Premature Heart Disease - Harvard Health Publishing
Blood Clot In Heart: Cardiac Thrombosis Vs Coronary Thrombosis
Medically reviewed by Jeffrey S. Lander, MD
Blood clots can form both in the heart's chamber (intracardiac thrombosis) and the coronary arteries that feed the heart (coronary artery thrombosis). A blood clot in the heart's chambers can break apart and lodge into other arteries, such as the coronary arteries, leading to a heart attack. This is a medical emergency that requires immediate treatment. A blood clot in the heart's chambers isn't the same type of emergency but requires treatment to prevent complications.
This article will discuss the types of blood clots that can happen in the heart, symptoms to look for, and treatment considerations.
Blood Clot in the Heart: Formation and ComplicationsIntracardiac thrombus is a blood clot that occurs in the heart's chambers. The heart has four chambers: two upper chambers and two lower chambers. Common places for a blood clot in the heart are the left atrial appendage, an ear-shaped area off the upper left chamber of the heart, or the left ventricle, the main pumping chamber of the heart that pumps blood out to the body. Blood clots can also form on the right side of the heart, but often, they travel there from veins in the legs.
These blood clots can break apart and "embolize" or travel out of the heart chamber, leading to life-threatening complications:
Travel to the coronary arteries, leading to heart attack
Travel to the brain, leading to stroke
Travel to the arteries in the abdomen, leading to intestinal ischemia
Travel to arteries in the leg, leading to acute limb ischemia
Travel to the pulmonary arteries, leading to pulmonary embolism
The main risk factor for left atrial appendage thrombosis is atrial fibrillation. This is an arrhythmia, or abnormal heart rhythm, in which the heart's upper chambers quiver instead of fully contracting in an organized pattern. This leads to stagnant blood in the appendage, which causes clot formation ( thrombosis). Risk factors for atrial fibrillation include:
The heart's main pumping chambers, the ventricles, are another site where thrombosis can occur. It's often caused when blood stagnates along parts of the heart that don't contract well or when foreign material exists in the heart. Risk factors include:
Risk factors for blood clots in the right side of the heart and pulmonary embolism include:
Deep vein thrombosis (a blood clot in large veins)
Cancer
Recent surgery
Obesity
Taking certain hormone-containing medications, like estrogen-containing birth control
Pregnancy
Blood clots in the heart may not cause any symptoms. However, when a blood clot in the heart travels and lodges in, or embolizes to, the coronary artery, it causes a heart attack. Symptoms of a heart attack include the following:
Chest pressure or discomfort that may radiate to the neck, jaw, or arm
Shortness of breath
Nausea
Lightheadedness or dizziness
Fatigue
If you experience symptoms of a heart attack, call 9-1-1 immediately for an ambulance to transport you to an emergency room for evaluation—every minute counts during a heart attack.
Atrial fibrillation is a common cause of blood clots in the left atrium. The blood clot itself does not cause any symptoms, but people with atrial fibrillation may experience:
Blood clots in the right side of the heart can cause pulmonary embolism. These often originate in the legs, known as deep vein thrombosis. Symptoms to watch for include:
Leg swelling, redness, and pain
Shortness of breath
Chest pain that is worse with taking a deep breath
Fast heart rate
Fast breathing
Coughing up blood
The treatment for a blood clot in the heart depends on its location. Intracardiac thrombus, a blood clot in the heart's chambers, is generally treated with anticoagulant medications (blood thinners). More powerful blood thinners that break up the clot, known as thrombolytics, are used in some cases.
The use of blood thinning medications to treat intracardiac thrombi lowers the risk of complications due to embolism. Jantoven (warfarin) is the preferred medication for blood clots in the left heart chambers. Direct oral anticoagulant medications (DOACs), such as Eliquis (apixaban), or Xarelto (rivaroxaban) may be considered in some cases. Anticoagulation medications are typically taken for at least three to six months. After that time, imaging tests can be performed to see if the thrombus is still in the heart to guide further treatment. Some people may need lifelong blood thinners.
In the event of a heart attack, a cardiologist (heart doctor) may perform a cardiac catheterization and place a stent to open up the blood vessels. Antiplatelet medications, such as aspirin and Plavix (clopidogrel), Brillinta (ticagrelor), or Effient (prasugrel), are given to help keep the stent open and prevent more blood clots.
