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3154 CA > DTSY > Flashcards

DTSY Flashcards

1
Q

State the location of DVT clot that has low risk of embolism and state the veins that these clots may occur in

A

Calf source.

Veins: Tibial, Peroneal

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2
Q

What are the risk factors for VTE (5)

A

1) Age > 75
2) Prior VTE history (highest risk during first 180d after VTE)
3) Hypercoagulability
4) Circulatory stasis
5) Vascular damage

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3
Q

Which condition is associated with both Thrombophilia and recurrent miscarriages?

A

Antiphospholipid syndrome

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4
Q

State the clinical presentation of DVT (5)

A

o Unilateral Calf or leg swelling (> 3cm between calves)
o Dilated superficial veins -> “palpable cord”
o Tenderness to the calf (particularly over the site of the deep veins)
o Oedema
o Colour changes to the leg

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5
Q

State what further procedure to carry out for a person with DVT Wells Score of 3 and state what to do depending on presence of clot

A

Imaging with whole leg CUS or proximal compression ultrasound (CUS)
o If DVT is proximal (above knee) -> initiate anticoagulant ASAP
o If DVT is distal (below knee) -> anticoagulation or surveillance done depending on risk factor
- Consider anticoagulation if patient is very symptomatic (e.g leg very red/ very pain) or if DVT is progressing
o Whole leg CUS negative -> DVT ruled out
o Proximal CUS negative -> surveillance

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6
Q

State what further procedure is done for DVT Wells Score of 2 or less

A

Conduct D-dimer test
o Positive D-dimer ≠ DVT -> proceed to compression ultrasound
o Negative D-dimer = DVT ruled out

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7
Q

State what is to be done for patient with PE Wells Score > 4 (and state which procedure is preferred)

A

Proceed to imaging using CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan.

CTPA is usually preferred unless the patient has significant kidney impairment or a contrast allergy

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8
Q

State what is to be done for patient with PE Wells Score 4 or less

A

Proceed to D-dimer
* Positive D-dimer -> proceed to CTPA or VQ
* Negative D-dimer -> PE ruled out

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9
Q

State the general duration of VTE treatment for:
a) 1st provoked DVT or unprovoked distal DVT
b) 1st unprovoked proximal DVT or PE
c) Active Cancer patients
d) Increased risk of recurrence/ have recurrent VTE

A

a) 3 months (90 days)

b) Consider beyond 90 days if bleeding risk acceptable and patient willing

c) at least 6 months

d) lifelong unless contraindicated

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10
Q

What are the clinical features of intermediate to high risk PE patients?

A

If right heart involvement = intermediate to high risk PE
* E.g of right heart involvement:
o Elevated cardiac troponin -> Rises in heart attack (when muscles die); marker that heart is working hard
o RV dysfunction on transthoracic echocardiogram (TTE; looks at EF) or CTPA

Hemodynamic instability = High risk
- Signs:
o Cardiac arrest (need resuscitation)
o Obstructive shock (SBP < 90 or require vasopressor to achieve SBP > 90 + signs of end organ hypoperfusion e.g altered mental state, cold clammy skin, no/ very little urine, incr serum lactate)
o Persistent hypotension (SBP < 90 or SBP drop > 40mmHg for longer than 15mins with no other cause)

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11
Q

What’s the dosing regimen of Rivaroxaban for VTE treatment?

A

15mg BD for 3 weeks followed by 20mg/day for up to 6 months

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12
Q

What’s the dosing regimen of Apixaban for VTE treatment?

A

10mg BD x 7d followed by 5mg BD up to 6 months

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13
Q

What’s the dosing regimen of LMWH (Enoxaparin) for VTE treatment?

A

SC at 1mg/kg Q12H

QD if CrCl < 30

Criteria applies for Cancer or Pregnant (only adjust if renal fn poor)

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14
Q

State clinical presentation of PE

A
  • cough, chest pain, chest tightness, shortness of breath, or palpitation
  • tachynpea, tachycardia, diaphoretic (sweaty)
  • If severe: cyanosis, hypoxia, hypotension
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15
Q

Whats the dosing of Rivaroxaban for VTE Prophylaxis?

