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Heme - Wier/Pallera > Evaluation of a Clotting Patient > Flashcards

Evaluation of a Clotting Patient Flashcards

1
Q 
Risk factors and Signs of DVT
• Active Cancer
• Paralysis
• Recently Bedridden 
• Localized Tenderness
•Swollen Leg
• Pitting Edema
A 
Risk factors and Signs of DVT
• Active Cancer
• Paralysis
• Recently Bedridden 
• Localized Tenderness
• Swollen Leg
• Pitting Edema
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2
Q 
Symptoms of Pulmonary Embolism
• Shortness of Breath
• Pleuritic Chest Pain
• Hemoptysis
• Shock 
• Sudden Death
A 
Symptoms of Pulmonary Embolism
• Shortness of Breath
• Pleuritic Chest Pain
• Hemoptysis
• Shock 
• Sudden Death
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3
Q

What is a white clot mostly composed of?

• Red Clot?

A

White Clot = HIGH FLOW:
• Platelets and Fibrin

Red Clot = LOW FLOW
• Red Cells and Fibrin

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4
Q

Which are the most important risk factors for atherothrombosis?
• Name some

A 
Conventional Risk Factors: 
• Smoking
• Increased Cortisol (Stress, Depression) 
• Hypertension
• Hyperlipidemia
• Metabolic Syndrome

note, these are better predictors of thrombosis than novel risk factors

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5
Q

What are some of the best biomarkers for atherothrombosis?

A

Best —-> No as Good but not bad
CRP + HDLC
CRP
LDL Cholesterol

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6
Q

Who is at the biggest risk of VTE (venous thromboembolism?

A

1 OLDER PEOPLE

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7
Q

What risk factors when in combination with obesity have a multiplicative effect?

A

Baseline Obesity risk = 2x as high as avg.

Oral Contraceptives + Obesity = 10x
Hormone Replacement Therapy = 6x

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8
Q

What is the Risk of Thrombosis in a Factor V Leiden Heterozygote?
• Homozygote?
• FVL heterozygote on oral contraceptives

A

FVL Hetero - 7x risk
FVL Homo - 80x risk
FVL Hetero + oral contraceptive (~4x) = 35x risk

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9
Q

What are the 3 biggest clotting abnormalities in White people and Black people?

A

White:
Factor 5 Leiden
Factor 8 elevated
Antiphopholipid Antibodies

Black:
Factor 8
Antiphospholipid antibodies
(factor 5 doesn’t play much of a role)

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10
Q

In terms of serverity of Thombotic events rate the following: Antithrombin Def., Protein C Deficiency, Protein S deficiency.

A

Note all of these people have a lot bigger chance of clotting than the people with cascade mutations

  1. AT
  2. P-C
  3. P-S
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11
Q

What test would you run if you suspected a prothrombin gene mutation in someone?
• what result would you expect?

A

PT or PTT

• Short PT/PTT

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12
Q

T or F: elevated homocysteine puts you at a huge risk of thrombosis

A

False, not until Homocysteine gets to like 2x normal do you really see any changes in the odds of VTE

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13
Q

What are some causes of acquired thrombophilia?

A
  • MALIGNANCY
  • Immobilization
  • Nephrotic Syndrome
  • Antiphospholipid Syndrome
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14
Q

How can antiphospholid Antibody lead to long PTT in vitro but not in vivo?

A

In Vitro:
Long PTT because the antibody sequesters the phospholipid and this takes away the surface for a clot to form on

In Vivo:
Antibody binds to the endothelium and leukocytes cause damage leading to destruction of Endothelium

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15
Q

What happens if you try to test someones clotting during thrombosis?

A

Everything will be tied up in the clot

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16
Q

What Triad Should you look for in PNH?

A
  • Hemolytic Anemia
  • Bone Marrow Failure (pancytopenia)
  • Venous Thrombosis
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17
Q

What cancers put you at the highest risk for Venous Thromboembolism?

A
  • Breast Cancer
  • Pancreatic Cancer
  • Gastrointestinal Cancer
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18
Q

When should you do a workup for thrombophilia?

A
  • Venous Thrombosis Before 45 y/o
  • Unprovoked OR Recurrent Thrombosis at any age
  • Unusual Sites Cerebral, Mesenteric, Portal, or Hepatic Veins
  • Positive Family History for Thrombosis
19
Q

T or F: you must do thrombophilia testing in to find out how you need to treat your patient?

A

False, the only reason it usually changes is if you are positive for Cancer or something.

20
Q

If someone is thombophilic, what will be your next step in therapy?
• how will cancer change this?

A

Heparin/LMWH then transition onto a vitamin K antagonist like Warfarin

How can cancer change this:
• LMWH is the only thing that should be used in cancer (use it chronically instead of warfarin)

21
Q

After starting someone on anticoagulative therapy how long should they be on it:
• after 1 time event with reversible cause?
• Unprovoked VTE, 1st or 2nd event?