In some cases, a surgeon may perform a procedure called a thrombectomy. This procedure involves the use of special instruments to remove the blood clot.
How Do Doctors Diagnose Blood Clots in the Heart?Healthcare providers diagnose blood clots in the heart chambers using imaging. One common test is the echocardiogram, which uses sound waves to produce images of the heart, allowing for evaluation of its structure and function. A more invasive type of ultrasound, known as a transesophageal echocardiogram, is needed to diagnose blood clots in the atrial appendage.
Other imaging tests, such as computed tomography scans (CAT scans) or magnetic resonance imaging (MRI), can also show blood clots in the heart. However, the coronary arteries are much harder to see using ultrasound. Blood clots in these areas are diagnosed using coronary angiography with cardiac catheterization, a procedure that also allows for immediate treatment.
Can It Dissolve on Its Own?The body does have a mechanism for breaking down blood clots on its own. However, leaving a blood clot to dissolve on its own carries the risk of life-threatening complications, including strokes and heart attacks. Treatment with blood thinners can help the clot dissolve more quickly, prevent more clots from forming, and lower the risk of embolism.
Your healthcare provider can determine the appropriate treatment for your situation.
Factors That Affect Survival and Ability to RecoverIn many cases, blood clots can be successfully treated. However, blood clots in the heart may be more likely to embolize and cause complications in certain situations:
Mobile thrombus (meaning it is moving independently from the heart's contraction)
Protrusion into the left ventricle
Failure of thrombus to improve with blood thinners
The treatment timeline also affects mortality. For example, for coronary thrombosis, a delay in treatment increases the mortality rate.
Post-Coronary Thrombosis (Heart Attack) ConsiderationsAfter a heart attack, the risk of additional heart attacks or stroke increases. Lifelong treatment with medications and lifestyle changes can lower the risk of experiencing complications. These include:
Taking antiplatelet medications like aspirin
Taking cholesterol-lowering medications like statins
Controlling blood pressure with medications when needed
Getting regular exercise and staying as active as possible
Eating a heart-healthy diet rich in vegetables, fruits, and whole grains and low in processed foods and saturated fats
Quitting smoking
Getting enough good quality sleep
Managing weight
Controlling blood sugar
If you develop a blood clot in your heart, you will need to follow up with a cardiologist regularly. For intracardiac thrombi, your healthcare provider can review imaging tests to ensure the clot goes away with treatment and help manage any underlying conditions that led to the formation of the blood clot, such as heart failure or atrial fibrillation.
For those with intracoronary thrombus or heart attack, regular follow-up with your healthcare provider is needed to monitor your condition and help lower your risk of future complications. Your healthcare team will carefully monitor your blood pressure, cholesterol, and blood sugar.
Certain preventable measures can help keep your heart as healthy as possible. These include:
Getting regular exercise and staying as active as possible
Eating a heart-healthy diet rich in vegetables, fruits, and whole grains and low in processed foods and saturated fats
Controlling blood pressure
Controlling cholesterol levels
Quitting smoking
Getting enough good quality sleep
Managing weight
Controlling blood sugar
In summary, blood clots can occur in the heart's chambers (intracardiac thrombus) or the coronary arteries feeding the heart (coronary artery thrombosis). Clots in the heart chambers may not cause any symptoms but can break apart and travel to the coronary arteries, leading to a heart attack. Early detection and treatment of blood clots in the heart with blood thinners can prevent complications like heart attack and stroke.
A heart attack is a medical emergency that requires immediate treatment to prevent complications like arrhythmias and death. If you experience symptoms of a heart attack, such as chest discomfort that may radiate to the neck, jaw, or arm, nausea, or shortness of breath, seek medical attention immediately.
Read the original article on Verywell Health.
View comments
Multidisciplinary Limb Salvage In A CLI Patient With Complex Care Coordination
CASE PRESENTATIONA man in his early 70s with critical limb ischemia presented for a second opinion after being advised to undergo amputation. His medical history was significant for type 2 diabetes mellitus (HbA1c, 8.4%), neuropathy, peripheral vascular disease, carotid stenosis, and hypertension. He was also a former smoker (2-3 packs/day for 20 years) and had stopped 1 year before presentation.