A

Once haemostasis achieved, start 6-10h post-surgery: 10mg/day x 2 weeks (Total Knee Replacement) or 5 weeks (Total Hip Replacement)

Medically-Ill: 10mg/day for up to 31-39 days

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16
Q

Whats the dosing of Apixaban for VTE Prophylaxis?

A

Once haemostasis achieved, 12-24h post-surgery:
2.5mg BD x 10-14 days (Total Knee Replacement) or 32-35 days (Total Hip Replacement)

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17
Q

What is used for high risk PE?

A

Alteplase + UFH

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18
Q

State the Drug of Choice(s) for the treatment of intermediate-low risk VTE/PE for:

a) General patients
b) Patients with Antiphospholipid syndrome
c) Patients with severe renal impairment
d) Patients who are pregnant (assume no APS S/Sx e.g spontaneous abortion, hist of thrombosis)

A

a) LMWH if parenteral needed, else if stable and prefer PO, DOAC

b) Warfarin

c) UFH or Warfarin, DOAC not recommended (not recommended only apply to DVT/PE only; UFH not renally excreted unlike LMWH)

d) LMWH

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19
Q

What are some risk factors for VTE recurrence? (~8)

A

1) Proximal VTE location
2) Males
3) Obesity
4) Old age
5) Non-zero blood group
6) Early PTS development
* Post-thrombotic Phlebitic syndrome (PTS) is a common complication of DVT that can be extremely painful and can last for months even when DVT resolve -> requires adequate treatment of DVT
7) Persistence of residual vein thrombosis at ultrasound
8) High D-dimer value

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20
Q

What additional thing needs to be done when starting Warfarin for VTE treatment?

A

Overlapping with LMWH is needed due to initial prothrombotic state conferred by warfarin in the first few days (applies to VTE only; need for overlapping less clear for AF)

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21
Q

Describe the pathophysiology of how AF can lead to stroke.

A
  • Irregular heart rhythm results in increased blood retention in atria due to loss of atrial kick.
  • This increased blood stasis in the atria (esp Left Atrial Appendage) causes concentration of clotting factors and the formation of clots.
  • The embolism of these clots to smaller vessels in the brain can lead to ischemic stroke.
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22
Q

List the criteria for modified CHA2DS2VAS scoring. State who should/ should not be offered anticoagulation

A

CHA2DS2VAS scoring is used to estimate stroke risk in AF pts, and determine if anticoagulants/antiplatelets need to be started for pt.

  • Congestive HF (+1)
  • Hypertension (+1)
  • DM (+1)
  • Prior stroke or TIA (+2)
  • Vascular disease (prior MI, PAD or aortic plaque) (+1)
  • Age 65-74 (+1)
  • Age 75 and above (+2)

0: no anticoagulation needed
1: Consider anticoagulants; no antiplatelets
2 and above: Start anticoagulants (VKA/DOAC)

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23
Q

List the criteria for HASBLED scoring.

A

HASBLED scoring is used to determine bleeding risk in pts, and identify modifiable risk factors.

  • Hypertension (SBP >160)
  • Abnormal liver or renal function (cirrhosis or bilirubin >2xULN, ALT/AST/ALP>3xULN, dialysis, renal transplant, or SCr >200umol/L)
  • Current or history of stroke
  • History or active predisposition to bleeding
  • Labile INR (<6 out of 10 INRs in therapeutic range)
  • Elderly >65yo
  • Drugs (concomitant NSAIDs, anticoagulants) or alchohol (8 or more units per week)
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24
Q

Should HASBLED scoring determine the decision to start OACs?

A

No.

HASBLED score should not delay the initiation of anticoagulants for patient.

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25
Q

State the dosing regimen of dabigatran in SPAF.