A

1 time event:
• 3-6 months at INR 2-3

Unprovoked VTE, 1st or 2nd time:
• 6-12 months INR 2-3, then re-access VTE risk

22
Q

What are some special situations where you may need to be on warfarin forever?

A
  • Cancer until Resolved (with LMWH)
  • Antiphospholipid Ab. Syndrome
  • Antithrombin Deficiency
  • Possibly with Protein C or Protein S deficiency
23
Q

What is the best way to assess someones risk of DVT recurrence after long term therapy?

A

D-Dimer Management

24
Q 
What is the role of the following in hemostasis: 
•ADPase
• NO
• PGI2
• TM
• t-PA
A

ADPase:
• Degrades ADP

NO:
• Elevates cGMP and prevents platelet aggregation

PGI2:
• Increases cAMP and prevents platelet aggregation

Thombomodulin:
• Binds II (thrombin) to activate protein C to APC and then with protein S to limit Factor V and VIII

t-PA:
• Activates Plasminogen to Plasmin to digest fibrin

25
Q

Suppose you are hypercoagulable because of an antithrombin deficiency. What is the primary anticoagulant you cannot give?

A

Unfractionated Heparin or LMWH (e.g. enoxaparin)
• will have no enzyme to activate

You could bipass this with some anti X drugs like Dabigatran*

26
Q

How do you measure the activity of Heparin?

A

• Measure the PTT

27
Q

What are some of the advantages and disadvantages to using heparin as your anticoagulant?

A

Advantage:
• Short Half Life

Disadvantage:
• Cumbersome (monitoring of PTT every 6 hrs)
• Hospitalization Required

28
Q

How is LMWH advantageous over Unfractionated Heparin?

• Disadvantages

A

LMWH
Advantages:
• NO MONITORING NEEDED (more predictable effects)
• Given Subcutaneously

Disadvantages:
• Long Half Life
• Contraindicated in Renal Failure

Can be given therapeutically or prophylatically

29
Q

Can you measure the effect of LMWH by PT or PTT?

A

NO, you must monitor LMWH with anti-Factor Xa assay

30
Q

What are the indications for the use of heparin?

A
  • Immediate Interruption of Coag.
  • Bridging Therapy to Warfarin
  • Patency of Indwelling lines
  • Prevent Clotting of Hemodialysis unit during open heart surgery
31
Q

Can you use protamine sulfate against both Low MW and Unfractionated Heparin?

A

• Yes, but it really on predictable with Unfractionated Heparin

32
Q

What are your 1st and 2nd line therapies in reversing the effects of Warfarin?

A

1st: Vit. K (not a rapid reversal)
2nd: Prothrombin Complex Concentrate (more rapid)
or FFP (but fresh frozen plasma adds a lot of volume that people may not be able to handle)

33
Q

Should you get an IM flu shot while taking warfarin?

A

NO, you will bleed like a motherfucker, do it SC

34
Q

T or F: Heparin can cause Osteopenia

A

True

35
Q

What anticoagulant is known to cause glottic edema?

• What else is it known for?

A

Warfarin

• also causes necrosis

36
Q

If someone has ever had a clotting issue or seems like they may be at risk then give them prophylactic Heparin
***Don’t use asprin, it doesn’t do shit

• The only time you wouldn’t do this is if someone was at a high bleeding risk

A

If someone has ever had a clotting issue or seems like they may be at risk then give them prophylactic Heparin
***Don’t use asprin, it doesn’t do shit

• The only time you wouldn’t do this is if someone was at a high bleeding risk

37
Q

What are some good long term therapies for someone with a-fib?

A
  • Warfarin

* Dabigatran

38
Q

T or F: in the case that someone has HIT, you can use Fondaparinux.

A

True, could also use Dabigatran

39
Q

When would you use from thrombolytics like alteplase?

A
  • MI
  • Pulm. Embolism
  • DVT
  • Stroke
40
Q

What are some reasons you might choose against giving someone Thrombolytic therapy?

A
  • CPR
  • Recent Surgical History
  • Significant Bleeding History
  • Being over 75
41
Q

What ADP (P2Y12) antiagonists might you use with asprin?

A

Clopidogrel

42
Q

Who are the best patients to put on asprin therapy?

A

ppl. 55-59, because there’s less of a GI bleeding risk

43
Q

T or F: NSAIDS and COX-2 inhibitors may increase the risk of Heart Disease

A

True

44
Q

What type of anticoagulant therapy is suggested in a TIA or stroke?

A

COX-1 inhibitor and:
• ADP antagonist (like clopidogrel) OR
• PDE/Cox-1 inhibitor (like Dypridamole)

Heme - Wier/Pallera (12 decks)

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