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Chapter 2 - Cardiovascular system > 3. Blood clots > Flashcards

3. Blood clots Flashcards

1
Q

xfTypes of venous thromboembolism

A
  1. Deep vein thrombosis
  2. Pulmonary embolism (life-threatening)
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2
Q

Deep vein thrombosis symptoms

A
  • Swollen veins
  • Hard and sore veins
  • Unitlateral pain in legs
  • Warm and red skin
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3
Q

Pulmonary emobolism symptoms

A
  • Chest pain
  • Dyspnoea
  • Coughing up blood
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4
Q

Groups whom require VTE prophylaxis

A
  • Immobility
  • Obesity BMI >30
  • Malignancy
  • First-degree relative
  • Pregnancy, post-partum
  • Oestrogens
  • Combined oral contraceptives
  • Personal history
  • Thrombophilic disorders
  • Varicose veins with phlebitis

C

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5
Q

Factors that increase a patient’s risk of bleeding

A
  • Acute stroke
  • Anticoagulants
  • Sytolic hypertension
  • Thrombocytopenia
  • Bleeding disorders: liver failure, haemophilia, von willebrands
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6
Q

Thromboprophylaxis treatment

A

Two types

1. Pharmacological
2. Mechanical

1. Pharmacological
* DOAC oral
~7 days in general surgery
~28/30 days in major cancer surgery and spinal surgery respectively
* Heparin (parenteral)
Alternatively: Fondaparinux

Unfractionated heparin is offered in renal impairement

2. Mechanical
If Pharmacological interventions usuitable, mechanical can be used. Worn until mobile

  • Pneumatic compression - inflatable sleeved worn on the legs
  • Anti-embolic stockings
    Should NOT be offered in acute stroke and legs conditions such as peripheral arterial disease
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7
Q

Hip and Knee replacement thromboprophylaxis

A
  • For 35 days in hip replacement
    LMWH + aspirin (10 days with further 38 days) OR LMWH + anti-embolism stockings
    OR rivaroxaban
  • For 14 days in knee replacement
    OR low dose aspirin for 14 days OR LMWH for 14 days WITH anti-embolism stockings
  • OR rivaroxaban

Apixaban or dabigatran can be used alternatively

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8
Q

Thromboprophylaxis and Venous thromboembolism treatment in pregnancy

A

Thromboprophylaxis:
LMWH + Pneumatic compression (if immbolised, alternatively: anti-embolism stockings)

Venous thromboembolism:
LMWH (unfractionated heparin if there is an increased risk of bleeding)

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9
Q

Venous thromboembolism treatment

A

Apixaban or Rivaroxaban

  • For at least 3 months (or up to 6 months in active cancer, as cancer increases likelihood of developing blood clots)
  • For unprovoked causes e,g combined oral contracepeptives, pregnant, leg cast: Around 3 months
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10
Q

Anticoagulants mechanism of action

A

Factor Xa Inhibitors:
* Oral DOAC: Apixaban, Edoxaban, Rivaroxaban
* Fondaparinux
* Heparins

Thrombin (Factor lla) inhibitiors
* Dabigatran
* Heparins:

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11
Q

Common errors associated with oral and parenteral anticoagulants

A

Dose
Wrong dose and duration
Wrong rate or frequency of parenteral anticoagulants

Drug-interaction
Duplication of therapy
Co-prescribing NSAID

Monitoring
Inadequate monitoring
Monitoring errors (lab values, vital signs)

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12
Q

Heparin uses and forms

A

Unfractionated heparin
Preferred if patient has HIGH risk of bleeding OR renal impairement (as it has a short half life so its effects can quickly be stopped, when discontinuing treatment)

LMWH e.g
tinzaparin
enoxaparin
dalteparin
It is Long-acting
lower risk of osteoperosis and thrombocytopenia

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13
Q

Heparin side effects

A
  • Bleeding
    Antidote: protamine
  • HyPERkalaemia
    Heparins block aldosterone secretion in the renin-angiotensin system = hyperkalaemia

Patients with chronic kidney disease
Patients who have diabetes mellitus are at a higher risk of this

  • Heparin-induced thrombocytopeonia
    If this occurs, heparin should be STOPPED
    Signs: skin allergy, thrombosis, reduced platelet count ~30%
  • Osteoporosis
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14
Q

Heparin interactions

A
  • Increased risk of HypERkalaemia, when taken with hyperkalaemic drugs:
    ACE inhibitors/ARBs, aldosterone anatagonists e.g spiranolactone, Ciclosporin and tracrolimus, NSAID, potassium-sparing diuretic, potassium supplement, trimethoprim
  • Increased risk of bleeding when taken with:
    Anitcoagulants e.g warfarin, DOAC’s, antiplatelets, SSRI’s NSAID, Venlafaxine
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15
Q