A
  • 150mg BD
  • 110mg BD (if 80 or above, use of PGP inhibitors or high risk of bleeding)

CrCl 30-50: No adjustments required unless significant DDIs

CrCl <30: CI (Sg)

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26
Q

State the dosing regimen of rivaroxaban in SPAF (incl dose in renal impairment)

A
  • 20mg/d

CrCl 30-50: 15mg/d
CrCl 15-29: Use with caution
CrCl <15: CI

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27
Q

State the dosing regimen of apixaban in SPAF.

A
  • 5mg BD
  • 2.5mg BD if fulfilled any 2 out of the following criteria (Age: ≥80, Weight: ≤ 60kg, or SCr ≥ 133µmol/L)

CrCl 15-29 (solely): 2.5mg BD = to meeting any 2/3 criteria above

CrCl <15: insufficient data
HD: as per above

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28
Q

State the dosing regimen of edoxaban in SPAF.

A
  • 60mg/d
  • 30mg/d if any of the following (CrCl 30-50, 60kg and below or concomitant verapamil, quinidine or dronedarone)

CrCl <30: No data

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29
Q

What is the duration of treatment with DOACs for SPAF?

A

Lifelong (if no CI)

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30
Q

What is the dose of Enoxaparin for VTE Prophylaxis?

A

SC ~20-40mg QD; flat doses (not weight based)

the more renally impaired, the lower the dose.

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31
Q

What is the general INR target range and for which group of patients is it different? State this range as well

A

INR 2-3 except patient with mechanical heart valve (2.5-3.5)

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32
Q

State what to do if Patient INR 4.5-10 but no bleeding and on Warfarin

A

Hold Warfarin, repeat INR and redose warfarin as necessary

PO Vit K 1-2mg can be considered

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33
Q

State what to do if Patient INR > 10 but no bleeding and on Warfarin

A

Hold Warfarin, repeat INR and redose warfarin as necessary
PO Vit K 2-5mg if patient is at risk of bleeding

34
Q

State what to do if Patient has minor bleeding and on Warfarin

A

Consider withholding warfarin and/or PO Vit K 1-2mg or IV 1mg PRN

35
Q

State what to do if Patient has major bleeding and on Warfarin

A

Withhold warfarin.
IV Vit K 5-10mg if INR > 1.5

36
Q

What problem may occur if Vit K > 10mg is given?

A

When Vit K given up to 10mg, may cause problems re-anticoagulating the patient for up to 3 weeks (patient will have high thrombogenic risk)

37
Q

When is Warfarin needed (cannot use DOACs) (3)

A

o Left Ventricular Thrombus
o Valvular AF (Prosthetic Heart Valve or moderate to severe mitral stenosis)
o Antiphospholipid Syndrome-related VTEs

38
Q

State what is to be done if a patient is to be swapped from Warfarin to DOAC

A

Requires stopping of Warfarin for a few days prior to starting. Duration to stop depends on INR on the day.
- If INR ≤ 2: can start DOAC immediately
* No need to cover with any parenteral agents since DOAC has faster onset than warfarin (for SPAF; Dabi and Edoxaban need cover with LMWH for VTE treatment)
- If INR 2-2.5: can start DOAC immediately or next day
- If INR ≥ 3: hold warfarin 3 days, take INR again on day 4, if INR still > 3, repeat INR the next day while continuing to hold warfarin.

39
Q

What are the contraindications for DOAC use?

A

1) Concomitant use of Azoles
o Warfarin able to be used if able to monitor INR, some azoles affect more than others (fluconazole worse than the rest)
o In general, try not to use DOAC if person on azole
* For Dabigatran only can use Itraconazole or Ketoconazole
2) Severe hepatic dysfunction, especially with coagulopathy
o Especially if Child Pugh C
3) ESRD
o Warfarin can use but limited benefit (dialysis patients have a lot of resistance to anticoagulants)
o Apixaban may potentially be used in dialysis (rmb DRAW)
4) Prosthetic heart valve replacement patients
o Use warfarin

40
Q

Clopidogrel loss of function is associated with?

