The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism
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.
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.
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.
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.
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.
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.
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.
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.
Goldhaber SZ, Tapson VF. A prospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004; 93: 284–288.