Warfarin mechanism of action

A

Antagonises Vitamin-K

It takes 48-72 hours to work

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16
Q

Warfain indications

A

For venous thromboembolism and preventing a stroke in atrial fibrillation

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17
Q

Warfarin dose

A

Maintenance dose: 3-9mg daily
If a dose is missed, should take it as soon as they remember

0.5mg WHITE
1mg BROWN
3mg BLUE
5mg Pink

For isolated calf DVT: 6 weeks
Provoked VTE (by surgery, pregnancy, combined oral contraceptives): 3 months
Unprovoked VTE: 3+ months

18
Q

Warfarin and pregnancy

A

Warfarin is teratogenic

Females of child-bearing age must take precautions

19
Q

Warfarin monitoring

A

INR is meased every 12 weeks
unless there is a change in the clinical condition

TARGETS:
2.5: VTE, AF, MI, cardioversion, artificial valves
3.5:Recurrent VTE if on anticoagulant
Can afford to be within 0.5 units of targets

Warfarin can cause Calciphylaxis (calcium accummulating in small blood vessels of fat and tissue). Patients must reprt painful skin rash

More likely to occur in patients with end-stage renal disease. consider stopping.

20
Q

Warfarin bleeding rules

A

If there is no bleeding
INR 5.0-8.0: Withold 1-2 doses of warfarin
INR>8.0: Oral phytomenadione

If there is bleeding
INR 5.0-8.0 OR INR>8.0: IV phytomenadione

Bleeding rules:
Patients must report nose bleeds >10mins, cuts that don’t stop bleeding, red urine, blood in vomiting, tarry stools, severe headaches, seizures

21
Q

Warfarin counselling

A

Patients should be given a yellow booklet and an anticoagulant alert card (shown to doctors and dentists before procedures)

Food interactions:
Green, leafy, vegetables (should eat similar amounts regularly)
Alcohol binge increases risk of bleeding
Cranberry juice increases risk of bleeding

OTC interactions:
Miconazole, NSAID, Vitamin E and K supplements

  • Avoid contact sports
  • Use a soft toothbrush to avoid bleeding gums
22
Q

Warfarin before surgery

A

Warfarin should be stopped 5 days before surgery
BUT
If patients are at a high risk of VTE, they can temporarily take a LMWH - bridging

If warfarin has not been stopped, in an emergency, IV phytomenadione can be used

23
Q

Warfarin interactions

A
  • Interacts with drugs that also cause bleeding as a side effects:
    Anticoagulants, Anti-platelet, SSRI’s, venlafaxine, tetracycline
  • NSAIDs and warfarin interact
    NSAIDs have a higher affinity for albumin than warfarin, displaces warfarin = more free warfarin in the blood = increased risk of bleeding
  • Interacts with cytochrome P450 inhibitors = reduce warfarin metabolism = more warfarin in blood
    Amiodarone, Azole antifungals, clarithromycin, erythromycin, metronidazole, quinolones, cranberry juice
  • Interacts with cytochrome P450 inducers = increase warfarin metabolism = less warfarin in blood
    Carbamazepine, Phenobarbital, Rifampicin, St John’s Wort
24
Q

DOAC’s special conditions

A

Used for venous thromboembolism and for non-valvular AF

  • Rivaroxaban - taken with food, only DOAC licensed to be crushed
  • Dabigatran - comes in a special container, must be kept in the original container. It has a 4 month expiry
  • Apixaban
  • Edoxaban*

DOAC’S End in ban or tran

25
Q

DOAC’s dose

A

Simpler dosing regimen, same dose is taken everyday.

Do not require regular monitoring

A missed dose is more than 6 hours, however as their effect only lasts for 12-24 hours, this means the anticoagulant effect is reduced or delayed when the dose is missed

26
Q

DOAC side effects and counselling (+antidotes)

A

Patients must carry their alert card at all times

Side effects:
* Bleeding
Caution in patients with renal impairement as DOAC’s are renally cleared. These patients have a higher risk of bleeds. These patients should be monitored.