A

CYP2C19 polymorphism

*2/ *3 alleles (results in intermediate or poor metabolisers)
Increases risk of MACCE and MACE

41
Q

Compare and contrast Clopidogrel and Ticagrelor in terms of MOA, onset/offset of effect

A

Clopidogrel is prodrug, Ticagrelor not
Clopidogrel irreversibly inhibits P2Y12, Ticagrelor reversibly inhibits.
Offset of effect from stopping ticagrelor twice as rapid as clopidogrel; faster onset also

Implication: Compliance to Ticagrelor more impt than Clopidogrel

42
Q

List 3 key points of Thrombolytic protocols

A

1) Best started in patients presenting between 3-4.5 hours of onset
- Outside of 4.5 hours window, benefits will not be as much as the risk involved
2) Thrombolysis has NO mortality benefits but associated with quality of life benefits if given at the right time
3) There are checklists that need to be checked before starting thrombolytic therapy
- Exclusion criteria for thrombolytic therapy are usually anything with risk factors for bleeds.

43
Q

State what is to be done if a patient is to be swapped from DOAC to Warfarin

A

1) Consider genotyping
2) Continue on DOAC for at least 3-5 days after starting Warfarin (like LMWH bridge)
o Measure INR after 3-5 days (before DOAC intake on the day). If INR:
* < 2: continue DOAC (if edoxaban used, half dose)
* > 2: stop DOAC, repeat INR 1 day after stopping

44
Q

State the various follow up intervals for patients on DOAC

A
  • 4 monthly: for those ≥ 75 y.o (especially if on Dabigatran), or frail
  • Every CrCl/10 months: for those with CrCl ≤ 60mL/min
  • Immediately: in case of concomitant illness especially with potential impact on renal or hepatic function (e.g infection, NSAID use, dehydration etc)
45
Q

State things to check during follow up for patient on DOAC (8)

A

1) Adherence (to assess cognitive fn also)
2) Thromboembolism
3) Bleeding
4) ADR
5) Co-medications
6) Blood test (Hb, Renal panel)
7) Modifiable risk factor for bleeding
8) Optimal DOAC choice and dose

Everything to be checked every visit except blood test (at least once a year, Q4mth if elderly, QCrCl/10 mths if CrCl <60, on indication for concurrent condition affecting renal/hep fn)

46
Q

Describe bleeding risk management for patient on DOAC for the following surgeries:

a) Unplanned invasive procedure
b) Elective invasive procedure

A

a) If got time to hold off, consider bleeding risk (high risk hold off, not high risk don’t bother)

b) Factors to consider: T1/2 of drug, renal impairment
Dabi: 1-4 days
Riva/Apix/Edox: 1-2 days

47
Q

What does FAST in stroke stand for?

A
  • Facial drooping
  • Arm weakness
  • Speech difficulty
  • Time to call 995
48
Q

What does Penumbra refer to?

A

Penumbra is the area of brain tissue [around the infarcted (dead) tissue] that is potentially salvageable with urgent pharmacologic and endovascular interventions in acute ischemic stroke

49
Q

What are the respective definitions of Minor Stroke and High risk TIA?

A

Minor stroke: NIHSS score 0-3
High risk TIA: ABCD2 score ≥ 4

50
Q

Severe major Intracranial Arterial Stenosis (ICAS) usually involves which 3 arteries?

A

o Anterior cerebral artery (ACA)
o Middle cerebral artery (MCA)
o Posterior cerebral artery (PCA)

51
Q

State what you would do for a patient with new AIS, not on anti-thrombotic therapy, eligible for alteplase

A

Start single antiplatelet therapy (SAPT): Aspirin after 24h (of alteplase use), but within 48 hours of symptom onset. Send for evaluation of stroke mechanism.

