Evaluation of a thrombophilic patient Flashcards
A 52-y female 4 days after undergoing a right mastectomy for breast cancer develops left leg swelling 3 cm more than her right leg. She has pitting edema on left leg only but no JVD or SOB; and no redness of skin but has calf pain. What is her diagnosis?
- Congestive heart failure
- Left leg DVT
- Post surgical cellulitis
- Allergic reaction to anesthesia
- Left leg DVT
cellulitis- would cause redness
allergic- usually global
*cancer is a high stakes situation for developing DVT
What are the symptoms of DVT?
- calf pain and swelling
- homans sign (pinch the calf)
(or none or sudden death)
What are the symptoms of pulmonary embolism?
- SOB
- pleuritic chest pain
- hemopytsis (coughing up blood)
- shock
(or none or sudden death)
What are some classic risk factors for atherothrombosis?
- smoking
- hypertension
- hyperlipidemia
- metabolic syndrome
- mental stress, depression, CV risk (= high cortisol levels)
What are some novel risk factors for atherothrombosis?
- high-sensitivity CRP + TC:HDLC
- inflammation
- homocysteine
- Fibrinogen and D-Dimer
- Excess VMF or VIII
What are some lab findings that indicate atherothrombosis risk (higher to lower)?
- high-sensitivity CRP + TC:HDLC
- hsCRP
- Apolipoprotein B
- serum amyloid A
- LDL cholesterol
Is obesity a risk factor for VTE?
Patient population at risk?
Yes, BMI over 30 associated with 2-2.5 fold increased risk
incident goes up with age (pre-menopausal females are slightly protected)
Obesity also potentiates the risk of VTE with other factors such as ____ and _____.
Oral contraceptives (10 fold instead of 2-3 fold)
HRT (6 fold instead of 2-3 fold)
What is Wells criteria?
scoring system for likelihood of getting DVT
What are some of the Wells criteria?
- active cancer treatment (within last 6 months)=1
- paralysis=1
- recent bedridden for 3+ days=1
- entire leg swollen=1
- localized tenderness along the distribution of the deep venous system=1
- 3 cm calf swelling=1
- pitting edema on leg=1
- previous DVT=1
- alternative cause = -2
5+ is very high
What are white clots?
clots in high flow arterial circulation consisting of platelets and fibrin mostly
What are red clots?
clots in low flow (stasis) venous circulation consisting of red cells and fibrin
Why would hemolytic anemias lead to thrombus formation?
- reversal of phosphotidylserine residues activates prothrombinase complex
- free hemoglobin quenches NO (increases vasospasm)
- more phospholipid surfaces are made (PF3)
T or F. Leukocytosis promotes thrombus formation
T. Obviously, too many red cells or platelets can cause thrombus formation too
T or F. The classical risk factors for atherothrombosis are less for VTE but are similar
T.
Factor V Leiden and G20210A Prothrombin are common in what populations?
Caucasian
Risk of DVT is factor V homozygous-80x (higher than prothrombin and oral contraceptive risks)
Elevated FVIII is common in what population?
African American (so is sickle cell trait)
T or F. Anticoagulant deficiencies are more severe than things like Factor V leiden or Prothrombin 20210A.
T. Antithrombin deficiency is more severe than protein C, followed by S deficiency
then Factor V then Prothrombin 20210A
What are you at risk of, bleeding or clotting, with a factor XII deficiency?
could be EITHER! XII is also a feedback inhibitor of the process
How would the PT of a prothrombin 20210A patient look?
shorter due to increased production of prothrombin
pregnancy is affected here too
How can renal failure lead to hyper-homocytseinemia?
renal failure leads to decreased folic acid levels
high homocysteine= high clot risk
What is the biggest acquired cause of thrombophilia?
cancer
What are some other acquired causes of thrombophilia?
- surgery
- diabetes
- nephrotic syndrome
- congestive heart failure
- antiphospholipid syndrome
- PNH, TTP, DIC
- oral contraceptives
Why would surgery cause a hyper-coagulable state?
whenever you cut someone open the body will naturally start to clot
