IC4: Management of Acute and Chronic VTE

Question 1

What are the three components of virchow’s triad?

Answer 1

Hypercoagulability
Vascular damage
Circulatory stasis

Question 2

DVT s/sx

Answer 2

signs - sueprficial veins dilated and palpable
symptoms - leg swelling, pain, warmth, usually unilateral

Question 3

PE s/sx

Answer 3

signs - tachypnea, tachycardia, distended neck veins
symptoms - cough, chest pain, SoB, palpitation, hemoptysis

Question 4

For what DVT score should imaging be done and what kind of imaging should be done?

Answer 4

More than 2, image whole leg or proximal compression ultrasound

If 2 or less proceed with D-dimer (if negative, confirm no DVT)

Question 5

Explain the difference in the course of action between distal and proximal DVTs

Answer 5

Distal (femur) - anticoagulation or surveillance

Proximal (fibula/tibula) - initiate anticoagulants right away

Question 6

What are the 4 possible treatment routes for VTE?

Answer 6

1. Apixaban (step down at 7 days)
2. Rivaroxaban (step down at 21 days)
3. LMWH x 5d then dabigatran/edoxaban
4. LMWH x 5d overlap with warfarin and INR > 2

Apixaban and rivaroxaban are oral only

Question 7

What are the two important time points for VTE treatment?

Answer 7

3 month - consider stopping tx if attack is transient

6 month - consider reduction of DOACs (apixaban/rivaroxaban) to prophylaxic doses

Question 8

Rank the disposition of DOACs

Answer 8

Dabigatran, Rivaroxaban, Apixaban, Warfarin
(increasingly dependent on liver clearance)

Question 9

Compare between tenecteplase and alteplase

Answer 9

Tenecteplase is ONLY used for MI
Alteplase is used for AIS

Dosing for alteplase is more confusing (both dosed by BW)

Question 10

Inclusion criteria for thrombolytic use includes (3)

Answer 10

clinical diagnosis of acute ischemic stroke (AIS),
defined onset and able to start treatment within 4.5h of onset (after 4.5h risk > benefits),
CT scan consistent with AIS

Question 11

Exclusion criteria includes (8)

Answer 11

CT scan with ICH for subarachnoid hemorrhage
suspicion or history of ICH/SAH
recent stroke of serious head trauma
major surgery or serious trauma
low platelet count
current use of anticoagulants (warfarin, heparin) or DOACs (dabigatran, rivaroxaban, edoxaban)

Question 12

Treatment options for high risk patients

Answer 12

Initiate thrombolysis, UFH preferred as it is easily reversible over LMWH

Question 13

Treatment options for low to intermediate risk patients (3)

Answer 13

If patient is unwell, initiate parenteral LMWH
If can use oral agents, consider DOACs
If patients are treated with warfarin, overlap with parenteral anticoagulation

Question 14

When should DOACs NOT be used

Answer 14

Pregnancy
Severe renal impairment
Patients with APS

Question 15

What are the VTE risk factors is in the elderly? (7)

Answer 15

prior VTE, obesity, medical comorbodidies, stillbirth, pre-eclampsia, post-partum hemorrhage and C-section

Question 16

What are the steps to take in DVT in pregnancy? (2)

Answer 16

Send for CXE to exclude PE
LMWH (SC Enoxaparin) is the drug of choice in pregnancy

Question 17

What are the steps to take in DVT in pregnancy? (5)

Answer 17

Send for CXE to exclude PE
LMWH (SC Enoxaparin) is the drug of choice in pregnancy