Evaluation of a Clotting Patient Flashcards
Risk factors and Signs of DVT • Active Cancer • Paralysis • Recently Bedridden • Localized Tenderness •Swollen Leg • Pitting Edema
Risk factors and Signs of DVT • Active Cancer • Paralysis • Recently Bedridden • Localized Tenderness • Swollen Leg • Pitting Edema
Symptoms of Pulmonary Embolism • Shortness of Breath • Pleuritic Chest Pain • Hemoptysis • Shock • Sudden Death
Symptoms of Pulmonary Embolism • Shortness of Breath • Pleuritic Chest Pain • Hemoptysis • Shock • Sudden Death
What is a white clot mostly composed of?
• Red Clot?
White Clot = HIGH FLOW:
• Platelets and Fibrin
Red Clot = LOW FLOW
• Red Cells and Fibrin
Which are the most important risk factors for atherothrombosis?
• Name some
Conventional Risk Factors: • Smoking • Increased Cortisol (Stress, Depression) • Hypertension • Hyperlipidemia • Metabolic Syndrome
note, these are better predictors of thrombosis than novel risk factors
What are some of the best biomarkers for atherothrombosis?
Best —-> No as Good but not bad
CRP + HDLC
CRP
LDL Cholesterol
Who is at the biggest risk of VTE (venous thromboembolism?
1 OLDER PEOPLE
What risk factors when in combination with obesity have a multiplicative effect?
Baseline Obesity risk = 2x as high as avg.
Oral Contraceptives + Obesity = 10x
Hormone Replacement Therapy = 6x
What is the Risk of Thrombosis in a Factor V Leiden Heterozygote?
• Homozygote?
• FVL heterozygote on oral contraceptives
FVL Hetero - 7x risk
FVL Homo - 80x risk
FVL Hetero + oral contraceptive (~4x) = 35x risk
What are the 3 biggest clotting abnormalities in White people and Black people?
White:
Factor 5 Leiden
Factor 8 elevated
Antiphopholipid Antibodies
Black:
Factor 8
Antiphospholipid antibodies
(factor 5 doesn’t play much of a role)
In terms of serverity of Thombotic events rate the following: Antithrombin Def., Protein C Deficiency, Protein S deficiency.
Note all of these people have a lot bigger chance of clotting than the people with cascade mutations
- AT
- P-C
- P-S
What test would you run if you suspected a prothrombin gene mutation in someone?
• what result would you expect?
PT or PTT
• Short PT/PTT
T or F: elevated homocysteine puts you at a huge risk of thrombosis
False, not until Homocysteine gets to like 2x normal do you really see any changes in the odds of VTE
What are some causes of acquired thrombophilia?
- MALIGNANCY
- Immobilization
- Nephrotic Syndrome
- Antiphospholipid Syndrome
How can antiphospholid Antibody lead to long PTT in vitro but not in vivo?
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
What happens if you try to test someones clotting during thrombosis?
Everything will be tied up in the clot
What Triad Should you look for in PNH?
- Hemolytic Anemia
- Bone Marrow Failure (pancytopenia)
- Venous Thrombosis
What cancers put you at the highest risk for Venous Thromboembolism?
- Breast Cancer
- Pancreatic Cancer
- Gastrointestinal Cancer
When should you do a workup for thrombophilia?
- 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
T or F: you must do thrombophilia testing in to find out how you need to treat your patient?
False, the only reason it usually changes is if you are positive for Cancer or something.
If someone is thombophilic, what will be your next step in therapy?
• how will cancer change this?
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)
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?
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
What are some special situations where you may need to be on warfarin forever?
- Cancer until Resolved (with LMWH)
- Antiphospholipid Ab. Syndrome
- Antithrombin Deficiency
- Possibly with Protein C or Protein S deficiency
What is the best way to assess someones risk of DVT recurrence after long term therapy?
D-Dimer Management
What is the role of the following in hemostasis: •ADPase • NO • PGI2 • TM • t-PA
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
Suppose you are hypercoagulable because of an antithrombin deficiency. What is the primary anticoagulant you cannot give?
Unfractionated Heparin or LMWH (e.g. enoxaparin)
• will have no enzyme to activate
You could bipass this with some anti X drugs like Dabigatran*
How do you measure the activity of Heparin?
• Measure the PTT
What are some of the advantages and disadvantages to using heparin as your anticoagulant?
Advantage:
• Short Half Life
Disadvantage:
• Cumbersome (monitoring of PTT every 6 hrs)
• Hospitalization Required
How is LMWH advantageous over Unfractionated Heparin?
• Disadvantages
LMWH
Advantages:
• NO MONITORING NEEDED (more predictable effects)
• Given Subcutaneously
Disadvantages:
• Long Half Life
• Contraindicated in Renal Failure
Can be given therapeutically or prophylatically
Can you measure the effect of LMWH by PT or PTT?
NO, you must monitor LMWH with anti-Factor Xa assay
What are the indications for the use of heparin?
- Immediate Interruption of Coag.
- Bridging Therapy to Warfarin
- Patency of Indwelling lines
- Prevent Clotting of Hemodialysis unit during open heart surgery
Can you use protamine sulfate against both Low MW and Unfractionated Heparin?
• Yes, but it really on predictable with Unfractionated Heparin
What are your 1st and 2nd line therapies in reversing the effects of Warfarin?
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)
Should you get an IM flu shot while taking warfarin?
NO, you will bleed like a motherfucker, do it SC
T or F: Heparin can cause Osteopenia
True
What anticoagulant is known to cause glottic edema?
• What else is it known for?
Warfarin
• also causes necrosis
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
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
What are some good long term therapies for someone with a-fib?
- Warfarin
* Dabigatran
T or F: in the case that someone has HIT, you can use Fondaparinux.
True, could also use Dabigatran
When would you use from thrombolytics like alteplase?
- MI
- Pulm. Embolism
- DVT
- Stroke
What are some reasons you might choose against giving someone Thrombolytic therapy?
- CPR
- Recent Surgical History
- Significant Bleeding History
- Being over 75
What ADP (P2Y12) antiagonists might you use with asprin?
Clopidogrel
Who are the best patients to put on asprin therapy?
ppl. 55-59, because there’s less of a GI bleeding risk
T or F: NSAIDS and COX-2 inhibitors may increase the risk of Heart Disease
True
What type of anticoagulant therapy is suggested in a TIA or stroke?
COX-1 inhibitor and:
• ADP antagonist (like clopidogrel) OR
• PDE/Cox-1 inhibitor (like Dypridamole)
