Blood clots Flashcards by Jullianna Paggabao

What are the types of venous thromboembolism?

Deep vein thrombosis - blood clot (thrombus) forms in deep vein in 1 leg + partially/totally blocks blood flow
Pulmonary embolism - life threatening - blood clot (embolus) travels to lungs + block blood flow

How well did you know this?

Not at all

Perfectly

What are the symptoms of deep vein thrombosis?

Unilateral pain + swelling
Warm + red skin
Vein distention

How well did you know this?

Not at all

Perfectly

What are the symptoms of pulmonary embolism?

Dyspnoea
Chest pain
Coughing blood

How well did you know this?

Not at all

Perfectly

Which Pts require thromboprophylaxis?

Immobility
Obesity BMI >30
60+
Pregnancy, postpartum
Oestrogens: HRT, COC

How well did you know this?

Not at all

Perfectly

What are the pharmacological treatment of VTE?

DOAC
Heparin
- Unfractionated in renal impairment
- Alt: fondaparinux

How well did you know this?

Not at all

Perfectly

What is the duration of VTE pharmacological prophylaxis?

General surgery/medical patient: 7 days
Major cancer surgery in abdomen: 28 days
Spinal surgery: 30 days

How well did you know this?

Not at all

Perfectly

What are the mechanical treatment for VTE?

For excessive bleed risk:
Pneumatic compression
Anti-embolism stockings
- Don’t offer in acute stroke + leg condition (peripheral arterial disease)

How well did you know this?

Not at all

Perfectly

What is the duration for VTE mechanical prophylaxis?

Until sufficiently mobile
Spinal injury, spinal/cranial surgery: 30 days
Acute stroke: 30 days

How well did you know this?

Not at all

Perfectly

What is used for pharmacological thromboprophylaxis in hip and knee replacement?

FIRST LINE - Rivaroxaban
- Hip: 35 days, Knee: 14 days
LMWH + anti-embolism stockings
- Hip: 28 days, knee: 14 days
Hip: LMWH 10 days + low dose aspirin 28 days
Knee: low dose aspirin 14 days
Alt: apixaban, dabigatran

How well did you know this?

Not at all

Perfectly

What is used for mechanical thromboprophylaxis in hip and knee replacement?

Knee: pneumatic compression
Hip: anti-embolism stockings

How well did you know this?

Not at all

Perfectly

What is the treatment for DVT + PE?

Apixaban OR rivaroxaban
- At least 3m (3-6m if active cancer) (Provoked VTE: surgery, COC, pregnancy, leg cast)
- Unprovoked 3m+ (6m+ if active cancer)

How well did you know this?

Not at all

Perfectly

What is the thromboprophylaxis + treatment for VTE used in pregnancy?

Thromboprophylaxis: LMWH + pneumatic compression (if immobilised)
VTE: LMWH (unfractionated if INC bleeding)

How well did you know this?

Not at all

Perfectly

Which anticoagulants are factor XA inhibitors?

Apixaban
Edoxaban
Rivaroxaban

How well did you know this?

Not at all

Perfectly

Which anticoagulant is a thrombin inhibitor?

Dabigatran

How well did you know this?

Not at all

Perfectly

What is the mechanism of action of heparins?

Activates antithrombin which inhibits clotting factors Xa + IIa (thrombin)

How well did you know this?

Not at all

Perfectly

What are the indications for heparins?

LMWH: tinzaparin, enoxaparin, dalteparin

For pregnancy (RED risk of osteoporosis + heparin induced thrombocytopenia)

Unfractionated heparin - shorter HL
- For high risk of bleeding + renal impairment

How well did you know this?

Not at all

Perfectly

What are the side effects of heparin?

Bleeding
- Antidote: protamine (reverse LMWH)

Hyperkalemia (heparins block aldosterone secretion in renin angiotensin system)
- Diabetics + CKD at higher risk
- Monitor: potassium

Heparin-induced thrombocytopenia → DISCONTINUE
- RED 30% platelet, skin allergy, thrombosis

Osteoporosis

How well did you know this?

Not at all

Perfectly

What are the interactions of heparins?

Hyperkalaemia
Anticoagulants, anti-platelet, NSAIDs, SSRI → INC Bleeding

How well did you know this?

Not at all

Perfectly

What is the MOA of warfarin?

Vitamin K antagonist - reduce ability to form blood clots by blocking formation of vitamin K dependent clotting factors (48-72H)

How well did you know this?

Not at all

Perfectly

What is the indication of warfarin?

VTE + stroke prevention in AF

How well did you know this?

