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High - Cardiovascular system > Blood clots > Flashcards

Blood clots Flashcards

1
Q

What are the types of venous thromboembolism?

A
  • 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
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2
Q

What are the symptoms of deep vein thrombosis?

A
  • Unilateral pain + swelling
  • Warm + red skin
  • Vein distention
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3
Q

What are the symptoms of pulmonary embolism?

A
  • Dyspnoea
  • Chest pain
  • Coughing blood
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4
Q

Which Pts require thromboprophylaxis?

A
  • Immobility
  • Obesity BMI >30
  • 60+
  • Pregnancy, postpartum
  • Oestrogens: HRT, COC
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5
Q

What are the pharmacological treatment of VTE?

A

DOAC
Heparin
- Unfractionated in renal impairment
- Alt: fondaparinux

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6
Q

What is the duration of VTE pharmacological prophylaxis?

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

What are the mechanical treatment for VTE?

A

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

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8
Q

What is the duration for VTE mechanical prophylaxis?

A
  • Until sufficiently mobile
  • Spinal injury, spinal/cranial surgery: 30 days
  • Acute stroke: 30 days
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9
Q

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

A

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

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10
Q

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

A
  • Knee: pneumatic compression
  • Hip: anti-embolism stockings
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11
Q

What is the treatment for DVT + PE?

A

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

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12
Q

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

A
  • Thromboprophylaxis: LMWH + pneumatic compression (if immobilised)
  • VTE: LMWH (unfractionated if INC bleeding)
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13
Q

Which anticoagulants are factor XA inhibitors?

A
  • Apixaban
  • Edoxaban
  • Rivaroxaban
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14
Q

Which anticoagulant is a thrombin inhibitor?

A

Dabigatran

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15
Q

What is the mechanism of action of heparins?

A

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

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16
Q

What are the indications for heparins?

A

LMWH: tinzaparin, enoxaparin, dalteparin

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

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

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17
Q

What are the side effects of heparin?

A

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

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18
Q

What are the interactions of heparins?

A
  • Hyperkalaemia
  • Anticoagulants, anti-platelet, NSAIDs, SSRI → INC Bleeding
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19
Q

What is the MOA of warfarin?

A

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

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20
Q

What is the indication of warfarin?

A

VTE + stroke prevention in AF

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21
Q

What are the rules for a missed warfarin dose?

A

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

22
Q

What are the pill colours for warfarin?

A
  • 0.5mg - white
  • 1mg - brown
  • 3mg - blue
  • 5mg - pink
23
Q

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

A

Isolated calf DVT: 6w

Provoked VTE: 3m

  • Surgery, COC, pregnancy, leg cast
24
Q

Can you take warfarin during pregnancy?

A

Teratogenic

25
Q

How often is warfarin monitored?

A

INR every 12 weeks
- More frequent: intercurrent illness

26
Q

What are the target INR when taking warfarin?

A

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

27
Q

What are the MHRA warnings for warfarin?

A
  • 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
28
Q

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

A

w/hold 1-2 doses

29
Q

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

A

IV phytomenadione + restart when INR <5

30
Q

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

A

Oral phytomenadione + restart when INR <5

31
Q

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

A

IV phytomenadione + restart when INR <5

32
Q

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

A

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

33
Q

What are the food interactions of warfarin?

A
  • Alcohol binge
  • Cranberry juice
  • Green, leafy veg
34
Q

What are the OTC interactions of warfarin?

A
  • Miconazole
  • NSAID
  • Vit E + K supplement
35
Q

What happens when taking warfarin and undergoing surgery?

A
  • Elective: stop 5 days before
  • VTE high risk: bridge w LMWH
  • Emergency: IV phytomenadione
36
Q

What are the interactions of warfarin?

A
  • NSAID, anticoagulant, SSRI → INC bleed
  • Enzyme inhibitors → INC anticoagulant effect
  • Enzyme inducers → DEC anticoagulant effect
37
Q

What is the MOA of DOACs?

A

Directly inhibits clotting factor Xa or IIa (thrombin)

38
Q

What are examples of DOACs?

A
  • Apixaban
  • Dabigatran (special container, protect from moisture: 4m expiry)
  • Edoxoban
  • Rivaroxaban (MHRA: after food, licensed to be crushed)
39
Q

What are the indication of DOACs?

A

VTE, prevent stroke in Non-valvular AF

40
Q

What are the missed dose rules when taking DOACs?

A

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

41
Q

What are the side effects of DOACs?

A

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

42
Q

What are the reversal agents for DOACs?

A
  • Idarucizumab - dabigatran
  • Andexanet alfa - apixaban, rivaroxaban
43
Q

What are the CI of DOACs?

A

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

44
Q

What are the interactions of DOACs?

A
  • NSAID, anticoagulant, SSRI → INC bleed
  • Enzyme inhibitors → INC anticoagulant effect
  • Enzyme inducers→ DEC anticoagulant effect
  • Carbamazepine red exposure to apixaban
45
Q

What are the types of strokes?

A

Ischaemic (includes TIA - mini strokes that temp interrupt blood supply to brain)

  • Atherosclerosis, thromboembolism in AF

Haemorrhagic

  • High BP, aneurysm, arteriovenous malformation
45
Q

What is the treatment for an ischaemic stroke?

A

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

46
Q

What is the treatment for a haemorrhagic stroke?

A
  • Antihypertensive
  • AVOID: aspirin, anticoagulant, statin - high risk of bleed
47
Q

What is used for secondary CVD prevention?

A
  • Low dose Aspirin (75mg OD)
  • Clopidogrel
  • Dipyridamole
48
Q

How is dipyridamole taken?

A
  • 30-60min before food
  • MR - after food
  • MR caps ‘special container’ - discard in 30 days/6 weeks
49
Q

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

A

Prasugrel + ticagrelor

50
Q

What is used for long term management of a TIA?

A

MR Dipyridamole and Aspirin

High - Cardiovascular system (7 decks)

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