Antidote for dabigatran: idarucizumab
Antidote for apixaban, rivaroxaban: andexanet alfa

Patiets must report signs of bleeding and read the PIL

27
Q

DOAC Contra-indications

A

DOAC’s should not be to patients with:

  • Prosthetic heart valves
  • Antiphospholipid syndrome
  • Patients already on other anticoagulants
28
Q

Rivaroxaban doses for VTE prevention

A

VTE prevention:
Replacement: 10mg OD
Replacing hip: 35 days
Replacing knee: 14 days

For recurring VTE: 10mg OD for 6 months+
Patients at high risk: 20mg OD

29
Q

Rivaroxaban doses for VTE treatment, stroke prevention and atherothrombotic event prevention

A
  • VTE treatment:
    15mg BD up to 20mg BD for 21 days
  • Stroke prevention in non-valvular AF:
    20mg OD
  • Prevention of atherthrombotic events:
    2.5mg BD
    It is the only DOAC that does this

Rivaroxaban can also be used for secondary prevention after a cardiovascular events

30
Q

Apixaban VTE prevention dose

A

VTE prevention:

Replacement of the hip:
2.5mg BD for 32-38 days

Replacement of the knee:
2.5mg BD for 10-14 days

For patients who have recurrent VTE:
2.5mg BD

31
Q

Apixaban dose for VTE treatment and stroke prevention in non-valvular AF

A

VTE treatment:
5-10mg BD for 7 days

For stroke prevention in non-valvular AF:
5mg BD
or
2.5mg BD (if the person is 80+, <61kg, creatnine ≥ 133)

32
Q

Edoxaban dose for VTE prevention and treatment, and for stroke prevention in non-valvular AF

A

Edoxaban doses are determined by weight

For VTE prevention
For VTE treatment
For stroke prevention in non-valvular AF:
30mg OD
If the person is above 61kg+: 60mg OD

33
Q

Dabigatran dose for VTE prevention

A

For hip replacement: 220mg OD for 35 days
For knee replacement: 220mg OD for 14 days
If the patient is 75years+, is taking amiodarone, or verapamil:150mg OD

34
Q

Dabigatran dose for VTE treatment and for stroke prevention in non-valvular AF

A

For VTE treatment
For stroke prevention in non-valvular AF:
150mg BD

If the patient is 75years+, has moderate renal impairement, is at risk of bleeding: 110-150mg BD
If the patient is 80years+, is taking verapamil:
110mg BD

35
Q

DOAC interactions

A
  • Interacts with cytochrome P450 inhibitors = reduce warfarin metabolism = more warfarin in blood
    Amiodarone, Azole antifungals, clarithromycin, erythromycin, metronidazole, quinolones, cranberry juice
  • Interacts with cytochrome P450 inducers = increase warfarin metabolism = less warfarin in blood
    Carbamazepine, Phenobarbital, Rifampicin, St John’s Wort
  • Interacts with drugs that also cause bleeding as a side effects:
    Anticoagulants, Anti-platelet, SSRI’s, venlafaxine, tetracycline
36
Q

What is arterial thrombosis

A

A blood clot forms in an artery, blocks blood supply to the heart and brain

Types:
* Ischaemic
Ischaemic (including transient ischaemic stroke) when blood supply is cut off to the brain:
Caused by atherosclerosis, Thromboembolism

  • Haemorrhagic:
    When a weak blood vessel that surrounds the brain bursts, spilling blood into the surrounding tissues
    Also known as a intracerebral haemorrhage caused by a very high blood pressure
37
Q

Symptoms of a stroke

A

act FAST

F - Facial weakness in one side
A - Arm weakness, paralysis on one or both sides of the body
S - Slurred speech, difficulty breathing
T - Time TO CALL 999

38
Q

Treatment of an ischaemic stroke (including TIA)

A
  • Clopidogrel (alternatively dypyridamole MR + aspirin) or aspirin alone
  • High-intensity statin (even if blood cholesterol is normal as most strokes are caused by atherosclerosis
  • Anti-hypertensive (NOT a beta-blocker unless they are taking it for another condition)
  • Patients with atrial-fibrillation should be reviewed for anti-coagulant)
39
Q

Treatment of an haemorrhagic stroke

A
  • Offer an antihypertensive
    as haemorrhagic strokes are commonly caused by high blood pressure
  • NO statin, NO aspirin, NO anticoagulant should be offered
40
Q

Antiplatelet mechanism of action

A

Lowers platelet aggregation and inhibits thrombus formation in arteries

41
Q

List of antiplatelets

A

Secondary CVD prevention
* Low-dose aspirin (75mg OD)
* Clopidogrel
* Dipyridamole (30-60mins before food, MR - after food and MR capsules are in “special container” to be discareded after 30 days/6weeks depending on manufacturer)

Glycoprotein llb/lla inhibitor
* Cangrelor
* Prasugrel
* Ticagrelor
* Tirofiban

Chapter 2 - Cardiovascular system (10 decks)

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