Blood clots Flashcards by Michelle Mwangi

What are the two types of venous thromboembolism?

-deep vein thrombosis
-pulmonary embolism

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what is a deep vein thrombosis?

a blood clot occurs in a deep vein, usually in calf of one leg

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what is a pulmonary embolism?

detachment of blood clot which travels to the lungs and blocks the pulmonary artery

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what is included in a VTE risk assessment?

-immobility
-obesity BMI >30
-Malignant disease
-60+ years
-history of VTE
-HRT/combined contraception
-varicose veins with. phlebitis
-pregnancy
-critical care
-significant co-morbidites

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what can increase risk of bleeding?

-thrombocytopenia
-acute stroke
-bleeding disorders acquired: liver failure inherited: haemophilia, von willebrands disease
-anticoagulants
systolic hypertension

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what is a type mechanical VTE prophylaxis?

-compression stockings
for patients schedule for surgery continued until sufficiently mobile

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When is pharmacological VTE prophylaxis needed?

-for high risk patients undergoing surgery or patient’s admitted to hospital as general medical.

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what the different types of parenteral anticoagulants?

-low molecular weight heparin
-unfractionated heparin in renal failure
-fondaparinux

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What VTE prophylaxis can be used after knee/hip replacement surgery?

NOACs

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what is the treatment length for recurrent VTE?

long term

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what is the needed duration of VTE prophylaxis for general surgery?

5-7 days or until sufficient mobility

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what is the needed duration of VTE prophylaxis for major cancer surgery in abdominal or pelvis?

28 days

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what is the needed duration of VTE prophylaxis for knee/hip surgery?

extended duration 35 days

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what is the treatment of VTE?

-lmwh or unfractionated heparin in renal failure
for at least 5 days and until INR at 2 or ore for at least 24 hours. Monitor APTT if unfractionated heparin given.
-start oral anticoagulant at the same time, usually warfarin

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what VTE is used in pregnancy?

-LMWH is the preferred choice
-Lower risk of osteoporosis and heparin-induced thrombocytopenia
-stop at labour-onset, seeks specialist advice on continuing after birth

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what are some examples of unfractionated heparin, duration of action, when its the preferred choice, when its essential?

-standard heparin
-shortest duration of action
preferred choice if: high risk of bleeding and renal impairment
-essential to measure APTT (Activated partial thromboplastin time)

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what are some examples of low molecular weight heparin, duration of action, when its the preferred choice, when its essential?

-tinzeparin
-enoxaparin
-dalteparin
-longest duration of action
-preferred choice lower risk of= osteoporosis, heparin-induced thrombocytopenia
-used in pregnancy

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what are the side effects of heparin?

-Haemorrhage= withdraw heparin. If rapid reversal required= antidote protamine
-Hyperkalaemia= heparin in hibit aldosterone secretion. Higher risk in Diabetes and CKD. Monitor before treatment and if >7 days use.
-Osteoporosis
-heparin-induced thrombocytopenia= occurs 5-10 days after. Clinical signs 30% reduction in platelets, skin allergy, thrombosis. monitoring: before treatment and if >4 days use

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what are some other parenteral anticoagulants?

-heparinoid
-argatroban
-hirudin
-heparin flushes
-epoprostenol
-fondaparinux

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how long does it take for warfarin to work?

48-72hours

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what are the different colors and strengths of the 4 warfarin tablets?

white- 0.5mg
brown- 1mg
blue- 3mg
pink- 5mg

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what is the usual dose and maintenance for warfarin?

-5mg initially and monitor every 1-2 days
-maintenance 3-9mg at same time each day

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how often is INR checked once the patient is stable on warfarin?

every 3 months

what is the duration of treatment for isolated/distal calf DVT?

6 WEEKS

what is the treatment for CONFIRMED proximal DVT and PE? unsuitable?

Apixaban or rivaroxaban -give LMWH for at least 5 days then dabagatran or edoxaban or -LMWH + warfarin for at least 5 days or till INR is at least 2 for 2 consecutive readings, followed by warfarin alone

what is the duration of treatment for warfarin in PROVOKED vte (COCs, pregnancy, immobile, leg plaster cast)~?

3 months

what is the duration of treatment in unprovoked (underlying condition that cant be reversed, AF)?

3+ months/long term

what is the target INR 2.5 indications for?

VTE= AF, MI, cardioversion, bioprosthetic mitral valve, treatment of DVT/PE

what is the target INR 3.5 indications for?

RECURRENT vte in patients receiving anticoagulant and INR >2

what two documents need to be given to patients when they are started on warfarin?

-yellow (red) treatment booklet -anticoagulant alert card

what can cause changes in INR? (mhra/chm advice)?

