Circulation. 2009;119:e480-e482
doi: 10.1161/CIRCULATIONAHA.108.841403
(Circulation. 2009;119:e480-e482.)
© 2009 American Heart Association, Inc.
The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism
Suman Rathbun, MD, MS
From the Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.
Correspondence to Suman Rathbun, MD, MS, Associate Professor of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. WP 3010, Oklahoma City, OK 73104. E-mail suman-rathbun{at}ouhsc.edu
 |
Introduction
|
|---|
On September 15, 2008, the US Surgeon General, Rear Admiral
Steven K. Galson, MD, MPH, issued the first Call to Action to
Prevent Deep Vein Thrombosis and Pulmonary Embolism.
1 What is
a "call to action" and why should we heed the recommendations
of the highest ranking physician in the nation? A call to action
is a science-based document to stimulate action nationwide to
solve a major public health problem. Over the years, the Surgeon
General has issued several calls to action. The first and most
important document was the Report on Smoking and Health issued
in 1964.
2 This warning about the health risks of cigarettes
was issued by the Surgeon General at a time when smoking was
common and fashionable. It caught the attention of the general
public and set the groundwork for the subsequent 40 years of
research and awareness that resulted in the lowest smoking rates
in history. Now, 44 years later, the alarm has been sounded
on another equally disabling and deadly disease, deep-vein thrombosis
(DVT) and pulmonary embolism, collectively known as venous thromboembolism
(VTE). DVT refers to blood clots forming most commonly in the
deep veins of the legs that can break off and travel to the
heart, ultimately lodging in the arteries of the lungs, a condition
known as pulmonary embolism, causing death and disability.
|
Why Is It Important to Issue a Call to Action on VTE Now?
|
|---|
Healthcare providers have recognized for many years that VTE
may occur in their patients, especially in those undergoing
surgery or being admitted to the hospital, but it has become
evident that the American public does not recognize their risk
for VTE or know the signs and symptoms. Further, life-saving
prevention is still underused. The American Public Health Association
found during a telephone survey that fewer than 1 in 10 Americans
know about DVT and are familiar with its symptoms or risk factors.
3 If the public is not engaged and educated, those who may ultimately
suffer from this disease will not be equipped to reduce their
risk of succumbing to VTE. These findings point to the urgent
need for this call to action.
|
The Surgeon General Has Called Us to Recognize That VTE Is a Significant Public Health Problem
|
|---|
Several longitudinal studies over the past few years have more
fully revealed the extent of the disease burden. Population
studies have found an incidence of VTE of 1 in 1000 on the basis
of diagnosed cases, which translates to more than 300 000 Americans
afflicted per year.
4 However, other studies have found that
for every case that is accurately identified, there may be 2
or 3 more that are not recognized.
5 Although the overall burden
of disease may not be definitely known, it is clear that more
than 100 000 Americans die each year from VTE. If we put this
in the context of other causes of death, more people die yearly
from VTE than from breast cancer, traffic accidents, and AIDS
combined. For those who survive, VTE confers significant morbidity.
Up to 40% of patients may suffer a recurrent event in their
first 10 years after diagnosis despite initial effective blood-thinning
treatment, necessitating life-long therapy with blood thinners.
6 VTE also has chronic manifestations. More than a third of those
with DVT may develop chronic venous insufficiency causing leg
pain, swelling, varicose veins, and venous ulcers.
7 Currently,
few therapies are available for these patients, who suffer markedly
reduced quality of life.
|
How Can We Reduce the Risk of VTE?
|
|---|
The Surgeon General has called us to reduce the risk of VTE.
To accomplish this task, we must do 3 things: be aware of the
signs and symptoms of VTE, know the triggering factors, and
employ effective methods of prevention during high-risk periods.
The most frequent signs of DVT and pulmonary embolism are presented
in
Table 1. Risk may be acquired or genetic. Acquired risk factors
include obesity, cancer, exposure to hormone therapy, and smoking,
among others. Genetic risk includes mutations in an individual’s
DNA that make him or her more susceptible to developing VTE,
including deficiencies or resistance to his or her natural blood
thinners. In addition, risk of VTE increases with advancing
age. Common triggering events include admission to the hospital
for medical illness or surgery, pregnancy, trauma, prolonged
immobility, or cancer. The risk of VTE may be reduced by employing
effective methods of prevention such as the use of blood-thinning
medications during hospitalization or after surgery or by reducing
vein blood stasis via mechanical compression devices or compression
stockings. Staying active and well hydrated and resuming activity
as quickly as possible after illness also reduces risk. Guidelines
for the prevention of VTE during a hospital stay, available
to every hospital and practitioner, are given in
Table 2.
