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Heme Week 3 > Evaluation of a thrombophilic patient > Flashcards

Evaluation of a thrombophilic patient Flashcards

1
Q

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?

  1. Congestive heart failure
  2. Left leg DVT
  3. Post surgical cellulitis
  4. Allergic reaction to anesthesia
A
  1. Left leg DVT

cellulitis- would cause redness

allergic- usually global

*cancer is a high stakes situation for developing DVT

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2
Q

What are the symptoms of DVT?

A
  • calf pain and swelling
  • homans sign (pinch the calf)

(or none or sudden death)

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3
Q

What are the symptoms of pulmonary embolism?

A
  • SOB
  • pleuritic chest pain
  • hemopytsis (coughing up blood)
  • shock

(or none or sudden death)

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4
Q

What are some classic risk factors for atherothrombosis?

A
  • smoking
  • hypertension
  • hyperlipidemia
  • metabolic syndrome
  • mental stress, depression, CV risk (= high cortisol levels)
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5
Q

What are some novel risk factors for atherothrombosis?

A
  • high-sensitivity CRP + TC:HDLC
  • inflammation
  • homocysteine
  • Fibrinogen and D-Dimer
  • Excess VMF or VIII
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6
Q

What are some lab findings that indicate atherothrombosis risk (higher to lower)?

A
  • high-sensitivity CRP + TC:HDLC
  • hsCRP
  • Apolipoprotein B
  • serum amyloid A
  • LDL cholesterol
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7
Q

Is obesity a risk factor for VTE?

Patient population at risk?

A

Yes, BMI over 30 associated with 2-2.5 fold increased risk

incident goes up with age (pre-menopausal females are slightly protected)

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8
Q

Obesity also potentiates the risk of VTE with other factors such as ____ and _____.

A

Oral contraceptives (10 fold instead of 2-3 fold)

HRT (6 fold instead of 2-3 fold)

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9
Q

What is Wells criteria?

A

scoring system for likelihood of getting DVT

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10
Q

What are some of the Wells criteria?

A
  • 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

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11
Q

What are white clots?

A

clots in high flow arterial circulation consisting of platelets and fibrin mostly

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12
Q

What are red clots?

A

clots in low flow (stasis) venous circulation consisting of red cells and fibrin

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13
Q

Why would hemolytic anemias lead to thrombus formation?

A
  • reversal of phosphotidylserine residues activates prothrombinase complex
  • free hemoglobin quenches NO (increases vasospasm)
  • more phospholipid surfaces are made (PF3)
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14
Q

T or F. Leukocytosis promotes thrombus formation

A

T. Obviously, too many red cells or platelets can cause thrombus formation too

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15
Q

T or F. The classical risk factors for atherothrombosis are less for VTE but are similar

A

T.

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16
Q

Factor V Leiden and G20210A Prothrombin are common in what populations?

A

Caucasian

Risk of DVT is factor V homozygous-80x (higher than prothrombin and oral contraceptive risks)

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17
Q

Elevated FVIII is common in what population?

A

African American (so is sickle cell trait)

18
Q

T or F. Anticoagulant deficiencies are more severe than things like Factor V leiden or Prothrombin 20210A.

A

T. Antithrombin deficiency is more severe than protein C, followed by S deficiency

then Factor V then Prothrombin 20210A

19
Q

What are you at risk of, bleeding or clotting, with a factor XII deficiency?

A

could be EITHER! XII is also a feedback inhibitor of the process

20
Q

How would the PT of a prothrombin 20210A patient look?

A

shorter due to increased production of prothrombin

pregnancy is affected here too

21
Q

How can renal failure lead to hyper-homocytseinemia?

A

renal failure leads to decreased folic acid levels

high homocysteine= high clot risk

22
Q

What is the biggest acquired cause of thrombophilia?

A

cancer

23
Q

What are some other acquired causes of thrombophilia?

A
  • surgery
  • diabetes
  • nephrotic syndrome
  • congestive heart failure
  • antiphospholipid syndrome
  • PNH, TTP, DIC
  • oral contraceptives
24
Q

Why would surgery cause a hyper-coagulable state?

A

whenever you cut someone open the body will naturally start to clot

25
Q

Why would nephrotic syndrome cause a hyper-coagulable state?

A

you are spilling out proteins like antithrombin

26
Q

Why would CHF cause a hyper-coagulable state?

A

because you are affecting the liver and slowing venous circulation

27
Q

Why would oral contraceptives cause a hyper-coagulable state?

A

increases FVIII and messes with fibrinolytic mechanisms

28
Q

Why would prothetic valves cause a hyper-coagulable state?

A

surface for coagulation

29
Q

When would antithrombin be reduced?

A 
pregnancy
liver disease
DIC
nephrotic syndrome
surgery
acute thrombosis
heparin
estrogen
30
Q

When would protein C be reduced?

A

liver disease
DIC
acute thrombosis
warfarin

31
Q

When would protein S be reduced?

A 
pregnancy
liver disease
DIC
acute thrombosis
warfarin
estrogen
32
Q

What is the clinical triad for PNH?

A
  • hemolytic anemia
  • venous thrombosis (much higher risk than anti-coag deficiencies)
  • bone marrow failure
33
Q

What will you see on a dipstick for PNH?

A

dipstick positive for blood but no red cells, only hemoglobin

34
Q

What are some of the side effects of lupus anticoagulant (APS)?

A
  • not bleeding
  • venous thrombosis
  • pregnancy loss in 2nd tri.
  • livedo reticularis
  • thrombocytopenia
35
Q

What cancer have the highest risk of VTE?

A

GI cancer, then pancreatic then breast on chemo

36
Q

What is the most common anti-coagulant therapy in cancer patients?

A

low molecular weight heparin

37
Q

When does thrombosis require workup for thrombophilia?

A
  • venous thrombosis under 45 y/o
  • unprovoked or recurrent thrombosis
  • family history
38
Q

What is the best predictor of recurrence for VTE?

A

D-Dimer

39
Q

What defenses does the endothelium have against clot?

A
  • ADPase
  • NO
  • PGI2
  • thrombomodulin
  • t-PA
40
Q

ACCP Guidlines for duration of anticoag therapy

A

first event reversible- 3-6 months at INR 2-3

unprovoked VTE, first or second event- 6-12 months at INR 2-3 and then review risk of recurrence

infinite- cancer, APS, any anticoag deficiencies

Heme Week 3 (11 decks)

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