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Cardiovascular 2018 > DVT & PE > Flashcards

DVT & PE Flashcards

1
Q

What is a PE?

A

Thromboemboli detach and travel through the right side of the heart to block vessels in the lungs

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2
Q

What cause haemodynamic collapse in PE?

A

right ventricle outflow doesn’t get round to left heart

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3
Q

What is a DVT?

A

Formation of thrombi within the lumen of the vessels that make up the deep venous system: venous valve pockets and other sites of presumed stasis

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4
Q

Describe an arterial clot?

A

Platelet rich clot

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5
Q

Why is venous clot fibrin rich?

A

in venous disease the bloodlfow is static and the coagulation cascade forms a fibrin rich clot

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6
Q

What percentage of cancer patients will have clot in their life?

A

20%

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7
Q

What are the three components of virchow’s triad?

A

Hypercoagulable state
Circulatory Stasis
Endothelial injury

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8
Q

What can contribute to hypercoagulable state?

A 
Malignancy
Pregnancy and permpartum period
Oestrogen therapy
IBD
Sepsis 
Thrombophilia
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9
Q

What contributes to endothelial injury?

A 
Venous disorders
Venous valvular damage
Trauma
Surgery
Indwelling catheters
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10
Q

What contributes to circulatory stasis?

A 
Left ventricular dysfunction
Immobility 
Paralysis
Venous insufficiency or varicose veins
Venous obstruction from tumour, obesity or pregnancy
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11
Q

Name some risk factors of clot?

A 
Smoking
Travel 
Prothrombin gene mutation
Combined oral contraception
Hormone replacement 
Protein C deficiency
Protein S deficiency
Factor V leiden mutation
Pregnancy 
Active malignancy
Day surgery 
Major surgery
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12
Q

What is a provoked VTE?

A

o transient reversible factors: surgery or hospitalisation

o continuing irreversible factors: cancer

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13
Q

What is an uprovoked VTE?

A

o unprovoked idiopathic: VTE

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14
Q

What type of VTE is likely to re-occur?

A

Unprovoked VTE; more likely to have reoccurrence than provoked over 10 yrs

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15
Q

What are the consequences of VTE?

A
  • fatal PE
  • risk of recurrent VTE
  • post thrombotic syndrome (PTS)
  • chronic thromboembolic pulmonary hypertension (CTEPH)
  • reduced quality of life
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16
Q

What is PTS?

A

post thrombotic syndrome (PTS)
o characterised by pain: much more significant than what you can see
o clear brown discolouration- pooling blood
o venous ulceration
o oedema
o eczema
o varicose collateral veins

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17
Q

What is the treatment for PTS?

A

o compression stockings are pretty much the only limited treatment

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18
Q

What is CTEPH?

A

chronic thromboembolic pulmonary hypertension
o serious complication of PE
o relatively rare
o unexplained progressive breathlessness and hypoxia
o right heart failure
o mortality rates are 4-20%

19
Q

What investigations can be done if VTE is suspected?

A

Pre-test probability scores
D-dimer
Ultrasound

20
Q

What are the different types of ultrasound?

A

compressibility- put pressure on vein- if they can compress the femoral it suggests the pressure is not high above it and there is no more proximal clotting

Doppler- shows any turbulent flow

21
Q

What is the significance of d-dimer in VTE?

A
  • Low positive predictive value for VTE
  • Valuable first line screening test for suspected VTE with low Wells score
  • 25-50% patients require no further investigations
22
Q

What are the other scoring systems for VTE probability?

A

Wells Score

Geneva Score

23
Q

What imaging techniques can be used in VTE?

A

CXR
-Usually normal in PE. Can show pleural effusions and occasionally infarct

V/Q scan

  • Ventilation/Perfusion imaging. Demonstrates mismatched perfusion defects. Still a useful test particularly in small peripheral PEs and pregnancy (perfusion only)
  • have to have a normal CXR for it to be useful
  • Limited by frequency of inconclusive results, hence

CTPA has become gold standard

24
Q

How can we treat DVT and PE?

A

Pharmacological interventions

Mechanical interventions

recommended
Screening

25
Q

What are the pharmacological interventions for DVT and PE?

A
  • Anticoagulation
  • Thrombolysis
  • Analgesia
26
Q

What are the mechanical interventions for DVT and PE?

A
  • Graduated compression stockings

- IVC filters

27
Q

What are the screenings recommended in DVT and PE?

A

-Thrombophilia
advices against screening in DVT

Cancer

28
Q

Why is warfarin so dangerous?

A

-no antidote;

oreverse effects with Vitamin K and Fresh frozen plasma

29
Q

What is the recommended medication for preventing recurrent DVT and PE in adults

A
  • Apixaban

- Rivaroxiban

30
Q

What do you do after a period of time on anticoagulants?

A
  • Continuing anticoagulants prevents further events
  • Apixaban has the same rate of major bleeding as a placebo: making it a very safe anticoagulant
  • rivaroxaban has roughly the same bleeding rate as aspirin
  • all men who have unprovoked VTE or irreversible provoking factors should continue on longterm coagulation
  • women have a lower recurrence rate than men but will also benefit
31
Q

Why is drug associated DVT and PE significant?

A
  • almost all IV drug users will develop a VTE at some point

- risk of haemorrhage/death vs. embolic disease

32
Q

What is the recommended medication for drug associated DVT or PE?

A

-rivaroxaban or fragmin

33
Q

What medication is sugested in cancer related DVT or PE?

A
  • evidence base favours weight adjusted fragmin

- safety benefit with fragmin

34
Q

What is significant about phlegmasia?

A
  • arterial compromise secondary to extensive DVT
  • high pressure in venous system it affects arterial flow causing a rapid ischaemic leg
  • often results in death
35
Q

What does phlegmasia require?

A

Quick thrombolysis

36
Q

Who should be considered for thrombolysis in DVT?

A

patients with symptomatic ileofemoral DVT symptoms less than 14 days duration and;

  • good functional status
  • a life expectancy of 1 year or more
  • a low risk of bleeding
37
Q

Who should be considered for thrombolysis with PE?

A

-Consider pharmacological systemic thrombolytic therapy for patients with PE and haemodynamic instability

38
Q

Which PE patients should not be considered for thrombolysis? Why?

A

patients with PE and haemodynamic stability

no data to suggest it’s that effective, unless haemodynamic collapse is present

39
Q

What is the compression stocking used for?

A

To prevent PTS

40
Q

When should compression stockings be worn?

A

as soon as possible after diagnosis (one week after diagnosis or when swelling is reduced sufficiently and there are no contraindications)

  • NB NICE QS29 states below-knee graduated compression stockings should be offered within 3 weeks of diagnosis
  • To be worn for at least 2 years post thrombosis
  • Stocking need only be worn on affected leg or legs
41
Q

What are the contraindications for compression stockings?

A

Arterial disease

42
Q

What is an IVC filter?

A

-sits in IVC designed to catch any big clots; preventing death by PE

43
Q

What does NICE recommend for IVCs?

A

-Offer temporary IVC filters to patients with proximal DVT or PE who cannot have anticoagulation treatment

^this is a really bad idea, if people cannot be anticoagulated doing a procedure like this is just going to make them clot

-Consider IVC filter for patients with recurrent proximal DVT or PE despite adequate anticoagulation only after considering increasing target INR or LMWH

44
Q

What is the opinion on IVCs in dundee?

A
  • IVC filters often = complications

- they thrombose. Ideally not a replacement for anticoagulation

Cardiovascular 2018 (39 decks)

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