|
What Are the Gaps in the Public Health Response?
|
|---|
The Surgeon General has identified gaps in the application and
awareness of evidence-based guidelines and interventions to
reduce the risk of VTE and developed a framework for how these
deficiencies may be overcome. Despite the availability of effective
preventive measures for VTE, many high risk patients including
those hospitalized or undergoing surgery do not receive this
prevention. A large US study of more than 5000 patients at 183
medical centers found that the majority of hospitalized patients
did not receive any prophylaxis for VTE.
8 Furthermore, it has
been found that many patients who develop VTE while in the hospital
do not receive adequate treatment or education about their illness.
In May 2006, the Surgeon General and the National Institutes
of Health hosted a workshop on DVT that began the development
process for this call to action. To overcome these gaps in awareness
by healthcare providers and citizens alike, the Surgeon General
has designed an action plan outlined by the acronym CARE: Communication,
Action, Research, and Evaluation.
1 The CARE action plan will
be facilitated in the settings of communities, the healthcare
system, and policymakers and government with the overall goal
of enacting a comprehensive plan aimed at stemming this public
health crisis.
|
What Does the Future Hold?
|
|---|
The Surgeon General’s call to action will serve as a catalyst
for promoting widespread awareness and development of new mechanisms
to reduce the burden of VTE. If successful, it will achieve
the goals of widespread public knowledge on the signs, symptoms,
and risk of VTE, employment of effective prevention for those
at highest risk, and development of new scientific strategies
to treat and prevent the long-term morbidity of the disease.
Over the past 40 years, since the first call to action, we have
been successful in reducing cardiovascular mortality in the
United States, an achievement largely attributed to education
about the harms of cigarette smoking. Our goal is to achieve
equal success in recognizing and preventing VTE, a disease as
common as sudden heart attack. The US Surgeon General has called
us to action, and indeed we must act: to educate, to prevent,
to treat, and to discover. Our lives depend on it.
|
Acknowledgments
|
|---|
Disclosures
None.
|
Footnotes
|
|---|
The information contained in this
Circulation Cardiology Patient
Page is not a substitute for medical advice, and the American
Heart Association recommends consultation with your doctor or
healthcare professional.
|
References
|
|---|
1. US Department of Health and Human Services. Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism 2008. Available at: http://www.surgeongeneral.gov/topics/deepvein. Accessed April 3, 2009.
2. Smoking and Health: A Report of the Advisory Committee to the Surgeon General of the Public Health Service 1964. Publication No. 1103. Washington, DC. US Public Health Service, Office of the Surgeon General; 1964.
3. American Public Health Association. Deep-vein thrombosis: advancing awareness to protect patient lives: Public Health Leadership Conference On Deep-Vein Thrombosis. White paper presented at: Public Health Leadership Conference on Deep-Vein Thrombosis; February 26, 2003; Washington, DC. Available at: http://www.apha.org/NR/rdonlyres/A209F84A-7C0E-4761-9ECF-61D22E1E11F7/0/DVT_White_Paper.pdf. Accessed April 3, 2009.
4. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ III. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998; 158: 585–593.[Abstract/Free Full Text]
5. Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, Forcier A, Dalen JE. A population-based perspective of the hospital incidence and case-fatality rates of deep-vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Intern Med. 1991; 151: 933–938.[Abstract/Free Full Text]
6. Prandoni P, Noventa F, Ghirarduzzi A, Pengo V, Bernardi E, Pesavento R, Iotti M, Tormene D, Simioni P, Pagnan A. The risk of recurrent venous thromboembolism after discontinuation of anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism: a prospective cohort study of 1626 patients. Haematologica. 2007; 92: 199–205.[Abstract/Free Full Text]
7. Kahn SR, Kearon C, Julian JA, Mackinnon B, Kovacs MJ, Wells P, Crowther MA, Anderson DR, Van Nguyen P, Demers C. Solymoss S, Kassis J, Geerts W, Rodger M, Hambleton J, Ginsberg JS Predictors of the post-thrombotic syndrome during long-term treatment of proximal deep vein thrombosis. J Thromb Haemost. 2005; 3: 718–723.[CrossRef][Medline]
[Order article via Infotrieve]
8. Goldhaber SZ, Tapson VF. A prospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004; 93: 284–288.
Top
Introduction
Why Is It Important...