Beware of the “silent killer” – venous thromboembolism (VTE)

Venous thromboembolism (VTE) is a serious vascular disease known as the "silent killer" that often leads to serious complications and even endangers life[1]. Nearly 10 million cases of VTE occur worldwide each year[2]. In the United States, the number of VTE cases exceeds 2 million per year, and 20,000 people die from pulmonary embolism each year, of which 11% die within 1 hour of onset[3]. In Europe, there are 1.12 million new cases of VTE each year, and the number of VTE-related deaths is as high as 543,000[4]. A cross-sectional survey of 90 provincial capitals or large and medium-sized cities in China showed that the prevalence of VTE in my country continued to rise from 2007 to 2016, reaching 17.5/100,000[5]. VTE is an important cause of unexpected death in hospital patients[6].

1. Overview of VTE

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE), is the third most common cardiovascular disease after myocardial infarction and stroke [7]. The Chinese Guidelines for the Diagnosis and Treatment of Acute Pulmonary Embolism (2023) point out that pulmonary thromboembolism (PTE) is the most common type of acute pulmonary embolism (PE), and PE generally refers to PTE.

DVT refers to a clinical syndrome in which blood in the deep veins coagulates and forms thrombi, causing blood reflux obstruction in the corresponding blood vessels. When the thrombus falls off, the embolus can flow into the pulmonary artery and cause PTE, which poses a serious threat to life and health. Deep vein thrombosis and pulmonary thromboembolism are two different stages of the same disease. Virchow, a famous physician in the 19th century, proposed that the three major factors of deep vein thrombosis are: slow blood flow, damage to the blood vessel wall, and hypercoagulable state of blood.

2. Clinical manifestations of VTE

The clinical manifestations of venous thromboembolism vary depending on the type and location. Deep vein thrombosis (DVT) usually occurs in the lower limbs, but can also occur in the upper limbs. Its symptoms may not be obvious, and sometimes even no obvious symptoms, but usually include limb swelling, pain in the affected limb, skin changes, venous dilation, etc. The symptoms of pulmonary embolism (PE) are more serious, including sudden dyspnea, chest pain, cough, hemoptysis, tachycardia and hypotension, cyanosis, etc. The appearance of these symptoms often indicates that the condition is already quite serious and requires immediate medical attention [8].

3. Common risk factors for VTE

3.1 Age: The risk of postoperative DVT in patients aged ≥50 years is twice that of patients under 50 years old, and the risk increases by approximately 100% with every 10-year increase in age[9].

3.2 Malignant tumors: The incidence of VTE in patients with malignant tumors increases 2 to 3 times. In addition, chemotherapy, radiotherapy, and central venous catheterization also increase the risk of VTE [10-11].

3.3 Varicose veins: The venous congestion and vascular wall damage caused by varicose veins are conducive to the formation of thrombi. Studies in my country have shown that the incidence of postoperative DVT in patients with varicose veins is as high as 29.2%, while that in patients without varicose veins is 8.5% [12].

3.4 Previous history of VTE: Compared with those without a history of VTE, those with a history of VTE have an approximately 8-fold increased risk of recurrent VTE[13].

3.5 Surgery-related factors: malignant tumor surgery, surgery duration ≥3 h, postoperative bed rest ≥48 h, and hospitalization time >5 d can all promote postoperative VTE[14]. Studies in my country have shown that the incidence of DVT after gynecological laparoscopic surgery is significantly lower than that after open surgery without preventive measures[15-17].

4. VTE prevention measures (different prevention and control strategies according to different risk stratification)

4.1 Basic prevention

4.1.1 Reasonable diet:

The diet should be light, low in salt, sugar, fat, and cholesterol, rich in dietary fiber (such as tomatoes, fungus, green leafy vegetables, cabbage, etc.), eat more fresh fruits (such as apples, bananas, etc.), eat more deep-sea fish, shrimps, walnuts, etc., which contain a lot of protein and fatty acids, can accelerate the flow of blood in the body and reduce the cholesterol content in the body. Drink more water. If you don't have heart or kidney disease, drink 1500-2000ml of water every day to reduce the body's blood viscosity, thereby facilitating blood flow and reducing the risk of VTE.

