Hypercoaguable states

Question 1

Virchows triad is?

Answer 1

Vessel wall damage/trauma
Venous Stasis
Hypercoagulability (inherited/acquired)

Question 2

Vessel wall damage typically due to?

Answer 2

Prior thrombosis
Vein inflam/inf
Direct vein trauma

Question 3

Venous stasis is typically due to?

Answer 3

Immobility (bed rest, post-op, obese, stroke)
Hyperviscosity (polycythemia)
INC central vein pressure (preggo or Low CO (CHF))

Question 4

Hypercoagulability inherited conditions?

Answer 4

Factor V leiden mutation

Question 5

Hypercoagulability acquired conditions?

Answer 5

>Age
Immobilization
Inflam
Preg/OCP/Hormonal therapy
Obese/DM
Cancer (esp. adenocarcinoma)

Question 6

Highest RF for VTE?

Answer 6

Major surgery/trauma

Question 7

VTE includes what?

Answer 7

DVT and PE

Question 8

Classic VTE Hx?

Answer 8

Prolonged immbolization (plane, drive, admits)
Recent surgery/trauma (esp. ortho surg like hip/knee)
Hx of Cancer

Question 9

Cardiopulm S/S considering VTE?

Answer 9

CP, Limb ischemia
Dyspnea, Hypoxia
Tachy-C, Sudden Death
Syncope, Stroke
Acute Renal Failure

Question 10

DVT S/S

Answer 10

Unilateral LE edema
Erythema, Warmth, TTP
Calf Diameter >2cm difference
Decreased extermity pulse/cyanotic (BAD!)
Heavy legs
Palpable venous cord
Homans sign POS - Calf pain w/ foot dorsiflexion

Question 11

Acute PE S/S?

Answer 11

Sudden SOB onset
Pleuritic CP
Tachypnea >50% pts
Hemoptysis
Syncope
EKG - Sinus Tach/non-specific ST and T wave changes
- or S1-Q3-T3 (indicates massive PE + Cor pulmonale)

Question 12

S1-Q3-T3 EKG finding is AKA?

Answer 12

McGinn-White Sign

Question 13

Wells criteria

Answer 13

+1
Hemopytsis
Cancer TXT w/in last 6mo

+1.5
Prev PE/DVT – >100 HR – W/in 30d Surg/immobilized

+3
S/S of DVT
Alternate DX less likely than PE

<=4 PE unlikely
>4 PE likely

Question 14

If Well’s score is <=4 then?

Answer 14

PE unlikely > order DD > <500 DD is low >R/O VTE

Question 15

If Well’s score is >4 then?

Answer 15

PE likely > order Images (No DD - wont change TXT)

Question 16

VTE initial approach

Answer 16

RFs? Virchows Triad satsified?

Question 17

VTE PE includes?

Answer 17

Attention to vascular system

- Extremities, heart/chest, ABD organs, skin

Question 18

VTE Labs

Answer 18

CBC
Coag - PT/PTT/DD
EKG - Tachy-C + nonspecific ST-T wave changes
Renal Fx
ABGs (acute respiratory alkalosis)

Question 19

DD is?

Answer 19

Degradation product fibrin and is elevated in presence of thrombus

<500 ng/mL = Strong evidence AGAINST VTE

Question 20

VTE imaging

Answer 20

DVT - Compression Venous U/S

PE

• CXR - exclude (most helpful if NL w/ hypoxemia)
• CT pulm angiography - Dx study for suspected PE
• Vent-Perf (VQ) scan - (Use if CT unavailable)

Question 21

What is Dx imaging of choice for PE?

Answer 21

CT Pulmonary angiography

Question 22

VTE mainstay TXT

Answer 22

Anticoagulation

• LMWH (SQ) Enoxaparin
• Rarely - Unfractionaed (IV) heparin

Bridge w/ Warfarin
- Heparin + (PO) warfarin/coumadin x5d until INR of >=2 achieved for 24hrs

Question 23

VTE newer TXT methods?

Answer 23

Factor 10a inhibitors - Bridging to heparin not req

• Rivaroxaban
• Apixaban

Question 24

RVB of Factor Xa TXT of VTE

Answer 24

Benefits - No INR monitoring or daily injections

Risks - Irrev agent (ensure compliance or bld, no monitoring available)

Question 25

PO direct F10a inhibitors

Answer 25

• Rivaroxaban
• Apixaban
• Betrixaban
• Edoxaban

Question 26

PO direct thrombin (IIa) inhibitors

Answer 26

• Dabigatran

- Etexilate

Question 27

VTE TXT lengths

Answer 27

1st episode w/ reversible (provoked) RF = 3mo

1st episode and idopathic (unprovoked RF) = 3mo or lifelongcase by case

Cancer VTE= LMWH 3-6m then until CA cured or indef
– Hematology refer

Recurrent VTE or those w/ irreversible RFs = Indef