In addition to the technical aspects of the patient's care, one of the greatest challenges we faced in caring for this patient was the coordination of care and transportation. This patient lived in a rural area and had limited social support. Due to the complexity of care, he required procedures and management at our main hospital, as well as significant wound care follow-up in his local area. This required us to work jointly with the local community hospital and arrange multiple transfers, which were challenged by significant transportation complexities.
This patient was initially evaluated at his local community hospital emergency department for foot pain. He was diagnosed with cellulitis and was prescribed antibiotics, with a recommendation for outpatient podiatry follow-up. At the outpatient visit with podiatry, significant concerns arose for ischemia, and transportation was arranged for vascular testing (Figure 1). Initial toe pressure and ankle-brachial index (ABI) were 9 mm Hg and 0.3 with minimal pulsatile flow, respectively. This was an outpatient procedure, and he returned home after the test with a plan to follow-up with vascular surgery. However, dependent rubor and pain progressed significantly over the next few days.
Figure 1. Ischemic-appearing foot noted at outpatient podiatry visit.
Arrangements were made for the patient to be urgently transferred to the main hospital for admission under vascular surgery, with a plan to perform angiography. Once transferred, vascular surgery evaluated the patient, and he was diagnosed with severe chronic left lower limb ischemia with nonhealing gangrenous toes, Rutherford category 2a for acute limb ischemia. He was taken urgently for a left lower extremity angiogram, which showed multilevel disease in the superficial femoral artery (SFA) and posterior tibial artery, with occlusion of the anterior tibial (AT) and peroneal arteries. The vascular surgeon recanalized his SFA, AT artery, and peroneal artery. Angioplasty was performed using a drug-coated balloon in the SFA and popliteal arteries, and a 3-mm balloon was used in the tibial arteries. The vascular surgeon also debrided necrotic tissue from the patient's foot in the same operative room visit and left the wound open, with Dakin's solution packed into the wound.
His toe pressure increased to 30 mm Hg postoperatively, but his course was complicated by a non–ST-segment elevation myocardial infarction, and plans for any further lower extremity revascularization were thus aborted. Cardiology was consulted, and the patient underwent coronary angiography via right radial access, which demonstrated a 30% ostial left main coronary artery, a long 50% mid left anterior descending, a 40% proximal left circumflex artery (LCX), a 70% proximal and severe diffuse distal LCX OM1, 80% mid LCX stenoses, and a collateralized mid right coronary artery total occlusion.
After cardiac MRI revealed evidence of a left ventricular thrombus, the patient was initiated on systemic anticoagulation with subcutaneous enoxaparin sodium injections and then transitioned to intravenous unfractionated heparin while awaiting high-risk percutaneous coronary intervention (PCI). After 1 week, the patient underwent high-risk PCI using intravascular ultrasound and Shockwave IVL (Shockwave Medical, Inc.), and two drug-eluting stents were placed. He was reloaded with clopidogrel (total of 300 mg orally). He was then transitioned to apixaban (5 mg twice daily) with aspirin and clopidogrel.
Third and fourth toe amputations were performed, and podiatry remained consulted for wound management. The wounds were initially packed with wet-to-dry dressings, followed by wound vac. He experienced significant lower extremity pain that improved throughout the hospital stay. Physical therapy worked with him, and he was maintained at heel-touch weight-bearing status. He was evaluated by infectious disease and discharged on a planned 6-week course of antibiotics based on bone culture data showing osteomyelitis.
Although the patient was discharged to a skilled nursing facility local to his home, he returned to the hospital emergency department 2 days later due to concerns for progression of necrosis to the wound.
On this admission, there was no clinical sign of infection; however, the dry gangrene did progress to the second and fifth toes (Figure 2). Vascular surgery and podiatry jointly determined that a transmetatarsal amputation (TMA) was indicated but was unlikely to heal without an increase in inflow. He had flow in his AT and peroneal arteries from the previous recanalization but no suitable vein for bypass. On CTA, he was noted to have plaque in the common femoral artery (CFA).
Figure 2. Dry gangrene seen in the second and fifth toes.
Vascular surgery performed a CFA endarterectomy while the patient remained on his antiplatelet medications, given that he did not have suitable vein and was within 1 month of his cardiac procedure. Toe pressure increased to 52 mm Hg after this procedure, and a TMA was then performed jointly with podiatry.