4.1.2 Optimize lifestyle:

Quit smoking and drinking. Nicotine in tobacco can cause blood vessels to contract strongly, affecting peripheral blood circulation; excessive drinking can damage blood cells, both of which greatly increase the risk of thrombosis; pay attention to weight management. Obesity is an important risk factor for VTE, and weight loss can significantly reduce the risk of thrombosis. Set a reasonable weight goal based on personal health status and manage it under the guidance of a professional doctor or nutritionist; raise both lower limbs when resting, 20-30cm above the level of the heart to facilitate blood return; shoes and socks should be of appropriate tightness, too tight will cause poor blood flow; avoid sitting or squatting for long periods of time to affect blood circulation; the incidence of lower limb venous thrombosis is 3 times that of upper limbs, so avoid lower limb venous puncture.

4.1.3 Morning activities:

For patients who are bedridden for a long time or have limited mobility, their family members should be instructed to strengthen their bed exercises, such as training them to take deep breaths and cough more often, turning over regularly, and assisting them to do passive or active exercises of their limbs. Passive exercises include assisting patients to do abduction and adduction exercises of their limbs. Active exercises include:

Ankle pump exercise, method: the patient lies on his back, stretches his lower limbs, slowly and forcefully hooks the dorsum of the foot to the maximum angle, hold for 5 seconds; then press down on the foot, straighten the toes, hold for 5 seconds. Exercise volume: 10 hook and stretch movements as a set, do 2 sets each time; do 3 times a day, or do a set every 2 hours.

Static contraction of quadriceps femoris: The patient lies on his back, a small towel roll is placed on the popliteal fossa, the heel is placed on the bed, and the knee joint presses down the towel roll, hold for 5 seconds, and then relax. Exercise volume: 10 movements per set, 2 sets each time, 3 times a day.

Heel exercise, method: The patient lies on his back, with his heels against the bed, slowly moving along the bed surface toward the buttocks, and then slowly straightening. Exercise volume: 1 set of 10 movements, 2 sets each time, alternating between the lower limbs; do 3 times a day.

Straight leg raise: Method: The patient lies on his back, straightens his knees, tightens his abdomen, and slowly raises one leg until a slight tightness appears on the back of the thigh. Hook up the dorsum of the foot, hold for 3-5 seconds, and then slowly lower it. Exercise volume: 1 set of 10 movements, do 2 sets each time, alternating between the two lower limbs; do it 3 times a day.

4.1.4 Psychological care:

Studies have shown that anxiety and depression may affect the patient's hemodynamic indicators to a certain extent, causing the body's stress hormones such as cortisol to increase, increasing the patient's pain sensitivity, leading to a decrease in exercise compliance during hospitalization, and having an adverse effect on the patient's recovery. Therefore, nurses should patiently explain to patients the general steps, precautions, expected treatment effects, etc. when they are expected to receive treatment and care, so that they can understand the implementation method, thereby alleviating their own negative emotions and strengthening the patient's confidence in treatment [18].

4.2 Physical prevention

Intermittent inflation and pressurization device: The host cyclically inflates and deflates its airbag to intermittently apply pressure to the limb wrapped by the airbag to promote passive contraction of the pressurized limb muscles, thereby promoting venous blood return, which is used for the prevention of venous thrombosis.

Plantar venous pump: By using pulsed gas to quickly impact the sole of the foot in a very short time, the venous blood in the limbs can obtain a pulsed acceleration similar to walking, thereby greatly increasing the blood flow rate and effectively preventing the occurrence of VTE.

Gradient pressure stockings: According to the physiological characteristics of the human body, different pressures are applied to different parts of the lower limbs. The pressure is highest at the ankle, and then gradually decreases from the distal end to the proximal end to promote venous blood return. It is often used to prevent patients with high risk of VTE.