52
Q

State what you would do for a patient with new AIS, not on anti-thrombotic therapy, not eligible for alteplase (incl duration of APT tx where eligible)

A

1) Minor stroke or high risk TIA
o Start DAPT ASAP for duration 21 days (Aspirin + Clopidogrel)

2) NOT minor stroke or high risk TIA
o Start Aspirin ASAP

Send for evaluation of stroke mechanism

53
Q

State what you would do for AIS patient, started on Antiplatelet but found to have Cardioembolic stroke. Include treatment duration where applicable.

A

Stop antiplatelet, look for underlying cardio sources e.g AF
* If AF confirmed, start OAC (but not within 24 hours of r-TPA if it was used)

Also start high intensity statin if no contraindications and manage other CV risk factors
* Atorvastatin 40-80mg OD
* Rosuvastatin 20-40mg OD

In hospital, since not mobile, risk of VTE -> use VTEP (esp if cannot be mobilised within 48-72 hours)
* Use LMWH within 48 hours of stroke onset but after 24 hours of rTPA if rTPA was used
* If bleeding risk high then use compression stockings (don’t use LMWH)

54
Q

State what you would do for AIS patient, started on Antiplatelet but found to have Non-cardioembolic stroke. Include treatment duration where applicable.

A

Severe major Intracranial Arterial Stenosis (ICAS) i.e large vessel involvement
o Consider adding Clopidogrel to Aspirin (form DAPT) to a total duration of 90 days, followed by lifelong Aspirin

No severe major ICAS
o Lifelong Aspirin

Also start high intensity statin if no contraindications and manage other CV risk factors
* Atorvastatin 40-80mg OD
* Rosuvastatin 20-40mg OD

In hospital, since not mobile, risk of VTE -> use VTEP (esp if cannot be mobilised within 48-72 hours)
* Use LMWH within 48 hours of stroke onset but after 24 hours of rTPA if rTPA was used
* If bleeding risk high then use compression stockings (don’t use LMWH)

55
Q

State the respective DAPT duration for CCS and ACS

A
  • ≥ 12 months: ACS
  • ≥ 6 months: CCS
56
Q

State the duration of DAPT for person with stent with very high and high bleed risk

A

o Very high bleed risk = 1 month therapy
o High risk = 3 months, consider stopping P2Y12 after 3 months but need to continuously assess bleed risk before deciding to stop.

57
Q

Precise-DAPT score of ___ is associated with high bleed risk during ____

A

> 25, stent insertion

58
Q

What are the major high bleed risk criteria at time of PCI? (11)

A

1) Anticipated long term use of oral anticoagulation

2) Severe or ESRD (CrCl < 30)

3) Hb < 11 g/dL

4) Spontaneous bleeding requiring hospitalisation or transfusion within past 6 mth or at any time if recurrent

5) Mod - severe baseline thrombocytopenia (platelet < 100 x 10^9/L)

6) Chronic bleeding risk

7) Liver cirrhosis with portal hypertension

8) Active malignancy (except nonmelenoma skin cancer) within past 1 yr

9) Prev spontaneous ICH (any time) or Prev traumatic ICH within last 1 yr or presence of brain arteriovenous malformation or mod-severe AIS in last 6 mth

10) Non-deferable major surgery while on DAPT

11) Recent major surgery or major trauma within 30d before PCI

59
Q

State when Ticagrelor is preferred over Clopidogrel and vice versa?

A

Ticagrelor preferred:
1) ACS w or w/o PCI
2) Patients with CYP2C19 loss of function

Clopidogrel preferred:
1) CCS
2) Patients with poor compliance

60
Q

What is the defintion of Anemia?

A

Hgb < 13g/dL (males); Hgb < 12g/dL (females)

61
Q

What information does a peripheral smear provide?

