DVT and PE

Question 1

What is a DVT?

Answer 1

• thrombus (clot) formed in the deep venous circulation

- usually found in the legs, but can be anywhere

Question 2

What is a PE?

Answer 2

• thrombus (clot) that has embolised (travelled) and lodged in the pulmonary circulation

Question 3

How are DVTs classified?

Answer 3

Proximal - popliteal vein or femoral vein

Distal - DVT of the calves

Question 4

What triad outlines the reasons that a patient may develop a venous clot?

Answer 4

Virchow’s Triad

• stasis of blood
• vessel damage/injury
• hypercoagulable state

Question 5

What risk factors cause blood stasis and therefore predispose patients to clotting?

Answer 5

• Left ventricular dysfunction
• Immobility or paralysis
• varicose veins
• insufficiency in venous valves (due to age/previous thombus)
• Venous obstruction from tumour, obesity or pregnancy

Question 6

What can cause vessel wall damage or injury which may lead to clotting?

Answer 6

• Venous valvular damage (Age/ previous thombus)
• Trauma or surgery
• Indwelling catheters

Question 7

What risk factors can put patients in a hypercoagulable state which may lead to clot formation?

Answer 7

Malignancy
Pregnancy /puerperium
Oestrogen therapy (COCP/ HRT)
Inflammatory bowel disease
Sepsis
Thrombophilia

Question 8

How does a DVT present?

Answer 8

• Painful and swollen limb
• with redness and heat
• Tenderness along vein

Question 9

How may a PE present?

Answer 9

• Sudden SOB
• Pleuritic Pain
  +/- Collapse +/- Haemoptysis

Signs:

• Hypoxia
• tachycardia
• BP may be low

Question 10

What scoring system is used to rank the probability of a PE?

Answer 10

Wells Score

Question 11

What test is used first line in patients with a suspected VTE?

Answer 11

D-Dimer
- measures fibrin degradation products
=> raised D-dimer indicates the patient COULD be breaking down a large clot
(Not diagnostic)

Question 12

How should DVT/PE probability tests such as the Wells Score influence investigation choice?

Answer 12

Mod- HIGH probability (aka PE or DVT likely)
=> patient needs a scan

Low Risk = check D-Dimer.
If D-Dimer HIGH patient needs a scan

Question 13

What type of scans are used to investigate DVT and PE?

Answer 13

DVT - doppler US

PE - V/Q scan

Question 14

What is Post Thrombotic Syndrome?

Answer 14

• Occurs in 1/3 of patients within 5years after idiopathic DVT
• DVT damages the valves
  => valvular reflux and venous hypertension

Question 15

What symptoms usually present in Post Thrombotic Syndrome?

Answer 15

• Pain
• Oedema
• Hyperpigmentation
• Eczema
• Varicose collateral veins
• Venous ulceration

Question 16

How are DVTs usually managed?

Answer 16

Oral Anticoagulation

thrombolysis may be considered for specific patients in specialist centres

Question 17

How are PEs usually managed?

Answer 17

if HIGH RISK - thrombolysis then anticoagulation

if LOW-MED RISK - oral anticoagulation

Question 18

Which anticoagulant is used to treat DVT/PE?

Answer 18

1st LINE = DOAC => Direct Oral Anticoagulant
=> Apixaban or Rivaroxaban

2nd LINE = Warfarin => Vitamin K antagonist

LMWH Injections used if:
- patients have active Cancer and PE

Question 19

How long should patients be treated with anticoagulants after a DVT/PE?

Answer 19

• Provoked VTE with reversible factor = 3-6 months treatment
• Provoked VTE with irreversible factor = 3-6 months or lifelong depending on patient factors
• Unprovoked VTE => dependent on patient, may be lifelong Tx

Question 20

Patients may choose to continue their anticoagulation after it is necessary, as they are scared of having another PE. TRUE/FALSE?

Answer 20

TRUE