAT in Ireland. "The first signs of this new measurement are that there has been an increase in hospital-acquired thrombosis since October last year," he added.

Report exactly
However, the incidence of HAT could be higher after Dr. Watts discovered there were problems with the collection of cases in the HSE's HIPE (Hospital In-Patient Inquiry) system.

"Data is very powerful, but it needs to be accurately reported. If you report it incorrectly, you will be misled," he warned. One of the "problems" with DVTs and VTEs is that people with blood clots sometimes do not come to the hospital at all.

He said the problem was made worse by patients who were successfully treated in the hospital but later developed blood clots after they were discharged. "The data that HSE uses, the HIPE system, is all based on hospital admissions so you can see how there might be a problem," he said.

"We'll take care of it and we have a way to deal with it."

A major benefit of a national clinical program would be the standardization of the risk assessment of cases. "If you come to the hospital with a medical condition such as a stroke or a heart attack, your risk of thrombosis is very high," said Prof. Watts. “Scores have now been developed and one of them that we use is called the Padua Score. This is simply a way of assessing someone in the hospital for VTE risk.

“They do this risk assessment and, if necessary, prescribe preventative medication to prevent clots from forming. It's been around for 30 years and it's more important than ever to have Covid on our shores. "