- Carotid dopplers (ultrasound) to look for plaques in the carotid arteries that can break off and end up in the brain. Plaques are the crap that builds up after too many years of bad lifestyle decisions.
- EKG and cardiac echo (ultrasound) to look for irregular heart rhythms or structural problems that could cause a clot. Irregular heart rhythms allow blood to swish around in the heart instead of rocketing through, and when blood holds still, it’s more likely to clot. Some structural heart problems can provide clots with ways to get to the brain (causing a stroke).
- More blood tests to figure out if you’ve got some kind of genetic predisposition to clotting.
In about a third of strokes, no cause is ever identified. Letang falls into that category – sort of.
A hole in the heart? What?
The hole in Letang’s heart is most likely a PFO (patent foramen ovale), which is actually present in about 25% of people, most of whom will never know it’s there. Before you’re born, your blood doesn’t circulate through your lungs. Fetal circulation is weird, and not worth getting into other than to say that blood skips the lungs by way of a hole between the two upper chambers of the heart – the foramen ovale. When you’re born, that hole closes up about 75% of the time. When a PFO and no other possible cause is found as part of a stroke workup, then you’ll probably assume it’s the culprit. The blood that sneaks through the PFO hasn’t been through the lungs. In addition to loading your blood up with oxygen, the lungs serve to filter out various garbage like little clots. A little clot you’d never even know was there, up until it skips the lungs and gets sent out of the heart up to the brain, where it blocks circulation. Then you have nausea and dizziness, and you’re Kris Letang.
OH CRAP! HOLE IN THE HEART! NOW WHAT???
If you haven’t had a stroke and you just happen to be having an ultrasound of your heart, you’ve got a one in four chance that they’ll find a PFO. What do they do about it? Usually nothing. If it’s small and you’re asymptomatic, the risk of fixing it or putting you on medication outweighs the benefit. If it’s huge, it’ll probably get fixed. That’s accomplished either with open heart surgery or with a small device that’s inserted into the hole by way of a catheter threaded through major vessels in the groin up into the heart. If you’ve had a stroke and they find a PFO, then the first step is antiplatelet therapy, and that’s why six weeks isn’t a ridiculous estimate. Antiplatelet therapy is not anticoagulation. It’s aspirin.
So… Aspirin? For a STROKE?
Yup. Aspirin isn’t the same as anticoagulants like coumadin/warfarin/the active ingredient in rat poison/the stuff guys like Pittsburgh’s Tomas Vokoun and Winnipeg’s Paul Postma were on. Very, very simply put, anticoagulants (“blood thinners”) like coumadin reduce your ability to clot by messing up your body’s clotting factors (fancy chemicals in your blood). That means you probably shouldn’t be playing hockey, because if you get hit you’re going to bleed easily and it’s going to be a pain in the ass to get you to stop. It’s a good thing if you’ve had a big clot somewhere you don’t want (like your leg) because you really don’t want more clots forming. Antiplatelet agents like aspirin keep platelets from clumping together, which also affects clotting, but doesn’t have nearly the same amount of scary side effects. It also isn’t affected by what you eat (like coumadin), doesn’t require frequent blood tests (like coumadin), and may not keep you from playing hockey (like coumadin). It’s particularly good for arterial clots, and those are the ones that cause strokes. Of course any doctor is going to tell you that you shouldn’t play contact sports if you take aspirin because of the bleeding risk. In reality, good luck telling a guy that takes one regular strength aspirin a day to stay off the ice.
So? What now?
Now Letang likely gets put on aspirin, and starts rehab to improve his symptoms. In six weeks he’ll be reevaluated, and is supposedly going to start skating after the Olympic break if he’s feeling well enough. While having a stroke at 26 is clearly awful, his outcome could have been far worse, and his attitude is clearly stellar:
I hope that by making my condition public at this time I can help other people by encouraging them to seek medical help if they experience some of the symptoms associated with a stroke, regardless of their age or general health. It obviously was a shock to get the news but I’m optimistic that I can overcome this and get back on the ice.
Elsewhere in blood clot news…
Tomas Vokoun is off the blood thinners! He had a large clot in an upper leg/pelvic vein in the preseason on which he had a thrombectomy (where the clot is broken up and sucked out), and was then placed on anticoagulants. He’s back on the ice and taking shots, but no word on if he’ll be able to return this season.
Paul Postma is off the blood thinners! Winnipeg’s Postma had some leg pain in October that turned out to be a blood clot. He spent three months on anticoagulants, and was back skating in mid-January. After a short conditioning stint in the AHL, the Jets have called him back up.
MARTY ST LOUIS IS GOING TO THE OLYMPICS. This has nothing to do with blood clots, it’s just great news for St. Louis and his massive majestic legs.