200 experts discuss thrombosis risk management in Kazan

Modification of risk factors — a new religion

As experts say, in the modern world, risk factor management should become a new religion for doctors and patients. During the pandemic, it became clear that the health care system may not be able to cope with the peak load, so taking care of your health and preventing diseases should become an obligatory element of every person's lifestyle. Do not wait for the onset of menacing symptoms or postpone regular care of your health: the sooner we think about it, the lower the risks of developing various diseases, including thrombosis.

There are modifiable risk factors (which can be influenced) and unmodified ones (which a person cannot change). The modifiable ones include, for example, smoking, low physical activity, unhealthy diet, excessive alcohol consumption, obesity, stress. But we cannot influence age, gender or heredity.

However, as Yevgeny Roytman said in his speech at the Thrombosis Risk Management open expert council, any risk factor means only the probability of the onset of a particular condition. This is not yet a diagnosis, not a verdict, not an unconditional occurrence of an event. For different risk factors or their totality to be realised, the action of a trigger event is required, which will trigger the chain of thrombosis development.

“The question is what will trigger this avalanche in its movement from the mountain," says Evgeny Roytman. “Speaking of risk factors, we are dealing with a certain statistical probability. In fact, you and I, colleagues, are engaged in risk management, we try to manage risks. There are different strategies in this: either we try to completely avoid the risk factor, or we accept it, or, for example, we do something to reduce the severity of its action. By and large, everything we do as part of therapy is determined by our ability to modify risk factors.”

What are the risk factors for thrombosis?

So, what can lead to thrombosis? There are quite a lot of risk factors for developing thrombosis. It is important that representatives of different fields of medicine gathered to discuss thrombosis — phlebologists and oncologists, cardiologists and neurologists, surgeons and laboratory diagnosticians. Everyone considered their own nosologies and approaches — thus a large general mosaic was formed, which showed almost all the main directions of studying thrombosis and modifying their risk factors.

For example, in a report of Doctor of Medical Sciences Alla Shabalina, a leading employee of the Scientific Center of Neurology (Moscow), thrombosis was considered from the position of a neurologist. First of all, the doctor noticed that the central target of any neurologist's study is arterial cerebral thrombosis and ischemic stroke, which is not only a medical, but also a socially significant problem. It is known to increase mortality and is difficult to treat. Another type of arterial thrombosis is peripheral artery disease.

Venous thrombosis becomes an equally important problem — first of all, cerebral venous insufficiency. Venous thromboembolic complications — deep and superficial vein thrombosis and the infamous PE (pulmonary embolism) are a separate line.

Russia, according to Alla Shabalina, occupies one of the leading places in the world in terms of the prevalence of cerebrovascular diseases (strokes, for example). In this regard, it is important to study the accumulation of risk factors in the population. The most common risk factor in the Russian population is dyslipidemia (a violation of fat metabolism leading to atherosclerosis). Smoking, arterial hypertension, obesity, hyperglycemia and diabetes are next in frequency of occurrence. The more risk factors a person accumulates, the greater the risk of developing cerebrovascular diseases, primarily acute.

Separately, the doctor said that obesity, hyperglycemia and diabetes are significant risk factors. All of them, according to Alla Shabalina, can become triggers of an increase in prothrombotic status, affect hypercoagulation and hyperfibrinolysis. Scientists even identified a direct correlation between the area of visceral fat and the concentration of prothrombotic factors in the blood.

Of course, they also discussed Covid-19: as you know, it has become a serious factor provoking the development of thrombosis. Thousands of doctors around the world are thinking about how to modify this risk today. For example, Evgeny Roytman drew attention to that the risk of myocardial infarction increases eight times and the risk of ischemic stroke increases more than six times at the turn of the first and second weeks after the active phase of the coronavirus. But attending physician often does not have the opportunity to check each patient for the risk of developing these diseases. However, if we take into account the results of the study, we can modify this risk factor and reduce it in time!

Smoking is a risk factor that completely depends on the person…

Alla Shabalina in her report separately focused on smoking as one of the main risk factors for the development of thrombosis, cardiovascular and many other diseases. As a neurologist, she stressed that this is, perhaps, almost the only one of dozens of risk factors that can be completely corrected and removed from your life. The main thing a smoker can do for his health is to quit smoking!

“The Scientific Centre of Neurology, together with other organisations, has been investigating the impact of smoking on the development of stroke, cerebrovascular diseases for a long time," said the specialist. “The influence of smoking on the process of hemostasis was also determined, depending on the status of the smoker. In this study, patients were divided into groups: the health of hard-core smokers (who smoke more than 20 cigarettes a day) and less hard-core ones (who “smoke sometimes” or smoke less than 20 cigarettes a day) were studied separately. It turned out that the indicators of hemostasis in heavy smokers are much worse. Their blood viscosity is increased, platelet aggregation is increased, which means that the risk of thrombosis and cerebrovascular pathology (for example, acute stroke) is incomparably higher.”