The patient was transferred back to his community hospital, where he was followed by the local general surgery team. Sutures were removed at 3 weeks postoperatievly, and concerns arose due to progressive necrosis at the TMA incision site and drainage (Figure 3). He was then transferred back to the mainland for evaluation for below-knee amputation.
Figure 3. Three weeks after TMA with necrosis of incision site.
Because the patient wished to exploit all options to save his limb and he was not systemically ill from his foot, our limb salvage team reevaluated, and a joint decision was made to continue to attempt limb salvage with debridement and updated wound care. He was taken to the operating room with podiatry for surgical debridement of necrotic tissue and partial closure of the left foot TMA site, as well as application of incisional wound vac (Figure 4A). Offloading consisted of strict non–weight bearing. The infectious disease team was reconsulted and recommended extending his antibiotic course to a total of 8 weeks.
Figure 4. Three days after TMA revision with incisional wound vac (A). Delayed wound healing of medial and lateral incision sites (B).
The patient was then discharged after 1 week in stable condition to the local hospital via repatriation, then transferred to a skilled nursing facility 2 weeks later. Wound healing had progressed significantly, with healing noted and no clinical signs of infection.
He was able to be discharged home and was seen for 7 months by the local outpatient podiatrist for his wounds. During this time, he was able to bear weight on his foot with a postoperative shoe and bandages. The wounds had delayed although progressive wound healing (Figure 4B).
At the 8-month mark, he continued to have unhealed wounds on the lateral and medial aspect of the foot, and his toe pressure had decreased to 30 mm Hg. Podiatry performed a surgical debridement with application of a skin substitute (umbilical tissue) and wound vac application. The next day, vascular surgery opted to perform a femoral-to–tibioperoneal trunk bypass with a PTFE graft, as he did not have suitable vein.
Nutrition was consulted due to malnutrition and significant weight loss over the previous 8 months. The patient was placed on a regular diet and was given a daily frappe and supplements with meals. He was also treated with multivitamins, thiamine, and folic acid for 10 days in the setting of his malnutrition. After the return to his local hospital, the wound vac was continued to the foot.
We arranged an in-person follow-up visit 2 weeks after discharge with both the vascular and the podiatry teams due to the patient's high risk, need for wound evaluation, and vascular testing. This required arranging an overnight stay in our main hospital, as a roundtrip would not be possible in 1 day.
At this visit, he underwent left foot debridement, skin substitute (umbilical tissue), and negative pressure wound therapy application with podiatry. A left lower extremity ultrasound showed a patent femorodistal bypass graft, and his leg incisions had healed nicely (Figure 5).
Figure 5. After debridement with application of a skin substitute and femoral-to-tibioperoneal trunk bypass.
CONCLUSIONThe objectives of limb salvage encompass enhancing the patient's quality of life, maintaining optimal function, and bolstering overall health. Achieving these aims typically necessitates prolonged treatment and a series of interventions. However, facilitating the patient's ability to walk for an extended period not only preserves their quality of life but also reduces their mortality risk over the next 5 years. Our patient expressed profound gratitude toward our limb salvage team, recognizing the effectiveness of the procedures and the meticulous coordination of care. Such success would have been unattainable without the collaborative efforts of our multidisciplinary team, which included experts from vascular surgery, podiatry, infectious disease, physical therapy, nutrition, and other crucial disciplines.
An important point is the idea of constant involvement and surveillance. Limb salvage is not a "one-and-done" procedure. For example, the patient discussed in this article underwent an endovascular procedure, then a femoral endarterectomy, and then a distal bypass to serve the presentation he had at the time. Although he had a number of wound healing issues, he expressed his desire to keep his foot and was ambulating, so our team was more than willing to serve him on his journey. He is currently healing nicely, mobilizing, and in good health.
Anahita Dua, MD, MS, MBA, FACSAssociate Professor of SurgeryCo-Director Limb Evaluation and Amputation Prevention Program (LEAPP)Director, Clinical ResearchAssociate Director, Wound Care CenterDivision of Vascular and Endovascular SurgeryMassachusetts General Hospital/Harvard Medical SchoolBoston, Massachusettsadua1@mgh.Harvard.EduDisclosures: None.
Sara Rose-Sauld, DPMSurgical PodiatristInstructor of Orthopedic Surgery, HarvardMassachusetts General HospitalBoston, Massachusettssrose-sauld@mgh.Harvard.EduDisclosures: None.
Comments
Post a Comment