Doc: Provoked clots may make case to end blood thinners
Dear Dr. Roach: I would like your opinion about staying on blood thinners for the rest of my life. In July 2017, a CT scan showed a small blood clot in my lower-left lung. This was an indirect result of a grade 3 hamstring pull suffered while jogging. I am now on 20 mg Xarelto daily.
My doctor said that I would need to stay on blood thinners for the rest of my life because in 2010, I had a DVT and blood clots in both lungs as a side effect of birth control pills. (At that time, I took Coumadin for six months.)
I am 63, exercise daily, maintain a 1,200-calorie diet and take no other medications. After the current blood clot is reabsorbed into my bloodstream, I want to stop taking Xarelto. Is that advisable, or do I really need to be on this medication for life?
Dear E.D.: There is not a clear right or wrong answer to your question. My guess is that if you saw 10 hematologists with expertise in managing people with blood-clotting issues, eight of them would tell you to stay on some kind of anticoagulant — both warfarin (Coumadin) and rivaroxaban (Xarelto) reduce your body’s ability to make clots — but two would not. There is much room for judgment in medical decision-making, and the patient’s desires need to be factored in.
In your case, you could make an argument that both of your clotting events were “provoked,” meaning there was some identifiable reason for them. In the first case, the risk was eliminated by stopping the oral contraceptives; in the second, it was due to a muscular injury (perhaps you were on bed rest for a period of time afterward, which is a clear risk factor). These factors argue against the necessity for lifelong anticoagulation.
On the other hand, a history of blood clots means that there is damage to those deep blood vessels. Even though the body partially heals them, you are always at higher risk for developing a clot. Also, a blood clot in the lung (pulmonary embolus) is potentially life-threatening, and two pulmonary emboli is generally an accepted indication for lifelong anticoagulation.
I’ve seen people go to doctor after doctor until they get the opinion they want. That’s a mistake, in my view (I’m not saying you are doing that). Rather, I’d try going back to the doctor who recommended the long-term Xarelto and ask what the risks and benefits are, and explain your reasons for wanting to avoid the medication.
Finally, do you really mean 1,200 calories? That’s not enough for most people.
Dear Dr. Roach: I read that swimming is considered the “perfect exercise.” Do you agree?
Dear R.C.: My experience with people who write that one exercise is the best (or the most difficult) is that they often choose the one they like best. For the vast majority, the best exercise for you is the one you will keep doing, since pretty much any exercise is better than none.
Swimming is great exercise: It works many muscle groups and has outstanding cardiovascular effects. It’s easy on the joints, which is a major benefit for some. However, it doesn’t provide as much benefit to your bones as higher-impact exercise. It doesn’t provide the balance benefits of yoga or tai chi. But if you like to swim, then swim! You can get additional benefit from other exercises, including walking, which may be the easiest exercise for most.
Email questions to ToYourGoodHealth@med.cornell.edu.