2- DVT & pulmonary embolism

Question 1

what is DVT?

Answer 1

Deep Venous Thrombosis. A thrombus (clot) formed in the deep venous circulation (usually legs) but can be anywhere

Question 2

what is pulmonary embolism (PE) ?

Answer 2

A thrombus (clot) that has embolised (travelled) and lodged in the pulmonary circulation

Question 3

what is VTE?

Answer 3

venous thromboembolic disease

= covers both DVT & PE

Question 4

where is
a) distal DVT?
b) proximal DVT?

Answer 4

a) from below knee down (calf and down)
b) DVT of the popliteal vein or the femoral vein. These thromboses are termed ‘proximal’ because they are closer to the heart

Question 5

what is virchows triad?

Answer 5

3 contributing factors in formation of thrombosis:
1. endothelial injury (venous disorders, trauma/surgery, indwelling catheters)
2. circulatory stasis (immobility or paralysis, varicose veins, venous obstruction from tumour, obesity ir pregnant)
3. hypercoagulable state (malignancy, pregnancy, oestrogen therapy, IBS, sepsis)

Question 6

what are predisposing risk factors for thrombosis?

Answer 6

• history of VTE
• chronic heart failure
• advanced age
• varicose veins
• obesity
• immobility or paresis
• myeloproliferative disorders

Question 7

how does DVT present?

Answer 7

painful & swollen limb with redness & heat, tenderness along vein, sub acute development. no other obvious cause (classical description)

Question 8

how does PE present?

Answer 8

sudden SOB with pleuritic pain, collapse, haemoptysis, hypoxia & tachycardia

• you can use WELLS score as points system to determine probability

Question 9

what is D-dimer blood test and why do you do it?

Answer 9

• D-dimer is a breakdown product of cross linked fibrin
• valuable 1st line screening test for suspected VTE with low wells score

= if low risk of having DVT and D-dimer negative then you can exclude it
= if randomly check D-dimer and it’s high then it’s unlikely they’ve got a clot
= if you think that they have a clot and high D-dimer than they probably do have a clot

Question 10

based on result of WELLS score what should you do?

Answer 10

• If moderate-high probability PE or DVT likely then patient needs a scan
• If DVT unlikely or Low Risk PE then check D-Dimer. If D-Dimer high patient needs a scan. If D-Dimer Normal then VTE excluded

Question 11

what does severity assessment involve for DVT?

Answer 11

mostly just clinical assessment of severity (can you walk, pain level etc). Almost all managed as outpatient.

Question 12

what is severity assessment for PE?

Answer 12

PESI score + Patient Characteristics

• (needs proper assessment as comes with risk of death)
• Because PEs cause right heart strain and pressure there can be risk of deterioration and death. Severity assessment guides initial management

Question 13

what type of thing involved in PESI score?

Answer 13

• age
• male sex
• chronic heart failure
• pulse rate
• systolic blood pressure <100bpm
• resp rate >30 bretahs per min
• temp <36 degrees

= class I = low mortality risk , class V = high mortality risk

Question 14

what is management of DVT?

Answer 14

= oral anticoagulation

→there’s a small subset of patients where thrombolysis can be considered but this is only in highly specialist centres

Question 15

what is management of PE?

Answer 15

PE- high risk = thrombolysis then oral anticoagulation

PE - intermediate/low risk = oral anticoagulation

→highly specialist centres may consider some intermediate risk patients for thrombolysis

Question 16

what is thrombolysis?

Answer 16

• aggressive clot destruction
• absolute evidence is limited outwith treatment of massive PE, although theory of use in venous disease is actually stronger than in arterial disease

Question 17

what are direct oral anti-coagulants first line?

Answer 17

apixaban or rivaroxaban

Question 18

do you ever use low molecular weight heparin injection?

Answer 18

still use in patients with active cancer & PE

Question 19

how long does treatment take for VTE?

Answer 19

• Provoked VTE with reversible factor = 3-6 months treatment
• Provoked VTE with irreversible factor = 3-6 months or lifelong depending on patient factors

Question 20

what is post thrombotic syndrome and what is it characterised by?

Answer 20

• Occurs in nearly one-third of patients within 5 years after idiopathic DVT

PTS is characterised by:

• Pain
• Oedema
• Hyperpigmentation
• Eczema
• Varicose collateral veins
• Venous ulceration

Question 21

what is consequences of chronic thromboembolic pulmonary hypertension?

Answer 21

• Serious complication of PE
• Up to 5% of patients with PE are reported to develop CTPH
• Initial phase of disease often asymptomatic and followed by progressive dyspnoea and hypoxaemia
• Right heart failure can frequently occur
• Progressive condition associated with mortality rates of 4–20%