4.3 Drug prevention

High-risk groups should be given drug prevention as prescribed by the doctor, such as: low molecular weight heparin calcium injection, rivaroxaban tablets, aspirin tablets and other anti-thrombotic drugs, and the efficacy and side effects of the drugs should be closely observed, and regular follow-up visits should be conducted.

5. Conclusion

VTE is the most common potentially preventable disease in hospital-related mortality, with the characteristics of high mortality, high disability and high recurrence rate. Effective prevention and control measures can greatly reduce the occurrence of VTE, reduce patients' hospitalization costs, shorten their hospitalization time and improve their quality of life. This is not only beneficial to patients, but also reduces my country's medical economic burden.

References:

[1] Liu Dongyuan. Venous thromboembolism: the "silent killer" hidden in the body[J]. Family Knowledge, 2024, (07): 21.

[2] Jha AK, Larizgoitia I, Audera-Lopez C, et al. The global burden of unsafe medical care: analytic modeling of observational studies[J]. Bmj Quality & Safety, 2013, 22(10):809-815.

[3] Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb V asc Biil,2008,28:370-372.

[4] Go AS, D Mozaffarian, Roger VL, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association.[J]. Circulation, 2013, 127(1):E6-E245.

[5] ZHANG Z, LEI JP, SHAO

[6] Tang Shuya, Zhou Huaxian, Xiong Wujun, et al. Improving the linkage rate of standardized prevention of venous thromboembolism in hospitalized patients[J]. Chinese Journal of Health Quality Management, 2022, 29(10): 84-88. DOI: 10.13912/j.cnki.chqm.2022.29.10.18.

[7] Liu Lei, Ma Zhuang. Interpretation of the "Guidelines for Quality Evaluation and Management of Venous Thromboembolism in Hospitals (2022 Edition)"[J]. Western Medicine, 2023, 35(09): 1249-1251.

[8] Sui Yongjuan. Silent "health killer": venous thromboembolism[J]. Family Medicine. Happy Health, 2024, (09): 54.

[9] Qu H, Li Z, Zhai Z, et al. Predicting of Venous Thromboembolism for Patients Undergoing Gynecological Surgery[J]. Medicine, 2015, 94(39):e1653.

[10] Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism[J]. Circulation, 2003, 107:I9-16.

[11] Paolo P, F Anna, Andrea P. Cancer and venous thromboembolism[J]. Lancet Oncology, 2005, 6(6):401-10.

[12] Qu H, Li Z, Zhai Z, et al. Predicting of Venous Thromboembolism for Patients Undergoing Gynecological Surgery[J]. Medicine, 2015, 94(39):e1653.

[13] Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism[J]. Circulation, 2003, 107:I9-16.

[14] Lang Jinghe, Wang Chen, Qu Hong, et al. Expert consensus on prevention of deep vein thrombosis and pulmonary embolism after gynecological surgery[J]. Chinese Journal of Obstetrics and Gynecology, 2017, 52(10): 649-653.

[15] Peedicayil A, Weaver A, Li X, et al. Incidence and timing of venous thromboembolism after surgery for gynecological cancer[J]. Gynecologic Oncology, 2011, 121(1):64-69.

[16] Suzuki N, Yoshioka N, Ohara T, et al. Risk factors for perioperative venous thromboembolism: A retrospective study in Japanese women with gynecologic diseases[J]. Thrombosis Journal, 2010, 8(1):17-17.

[17] Qu H, Li Z, Zhai Z, et al. Predicting of Venous Thromboembolism for Patients Undergoing Gynecological Surgery[J]. Medicine, 2015, 94(39):e1653.

[18] Fang Yuanyuan. Research progress on preventive care for deep vein thrombosis[J]. Chinese Journal of Health Standard Management, 2023, 14(10): 185-188.

(First author: Gao Jiemei, deputy chief nurse, Guangzhou Chest Hospital; Corresponding author: Zhou Minjuan, deputy chief nurse, Guangzhou Chest Hospital)