Not at all

Perfectly

What are the rules for a missed warfarin dose?

Missed dose: take ASAP but don’t take more than 1 dose in a day

What are the pill colours for warfarin?

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

How long do you take warfarin in provoked VTE + isolated calf DVT?

Isolated calf DVT: 6w

Provoked VTE: 3m

Surgery, COC, pregnancy, leg cast

Can you take warfarin during pregnancy?

Teratogenic

How often is warfarin monitored?

INR every 12 weeks - More frequent: intercurrent illness

What are the target INR when taking warfarin?

Must be w/in 0.5 of target - 2.5: VTE, AF, MI, cardioversion, artifical valves - 3.5: recurrent VTE if on anticoagulant + INR >2

What are the MHRA warnings for warfarin?

- Reports of calciphylaxis: consider stopping if diagnosed. Risk factor: end stage renal disease. Report painful skin rash - MHRA: OTC oral miconazole gel CI. Report signs of serious bleeding - if prescribed, monitor INR

What happens if a patient has an INR of 5-8 with no bleed?

w/hold 1-2 doses

What happens if a patient has an INR of 5-8 with minor bleed?

IV phytomenadione + restart when INR <5

What happens if a patient has an INR of >8 with no bleed?

Oral phytomenadione + restart when INR <5

What happens if a patient has an INR of >8 with minor bleed?

IV phytomenadione + restart when INR <5

What happens if a patient is on warfarin with a major bleed?

ADD dried prothrombin complex or fresh frozen plasma + restart when INR <5

What are the food interactions of warfarin?

- Alcohol binge - Cranberry juice - Green, leafy veg

What are the OTC interactions of warfarin?

- Miconazole - NSAID - Vit E + K supplement

What happens when taking warfarin and undergoing surgery?

- Elective: stop 5 days before - VTE high risk: bridge w LMWH - Emergency: IV phytomenadione

What are the interactions of warfarin?

- NSAID, anticoagulant, SSRI → INC bleed - Enzyme inhibitors → INC anticoagulant effect - Enzyme inducers → DEC anticoagulant effect

What is the MOA of DOACs?

Directly inhibits clotting factor Xa or IIa (thrombin)

What are examples of DOACs?

- Apixaban - Dabigatran (special container, protect from moisture: 4m expiry) - Edoxoban - Rivaroxaban (MHRA: after food, licensed to be crushed)

What are the indication of DOACs?

VTE, prevent stroke in Non-valvular AF

What are the missed dose rules when taking DOACs?

Missed dose >6h - Take dose at normal time - Anticoagulant effect last 12-24h

What are the side effects of DOACs?

Bleeding (Monitor signs of bleeding + anaemia, Renal function test in RI) - MHRA

What are the reversal agents for DOACs?

- Idarucizumab - dabigatran - Andexanet alfa - apixaban, rivaroxaban

What are the CI of DOACs?

Prosethetic heart valve - MHRA: rivaroxaban not for thromboprophylaxis - Inc risk of mortality, thromboembolic + bleeding events Antiphospholipid syndrome - MHRA: INC risk of recurrent thrombotic events MHRA: CI w new oral anticoagulants

What are the interactions of DOACs?

- NSAID, anticoagulant, SSRI → INC bleed - Enzyme inhibitors → INC anticoagulant effect - Enzyme inducers→ DEC anticoagulant effect - Carbamazepine red exposure to apixaban

What are the types of strokes?

Ischaemic (includes TIA - mini strokes that temp interrupt blood supply to brain) - Atherosclerosis, thromboembolism in AF Haemorrhagic - High BP, aneurysm, arteriovenous malformation

What is the treatment for an ischaemic stroke?

Clopidogrel (first line) - Alt: aspirin - Co-prescribe PPI, prevent dyspepsia + GI bleed High intensity statin Anti-hypertensive if BP is high - Don’t offer Beta-blocker unless for co-existing condition Review anticoagulant in patients w AF

What is the treatment for a haemorrhagic stroke?

- Antihypertensive - AVOID: aspirin, anticoagulant, statin - high risk of bleed

What is used for secondary CVD prevention?

- Low dose Aspirin (75mg OD) - Clopidogrel - Dipyridamole

How is dipyridamole taken?

- 30-60min before food - MR - after food - MR caps ‘special container’ - discard in 30 days/6 weeks

What are examples of glycoprotein IIB/IIA inhibitor (antiplatelets)?

Prasugrel + ticagrelor

What is used for long term management of a TIA?

MR Dipyridamole and Aspirin