Hubbard: DVT and PE

Question 1

Which 3 factors of the anticoagulant pathway regulate clot formation by preventing excess thrombin production?

Answer 1

Protein C and S and antithrombin

Question 2

What are the components of Virchow’s triad (3 factors that contribute to thrombosis)

Answer 2

1. Venous stasis
2. Endothelial damage
3. Hypercoagulability

Question 3

What is the most common thrombophilic disorder; leads to what?

Answer 3

• Factor V Leiden mutation –> activated protein C resistance
• Results in protein C being unable to inactivate factor V and VIII, which leads to unregulated prothrombin activation

Question 4

Inherited Thrombotic Disorders

Answer 4

1. Antithrombin III Deficiency
2. Protein C and Protein S Deficiency
3. Factor V Leiden Mutation
4. Prothrombin 20210 Mutation
5. Methylene Tetrahydrofolate Reductase Deficiency (Hyperhomocysteinemia)
6. Factor XII Deficiency
7. Dysfibrinogenemias

Question 5

Acquired Thrombotic Disorders

Answer 5

1. Protein C and Protein S Deficiency
2. Dysfibrinogenemias
3. Antiphospholipid Syndrome

Question 6

Clinical clues of DVT/PE

Answer 6

1. Homans sign: Pain in calf or popliteal area on
   dorsiflexion of the foot
2. Moses sign (Bancroft signs): Pain with
   compression of the calf against the tibia but not when
   squeezing the calf itself (see
   photo)

Question 7

What is Lisker’s Sign?

Answer 7

Pain with percussion of the anteromedial tibia;

Question 8

What is Lowenberg’s sign:

Answer 8

BP cuff applied to mid-calf and pain

elicited with inflation to 80 mmHg

Question 9

What is Unilateral superficial venous distention/

Answer 9

veins of affected leg
distended in comparison to non-affected leg; not sensitive or
specific for DVT

Question 10

Wells Criteria for DVT = (Risk of getting DVT)

Answer 10

1. Active cancer = 1
2. Paralysis/immobilization = 1
3. Bedridden for >3 days or major surgery within 4 weeks = 1
4. Entire leg swollen = 1
5. Tenderness along deep vein = 1
6. Calf swelling >3cm = 1
7. Pitting edema (unilateral) = 1
8. Collateral superficial vein = 1
9. Alternative dx more likely than DVT = (-2)

Question 11

Score and probability for Wells Criteria for DVT

Answer 11

High (3 or higher) = 75% risk
Moderate (1-2) = 20% risk
Low (0) = 3% risk

Question 12

Wells Criteria for PE = (Risk of getting PE)

Answer 12

1. Clinical evidence of DVT = 3
2. Other dx less likely than PE = 3
3. HR (>100) = 1.5
4. Immobile >3 day or major surgery within 4 weeks = 1.5
5. Previous DVT/PE = 1.5
6. Hemptysis = 1
7. Malignancy = 1

Question 13

Score and probability for Wells Criteria for PE

Answer 13

High (6 or >) = 70% risk of PE

Moderate (2-6) = 20-30% risk

Low (<2) = 2-3% risk

Question 14

20% of all patients with symptomatic DVT have underlying ______

Answer 14

malignancy

Question 15

20% of all patients with symptomatic DVT have underlying malignancy. What are the MC?

Answer 15

1. Lung
2. Pancreas
3. Colon/rectum
4. Kidney
5. Prostate

Question 16

Trousseau’s Syndrome…
35% of Trousseau’s original
patient population eventually
died of

Answer 16

metastatic cancer

Question 17

What cancer medications cause drug-induced hyper coagulability?

Answer 17

1. Tamoxifen = proestrogenic effect increases risk of DVT/PE and stroke
2. Bevacizumab = arterial and venous thromboses
3. Thalidomide/lenlidomide = arterial and venous thromboses

Question 18

What surgeries increase risk of DVT/PE?

Answer 18

Orthopedic, major vascular, neurosurgery, cancer

Question 19

RF for getting DVT/PE during surgery

Answer 19

1. Older age
2. Previous venous thromboembolism
3. Malignancy
4. Medical illness
5. Longer surgical, anesthesia, and
   immobilization times

Question 20

Other cases of hypercoagubility

Answer 20

1. Sitting still for Long time
2. Extended travel
3. HF is a hyper coagulable state = greatest with R HF

Question 21

What are Major risk factors for intracardiac thrombi

Answer 21

1. Reduced L ventricular
function and a-fib

Question 22

List 7 acquired prothrombic states which increase risk for thromboembolism.

Answer 22

• Antiphospholipid antibodies
• Malignancy
• Immobilization
• Surgery
• Pregnancy
• Estrogen
• Heparin-induced thrombocytopenia

Question 23

What heriditary RF poses a 80x risk of first DVt/PE.

Answer 23

Homozygous Factor V Leiden or prothrombin gene mutation

Question 24

Oral contraceptives/hyperhomocysteinemia and heterozygous Factor V
Leiden have a _____ effect on probability of developing DVT/PE

Answer 24

Synergistic (35x)