Cardio: DVT

Question 1

what kind of problem is a DVT?

Answer 1

cardiac/pulmonary - venous fibrin clotting (will need anti-coag > anti-plt)

Question 2

what is vichor’s triad?

Answer 2

1. venous stasis/ turbulent flow
2. hypercoag state
3. endothelial damage
   aka abnormalities in Flow (1) , blood composition (2) , vessel wall (3)
   *three things that are often in the history of someone w/ DVT

Question 3

what are 3 endogenous anti-coags ?

Answer 3

protein C & S
TFPI (tissue factor path inhib)
anti-thrombin III

Question 4

significance of protien C or S deficiency

Answer 4

serious genetic condition with excessive clotting b/c you dont have the protein that naturally breaks down clots

• multiple clotting events in life
• can happen at young age

Question 5

tPA vs PAI-1

Answer 5

opposites (natural influencers of clots)
tPA: cleaves plasminogen into ACTIVE plasmin which then DISSOLVES CLOT

PAI-1:(PROTHROMBOTIC) pLT activating inhibitor- inhibits plasmin creation (so you can’t dissolve clots) (there will be an inc. level of this in someone w/ HTN)

Question 6

pts w/ excessive clotting may present with what major venous or arterial problems?

Answer 6

vein: DVT/PE
artery: stroke/MI/PVD (prothromic state or stasis (Afib))
…also may have family history of stroke or other CVD

Question 7

PE: DVT usually presents as…

Answer 7

• often after minor trauma or immobilization
• unilateral lower extremity
• inflamm. (blood causes inflamm response), pain, warmth

Question 8

Dx of DVT - what can you use to localize the clot?

Answer 8

doppler US

Question 9

medication txt for DVT

Answer 9

anti-coag

Question 10

SOB, pleuritic CP, Right-side HF, Virchow’s triad…. all could be indications of …

Answer 10

DVT

Question 11

sudden right sided heart failure and rapid peripheral edema and JVD could be indications of …

Answer 11

DVT

Question 12

what are you weighing when consider whether to image test for DVT?

Answer 12

how highly you suspect there to be one

Question 13

what is the GOLD STANDARD Dx test for DVT?

Answer 13

contrast venography … but we dont really use it

Question 14

what is plasma D-Dimer ?

Answer 14

degradation product of fibrinolysis (elevation in plasma will indicate that this is happening)

• normal? low likelihood of DVT/PE
• negative? MOST useful b/c you can r/o DVT/PE

Question 15

*almost all pt’s have _____D-dimer

Answer 15

elevated (means you can get many false positives w/ this test)

Question 16

homan’s sign is usually used to test ___ not ____ (according to Hadley)

Answer 16

thrombophlebitis NOT DVT

Question 17

what do you do to estimate pre-test probability of DVT?

Answer 17

wells score.
>2 = 28% likelihood of DVT
<1 = 6% liklihood of DVT

Question 18

when is D-Dimer a “high value test” over venous doppler?

Answer 18

when you have LOW PRE-TEST PROBABILITY (from wells score) , negative D-dimer gives you an answer at 1/10 the cost of Venous doppler US

Question 19

what is Duplex doppler scanning? what is it best for?

Answer 19

combo of US and pulsed doppler- moving while it takes imaging to see the change (if any) in flow
-best for proximal disease (e.g. femoral and up)

Question 20

what is prevention for DVT for …
1. short/uncomplex surgery
vs
2. long/high-risk surgery or pt w/ risk factors?

Answer 20

1. early ambulation
2. heparin, (quick onset, easily reversible) (short term)
3. warfarin/direct thrombin inhibit (for long term)

Question 21

how long is the “longterm” for warfarin for DVT txt/prophylaxis? and what are you monitoring?

Answer 21

3 months - checking PT/INR

Question 22

what would you use for MI/stroke prophylaxis is ASA fails?

Answer 22

warfarin

Question 23

how long does it take to get therapeutic levels of warfarin ?

Answer 23

4-5 days

Question 24

what two situations would someone need lifelong prophylaxis for DVT?

Answer 24

1. recurrent DVT

2. no clear cause of the DVT

Question 25

anti-coag for ____ DVT helps prevent PE. for ____DVT it is less clear

Answer 25

proximal | distal (much lower probability of getting a PE from distal)

Question 26

anti-coag for distal DVT? if symptomatic vs asymptomatic?

Answer 26

symptomatic: anticoag as you would for proximal asymptomatic: maybe surveillance, maybe txt w/ anti-plt ASA * *which prevents "sticking" (clot progression) but not the cascade (clot initiation)

Question 27

pulmonary embolism: pt often has preceding ____ that may be ____

Answer 27

DVT, asymptomatic

Question 28

etiology of pulmonary emb.

Answer 28

embolization from venous system through right V to lung

Question 29

tachycardia, tachypnea, low O2, low grade fever from inflamm., possible DVT signs... what may this be?

Answer 29

PE

Question 30

what is the "gold standard" for Pulm. embolism and what do we actually use more commonly?

Answer 30

gold: pulmonary angiography (invasive and expensive) actually: spiral CT (spins around body)

Question 31

____ of PE arise from ____ in deep venous system

Answer 31

>90% of PE arise from venous thrombi in deep venous system (thigh > calf)

Question 32

3 presentations of PE

Answer 32

1. acute cor pulmonale (massive pulmonary embolism that obstructs >50% pulmonic circulation) 2. pulmonary infarction 3. acute unexplained dyspnea

Question 33

what can pulmonary infarction be easily confused with? and what S&S does it present with?

Answer 33

pneumonia, pleuritis, MI S&S: pleuritic (sharp local) CP, dyspnea, tachy, hemoptysis AKA hard to Dx

Question 34

what 2 things are important for Dx unexplained dyspnea?

Answer 34

history and risk factors (b/c S&S are very vague and confusing)

Question 35

Dx test for "unexplained dyspnea"?

Answer 35

arterial blood gas (ABG) : classic drop in PO2 and PCO2 | * PO2 can be WNL at expense of PCO2 (very low CO2)

Question 36

what is a ventilation/perfusion (VQ) scan? what are you trying to Dx between? what do results indicate?

Answer 36

examines air and bloodflow in lungs: shows ventilation:perfusion mismatch (trying to Dx unexplained dyspnea to see if its a PE) - normal scan is helpful ( r/o PE) - high probability scan is helpful (r/i PE) - low probability scan = not helpful

Question 37

what is unexplained dyspnea?

Answer 37

sub massive embolism w/out infarction

Question 38

what is MUD (medically unexplained dyspnea)? how are they presenting?

Answer 38

pt presents with dyspnea but no cardio-pulmonary explanation for it. "submassive embolism w/out infarction" - "no infarction but poor perfusion" (hadley) -usually presenting w/ anxiety and hyperventilation, tachypnea, tachycardia (nervous friggin nelly)

Question 39

suspect a PE? what do you need to give RIGHT AWAY?

Answer 39

heparin at least 10,000 unit bolus

Question 40

Txt for stable pts w/ PE ?

Answer 40

O2 and close monitoring in ICU heparin then warfarin/ other non-vitk anticoag (NOAC) (longterm anti-coag)

Question 41

IVC filter

Answer 41

used for high risk PE - small device placed in center of Vena Cava to prevent PE

Question 42

order to tests once you suspect PE...

Answer 42

D-dimer - if its elevated --> spiral chest CT --> pos? txt for PE Txt: continue anticoag- for non high risk thrombolysis or IVC filter for high-risk