A
  • Variation of RBC size (Anisocytosis)
  • Colour of RBC
  • Shape of RBC (Poikilocytosis = abnormal shape RBC)
62
Q

Situations where prompt evaluation for blood loss needs to be done

A

1) Normal MCV but high reticulocyte count
2) Low MCV and LOW serum ferritin

63
Q

Name the various microcytic anemias (2)

A

1) Iron deficiency anemia
2) Anemia of Chronic disease

64
Q

State the differences between Vit B12 Anemia and Anemia of Chronic disease with respect to:

a) Serum Ferritin
b) TIBC (Transferrin)

A

Vit B12: Low serum ferritin, high TIBC

AoCD: Normal/high serum ferritin, low TIBC

65
Q

In Anemia of chronic disease, chronic inflammation leads to increased _____ which _____

A

Hepcidin, inhibits iron absorption

66
Q

State dose and duration of Iron supplementation and special administration instructions

A

~1000-1500mg of ELEMENTAL Fe per week
* At least 200mg (administered over 2-3 divided doses) per day -> minimise GI side effects
* Take without food/medications
Duration: at least 3-6 months

67
Q

Name the various types of Megaloblastic anemias (3)

A

1) Vit B12 deficiency anemia
2) Folic acid deficiency anemia (Vit B9 deficiency)
3) Drug induced anemia

68
Q

Vit B12 also known as?

A

Cobalamin

69
Q

When is IM (or SC) Vit B12 preferred over PO Vit B12?

A

Reduced B12 absorption due to missing intrinsic factor

70
Q

State how to manage patients with Aplastic Anemia with Neutropenia if:

a) Pt is febrile
b) Pt has neutrophil count < 0.5 x 10^9/L

A

a) Start broad spectrum antibiotic
b) Start antibiotic AND antifungal prophylaxis

71
Q

State how to manage patients with Aplastic Anemia with bleeding

A
  • Transfusion support with erythrocytes and platelets
  • If heavily transfused, iron chelation therapy with deferoxamine or deferasirox may be necessary (avoid iron overload)
72
Q

State how to manage patients with Aplastic Anemia and extremely ill

A

May require allogeneic hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (Cyclosporine) -> don’t know when bone marrow will recover

73
Q

State how to manage Agranulocytosis (Neutropenia)

A

1) Hold off drug
2) Not recommended to restart offending agent EXCEPT:
* Penicillin: Can restart at a lower dosage, after the neutropenia has resolved without any recurrence of drug-induced agranulocytosis
3) Filgrastim if Neutrophil < 0.1 x10^9/L

74
Q

Name the drugs not safe for use in G6PD deficient patient (3)

A

Fluoroquinolones
Primaquine and Tafenoquine (Malaria drugs)
Sulfonylurea

see DTSY list for more

75
Q

Name the drugs that may cause Megaloblastic anemia and how to manage it (3)

A

1) Phenytoin, Phenobarbital
* MOA in causing anemia: Inhibit folate absorption or catalyse folate catabolism
* Management: Folic acid 1mg/day (controversial) -> may reduce efficacy of Phenytoin in some patients -> consider switching antiseizure medicines instead

2) Co-trimoxazole
* May cause especially if patient got concurrent folate/ B12 deficiency
* Management: Folinic acid, 5 to 10 mg up to four times a day + hold off

3) Antimetabolite
* Usually used in chemotherapy (e.g methotrexate)
* Common but acceptable cause of megaloblastic anemia
* Management: Hold off and give alternative agent

76
Q

Define thrombocytopenia

A

Platelet count ≤ 100,000 cells/mm3 (100 × 10^9/L) or greater than 50% reduction from baseline values

77
Q

What score is used to determine probability of HIT and what is the score associated with high HIT probability?

A

4T score ≥ 6

78
Q

What are risk factors for HIT?

A

1) PCI
2) Dialysis

79
Q

HIT is asociated with what coagulation disorder?

A

Thrombosis

80
Q

What factors does INR measure?

A

INR is the collective measure of factors II, VII and X

81
Q

What is INR?

A

[Ratio of patient prothrombin time to normal prothrombin time] to the power of ISI (international sensitivity index)

3154 CA (5 decks)

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