An active campaign to combat smoking in Russia has been going on for more than a decade, and some success has already been achieved in this. The ban on smoking in public places, pricing policy and active educational activities — all this has had a considerable effect.

However, 33% of the Russian population still smokes. Every fifth Russian smokes at least a pack of cigarettes every day. Experts note with regret that the process of quitting smoking in Russia has actually stopped. If in 2017 74% of smokers reported that they wanted to give up the bad habit, today they are only 62%. There is nothing surprising in this: nicotine causes persistent addiction, so not everyone strives to give up smoking if the habit has already been formed. Let's recall the immortal words of Mark Twain, which are still relevant today: “Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.”

What should we do? Don't start smoking. But what if a person already smokes?

...but there is a nuance

Here experts pay attention to the following point: the main thrombogenic and oncogenic load from smoking is caused by tobacco combustion products and resins. It has long been known that a person inhales more than 7,000 chemical compounds as part of tobacco smoke. Nicotine itself does not cause cancer, is not a carcinogen. But the products of tobacco burning in a cigarette — yes, and it is proved. They also affect the formation of blood clots:

• they cause damage to the vascular endothelium through the activation of oxidative stress and chronic systemic inflammation;
• they affect blood clotting factors (fibrin, platelets, prothrombogenic factors), increasing hypercoagulation;
• they have an overwhelming effect on the DNA loci of the cell associated with the protection of the vessel wall.

What about alternative nicotine delivery systems? After all, there are also electronic tobacco heating systems that do not burn, but heat tobacco. Probably, the conference participants say, they are less harmful in this sense than smoking ordinary cigarettes — which means that if a person categorically cannot give up smoking, he can reduce the harm to health by switching to alternative smokeless products. However, as experts note, the long-term impact of electronic cigarettes and tobacco heating systems on the health of the cardiovascular system and lungs requires additional research.

Evgeny Roytman cited data from American colleagues in his report: in a study by the National Heart, Lung and Blood Institute — NHLBI (USA), the results of which were published on May 17, 2022, it turned out that, compared with traditional smoking, the use of electronic cigarettes reduced the risk of developing cardiovascular diseases by 30-40%. Yevgeny Roytman stressed:

“Combustion products, first of all, are passed by a heavy tank through the endothelium. Pay attention to the summary studies on alternative nicotine delivery systems. I really ask you not to conclude that their use is useful. All this is harmful. But, unfortunately, prohibitive measures alone do not work. And if we can modify this risk factor in heavy smokers, then we should use the already accumulated scientific data and, based on this, build communication with society. Not to avoid discussing alternative smokeless products, but to speak openly, including involving health administrators and the press, involving all interested parties, including manufacturers, in this dialogue. So we can modify this risk factor as well!”

Prescribing the right drug and no harm

The conference participants paid great attention to the methods of treatment of thrombosis, mistakes and successes, rare cases and discussion of the use of anticoagulants. For example, Professor Tatiana Vavilova, chief visiting specialist of the Ministry of Healthcare of the Russian Federation for Clinical Diagnostics, head of the Department of Laboratory Medicine and Genetics of the V.A. Almazov National Medical Research Centre (St. Petersburg) said:

“It is very good that we have great opportunities today, a wide selection of anticoagulants. But how we use this set is another question. When consulting my patients, first of all, I try to answer the main question: 'Was it necessary in principle to prescribe anticoagulants to this patient?' Everything is important: the ratio of indications and contraindications, restrictions, compliance with clinical recommendations. Because no matter how angry we are at the availability of clinical guidelines, standards and rules of medical care, they, of course, do not cover all cases, but they are a great help and help in our daily work!”

However, as the professor says, some cases do not fit into the standards, so the main goal of any antithrombotic therapy is to find a balance between the recommendations derived from large groups of patients and the specific clinical situation with this particular patient. Doctors face a huge number of situations of special, difficult choice. Not all of them fit into the usual combination. Tatiana Vavilova gives an example: these may be comorbid patients with multiple somatic pathologies, the elderly, pregnant women, children — it is difficult for all of them to prescribe anticoagulant therapy. It is often necessary to consider cases with neurological patients separately. And so on.

“That is, the recommendations are prescribed, but for many patients these issues have to be solved anew. The doctor should know how to prescribe the right drug and do no harm!” Tatiana Vavilova concluded her report.

In total, almost 200 doctors from all over Russia took part in the conference “World Thrombosis Day”. The Kazan cohort of doctors was very representative. About 1,300 doctors joined in to listen to the reports online. Within the framework of four sections, 20 specialists read 22 reports. The event was an excellent opportunity to draw attention to the serious problem that concerns millions of Russians. In conclusion, Yevgeny Roytman proposed to make the topic of modifying thrombosis risk factors the topic of the work of the medical community for the whole year until the next conference — World Thrombosis Day 2023.