-direct acting antivirals to treat chronic hepatitis C: AFFECTS EFFICACY OF WARFARN SHOULD CLOSELY MONITOR -over the counter oral miconazole gel (Dakarin) contraindicated in patients taking warfarin. Closely monitor if miconazole prescribed. It is a potent enzyme inhibitor; increases anticoagulant effect of warfarin- risk of bleeding

what are some side effects of warfarin?

-bleeding: nose bleeds <10mins, bleeding gums, bruising -calciphylaxis; patient should report painful skin rashes. Risk factor is end stage renal disease

what is the antidote for warfarin?

vitamin K; phytomenadione

what should a patient do if they start bleeding when they are on warfarin?

major bleeding: -stop warfarin -IV phytomenadione (vitamin K) -dried prothrombin complex or fresh frozen plasma

what should be done if a patient's INR is between 5-8 with no bleeding?

-withhold 1-2 doses -reduce maintenance dose -measure INR after 2-3 days

what should be done if a patient's INR is > 8 with no bleeding?

-omit warfarin -oral phytomenadione -repeat if INR still high after 24hrs -restart warfarin when INR < 5

what should be done if a patient's INR is between 5-8 with minor bleeding?

-omit warfarin -IV phytomenadione -repeat if INR still high after 24hrs -restart warfarin when INR <5

what should be done if a patient's INR is >8 with minor bleeding?

-omit warfarin -IV phytonadione -repeat if INR still high after 24hrs -restart warfarin when INR <5

what should be done if a patient is on warfarin and has a surgery and is minor risk, high risk patients and risk of thromboembolism ?

-Minor risk: surgery goes ahead if INR <2.5, restart warfarin 24hr after surgery. -increased risk of bleed: stop warfarin 3-5 days before elective surgery -give oral phytomenadione if INR >1.5 on day before surgery -patient high risk of thromboembolism bridge with LMWH, STOP LMWH 24hrs before then restart 48 hrs after surgery

what should be done if a patient is on warfarin and has an emergency surgery?

-delay 6-12 hours -no delay: give IV phytomenadione and dried prothrombin complex

what should be done if a patient is on warfarin and is high risk of VTE?

vte IN LAST 3 MONTHS, af WITH PREVIOUS STROKE/TIA, mechanical valve= bridge with LMWH (treatment dose) and stop 24hrs before surgery

what should be done if a patient is on warfarin and is high risk of bleeding?

-start LMWH 48 hours after surgery

what are the difference between dabigatran and the other NOACs?

dabigatran is a direct thrombin inhibitor and the others are direct factor Xa inhibitors

what are some examples of direct Xa inhibitors?

-apixaban -edoxaban -rivaroxaban

why are NOACs used instead of warfarin?

rarely causes bleeding and no monitoring required

what does ischaemic mean and what are the different types of stroke?

-blood clots obstruct blood supply -ischaemic stroke -Transient ischaemic attack 'mini stroke' -haemorrhagic

what does haemorrhagic mean and what should be avoided in them when managing?

-intracerebral haemorrhage -manage blood pressure and avoid statins

what is the initial management for a TIA or ischaemic stroke?

300mg aspirin TIA- continue till diagnosis is established Ischaemic stroke- aspirin for 14 days

what is the long term management for stroke?

TIA- first line: clopidogrel 75mg, second line: MR dipyridamole and aspirin Ischaemic- clopidogrel and in AF related stroke review for anticoagulant -Both TIA/ischaemic strokes- statin irrespective of serum cholestrol 48 hours after stroke , treat hypertension, not with beta-blocker unless indicated for another condition

what is the target BP for patients after a stroke?

<130/80 no beta blockers

what should be avoided with patients that have intracerebral haemorrhage?

-avoid aspirin, statin and anticoagulants as it increases the risk of bleeding; only give if essential -treat hypertension and take care to avoid hypoperfusion

what are antiplatelet drugs?

decrease platelet aggregation and Inuit thrombus formation in the arterial circulation

when is a low-dose aspirin used? dose?

75mg daily for secondary prevention of cvd/event

when is clopidogrel used?

following acute coronary syndromes or PCI

when is dipyridamole used and how? special features

used for secondary prevention of stroked. Take tablets 30-60mins before food. Persantin retard capsules special container- 6 weeks expiry

what are some examples of antiplatelets?

-cangrelor -prasugrel -ticagrelor -abciximab (monoclonal antibody)=glycoprotein IIa/IIb inhibitor -eptifibatide=glycoprotein IIa/IIb inhibitor -tirofiban=glycoprotein IIa/IIb inhibitor

what should the inn BE IF SWAPPING FROM WARFARIN DIRECTLY TO APIXABAN?