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Your Good Health: Active woman, 70, suffered clot to lung

Dear Dr. Roach: I am an active, healthy 70-year-old lady who, out of the blue, was hospitalized with a pulmonary embolus. I had no prior surgeries.

Dear Dr. Roach: I am an active, healthy 70-year-old lady who, out of the blue, was hospitalized with a pulmonary embolus. I had no prior surgeries. After discharge, my GP diagnosed me with Factor V Leiden mutation, heterozygous and an elevated homocysteine level. I was prescribed folic acid, vitamin B-6 and vitamin B-12 daily. Can you enlighten me further?

G.K.

A pulmonary embolus -- a blood clot to the lung — is a life-threatening emergency treated with anticoagulants. There are many risk factors for PE, such as surgery, but also prolonged immobilization, such as a long plane flight (which is why we recommend walking around during one).

There are some inherited predispositions for blood clots, and you mention two: factor V Leiden and homocysteinemia. Factor V Leiden is a common genetic variant (mutation), found in about five per cent of white North Americans. There are two copies of the gene. A person who is heterozygous, like you, has one normal and one abnormal copy. This has about a sevenfold risk of abnormal blood clotting. A homozygous person, one with two abnormal genes, has about an 80-fold risk of abnormal blood clotting. Although the relative risk is high, the absolute risk is not high enough to prescribe anticoagulants to treat most people who have a factor V Leiden mutation if they have never had an abnormal blood clot. But this decision should be personalized, with an expert such as a hematologist.

High homocysteine levels can come from a vitamin deficiency or from a different genetic variant, in the MTHFR gene. Having high homocysteine levels can increase your risk of blood clotting by two to three times. Although homocysteine levels usually go down after supplementation with folic acid (and to a lesser extent, vitamins B-6 and B-12), supplementation does not reduce the risk of further blood clots.

Using vitamin supplements is inexpensive and is unlikely to be harmful. Perhaps this is why your doctor recommended the vitamin therapy for you.

I would seek out a consultation with a hematologist who has special expertise in clotting disorders.

 

Dear Dr. Roach: I am an 85-year-old woman and have been taking gemfibrozil for more than 10 years. The only side-effect was slight memory loss. My doctor had me stop the medicine for six months and retested my cholesterol panel. My total cholesterol was 220, high-density lipoprotein 60, triglycerides 180 and low-density lipoprotein 130. The doctor said my high HDL protects me and I don’t need the gemfibrozil. I recently read researchers found HDL doesn’t protect the heart. I am not sure if I should continue gemfibrozil.

B.N.

People with high HDL levels have lower risk of heart attack than people with low HDL levels, although the mechanism for this is not clear. There is evidence that it is another factor present in people with high HDL levels that protects them. Certainly, medications that increase HDL have not had success in reducing heart-attack rates.

I have a high threshold to treat 85-year-olds with medications to reduce heart-attack risk unless they have known heart disease. The studies on gemfibrozil have shown it has very little effect on overall risk, so I would not recommend gemfibrozil or any cholesterol-lowering medication to someone with the cholesterol panel you have, unless there were other compelling reasons to do so.

 

Readers can email questions to ToYourGoodHealth@med.cornell.edu.