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CR2 > 16 - Venous Thromboembolism > Flashcards

16 - Venous Thromboembolism Flashcards

1
Q

Where do the majority of DVT originate from

A

calf venous sinuses

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2
Q

Is PE common

A

3rd most common cause of CV death

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3
Q

What are the causes of DVT

A

Virchow’s triad

  • Reduced blood flow – stasis
  • Vessel wall disorder
  • Hypercoagulability
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4
Q

What percentage of DVT are heritable, acquired and idiopathi

A

Heritable – 25%
Acquired – 50%
Idiopathic – 40%

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5
Q

What are some genetic risk factors for DVT

A

Antithrombin deficiency
Protein C, S deficiency
Factor V Leiden
Prothrombin gene mutation

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6
Q

Strong risk factors for DVT

A

Hip/pelvis fracture
Hip or knee replacement surgery
Trauma

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7
Q

Moderate risk factors

A

Pregnancy
Cancer
Combined OC picc

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8
Q

Weak risk factors

A

Bed rest > 3 days
Obesity
Varicose veins

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9
Q

Presentation of DVT

A 
Pain
Swelling
Warmth
Oedema 
(usually unilateral)
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10
Q

Why is objective diagnosis important in VTE

A

Drugs used to treat VTE cause serious side effects

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11
Q

Differential diagnosis

A

Post thrombotic syndrome
Cellulitis
Lymphoedema
Congestive heart failure

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12
Q

How do you diagnose DVT

A

1) Clinical pre test probability
2) D dimer test
3) Radiological assessment - Compression ultrasound, Venography (Gold standard)

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13
Q

What is the D-dimer test

A

blood test for non-specific marker of fibrin formation (usually raised in VTE but also in cancer, infection, inflammation, post-op, pregnancy)

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14
Q

What is post-thrombotic syndrome

A

Recurrent pain and swelling in the leg

more common with proximal DVT

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15
Q

What is the cause of post-thrombotic syndrome

A 
Venous hypertension (obstruction and valve damage)
Abnormal microcirculation with reversal of blood flow from deep to superficial veins
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16
Q

What are some signs and symptoms of a pulmonary embolism

A

Breathlessness
Pleuritic chest pain
Tachypnoea and tachycardia
Crepitations and pleural rub

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17
Q

What preliminary examinations would you carry out in a PE

A

ECG - sinus tachycardia,S1Q3T3 pattern
CRX - often normal, may see peripheral wedge shaped density above diaphragm
Arterial Blood Gas

All these can rule out other conditions

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18
Q

What is the differential diagnosis for PE

A 
Pneumonia
Asthma
Pneumothorax
Lung Cancer
COPD
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19
Q

What are the diagnostic tests for PE

A

Pulmonary Angiogram - Gold standard
D-dimer
pre-test probability (wells)
Isotope lung scan

20
Q

Prognosis of PE

A

If treated the prognosis is a lot better and mortality risk reduced to <5%

21
Q

What is the acute treatment of DVT and PE

A

IV heparin
SQ LMWH
SQ Fondaparinux

22
Q

What is the short term treatment of DVT and PE

A

Warfarin

SQ LMWH

23
Q

What is the long term treatment of DVT and PE

A

Warfarin
LQ LMWH
ASA (Aspirin)

24
Q

What blood tests would you ask for a patient with suspected DVT/P

A

FBC, clotting screen (PT and APTT), D-dimer, U&Es/LFTs

25
Q

Why is LMWH used instead of UFH

A

LMWH - SQ administration, 4hour half life, Fixed dose, no monitoring needed
UFH - IV administration, 60-90min half life, have to monitor with APTT, Variable adjusted dose

26
Q

What is the difference between the use of heparin and warfarin

A

Heparin is faster acting so would first use heparin for minimum of 5 days with warfarin as it takes a few days for warfarin to start working

27
Q

What is the therapeutic range for the INR

A

2.0-3.0

28
Q

What is Fondaparinux

A

Synthetic pentasaccharide
An anticoagulant that inhibits factor X
Has a 18 hour half life

29
Q

What drugs work on factor Xa

A

Apixaban
Endoxaban
Rivaroxaban

30
Q

How does heparin work

A

Activates antithrombin so thrombin is inactivated

31
Q

How does warfarin work

A

VitaminK antagonist

Prevents clotting factors 2, 7, 9 and 10, as well as the regulatory factors protein C, protein S, and protein Z.

32
Q

What is the half life of warfarin

A

36 hours

33
Q

What are the risk of warfarin

A

Has teratogenicity so not given to pregnant women as a risk to fetus
Major bleeding

34
Q

What can you use if you need to reverse the effects of warfarin

A

Prothrombin complex concentrate - contains the missing clotting factors

35
Q

What are some side effects of heparin

A

Major bleeding
Heparin induced thrombocytopenia
Osteoporosis

36
Q

Eg of a heparin antagonist

A

Protamine sulphate

37
Q

What do you give to a pregnant woman with VTE

A

LMWH

AVOID WARFAIN AND DOAC as they cross the placenta

38
Q

What do you give to a breastfeeding woman with VTE

A

LMWH and Warfarin are fine

but not DOACs

39
Q

What do you give to a patient with cancer associated thrombosis

A

LMWH (more effective than warfarin)

DOAC - under evaluation

40
Q

What is the risk of recurrence of VTE after stopping anticoagulants

A

Depends on reason for initial event
Overall initially 5% risk in 1 year
30% by 10 years
= If provoked by transient risk factor – 1-4% in 1st year
= If unprovoked or persisting cause – 5-10+% in 1st year

41
Q

When are thrombolytics used and what do they do

A

Clot busting

used in massive PE or limb threatening DVT

42
Q

When is a inferior vena cava filter used

A

if major contra-indication to anticoagulation or if recurrence of PE despite adequate anticoagulation

43
Q

What are the percentages of thrombophilia due to -

Factor V Leiden
Prothrombin gene mutation 
Protein C deficiency		  
Protein S deficiency		  
Antithrombin deficiency
A 
Factor V Leiden - 15%
Prothrombin gene mutation - 5%
Protein C deficiency - 1-2%
Protein S deficiency - 1-2%
Antithrombin deficiency - <1%
44
Q

What does protein C do

A

inactivates factors Va and VIIIa

45
Q

What does protein S do

A

Cofactor for Va and VIIIa inactivation by protein C

46
Q

What is antiphospholipid syndrome

A

Acquired form of thrombophilia
Diagnosed with thrombosis and pregnancy morbidity AND lab criteria (Lupus anticoagulant, anticardiolipin antibodies, anti-b2glycoprotein 1 antibodies)

CR2 (34 decks)

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