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Senior - Heme-Onc > Lecture 8 - Hypercoagulable States > Flashcards

Lecture 8 - Hypercoagulable States Flashcards

1
Q

3rd leading cause of death in hospital pts?

A

Pulmonary embolism

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2
Q

Abbrox 40% of PE pts will develope?

A

proximal DVT

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3
Q

Verchows triad

A

Vessel wall damage/trauma

Venous stasis

Hypercoagulabiity

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4
Q

What causes venous stasis?

A

Immobility
Hyperviscosity (polycthemia_
Increased central venous pressures
- preggo/CHF

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5
Q

While only 1% of the population ___ accounts for 50-60% of enous thromboembolism (VTE)

A

Inherited hypercoagulabilty

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6
Q

Inherited hypercoagulabilty conditions?

A
  • Factor V leiden mutation
  • Antithrombin III deficiency
  • protein C deficiency
  • protein S deficiency
  • prothrombin gene mutation
  • antiphospholipid antibody syndrome (APS)
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7
Q

What is included in antiphospholipid antibody syndrome (APS)?

A

Lupus anticoagulant
Anticardiolipin antibody
Anti-beta2-glucoprotein

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8
Q

Acquired hypercoagulability conditions?

A 
Advanced age
Immobilization
Inflammation
Pregnancy
Oral contraceptive use
Hormonal replacement therapy
Obesity
DM
Cancer
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9
Q

Can VTE be idiopathic?

A

Yeah it can be

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10
Q

VTE is rare right?

A

No its pretty common

1% incidence after age 60

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11
Q

VTE includes?

A

DVT
PE
Post thrombotic syndrome

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12
Q

Classic VTE hx?

A

Prolonged immobilization

  • coach class syndrome
  • hospitalization

Recent surgery or trauma
- especially ortho

Hx of cancer

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13
Q

Cardiac symptoms that may be VTE?

A 
Chest pain
Dypsnea
Limb ischemia
Stroke
Acute renal failure
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14
Q

DVT and PE together?

A

70% Pts with PE have DVT

50% of pts with DVT have PE

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15
Q

S/X of DVT

A

Unilateral lower extremity

  • edema
  • erythema
  • warmth
  • ttp

Decreased extremity pulses/cyanosis
“Heavy legs”
Palpable venous cord
Homan’s sign

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16
Q

Bad signs with DVT?

A

Calf diameter >2cm difference

Cyanotic hue

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17
Q

Homan’s sign?

A

Unreliable

Calf pain on foot dorsiflexaion

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18
Q

Post-thrombotic syndrome (PTS) is a ?

A

Long term sequelae of DVT 2/2 chronic venous insufficiency

Approx 50% of pts 6mo post DVT

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19
Q

What causes PTS?

A

Reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction

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20
Q

PTS S/S

A
  • Extremity pain
  • Venous dilation
  • Edema
  • Pigmentation
  • Skin changes
  • Venous ulcers
21
Q

Acute PE S/S?

A
  • sudden SOB
  • pleuritic chest pain
  • tachypnea
  • hemoptysis
  • syncope

ECG changes

22
Q

MC ECG findings for PE?

A

Sinus tach

Nonspecific ST and T wave changes

23
Q

S1-Q3-T3 usually means?

A

Massive acute PE

Cor pulmonale

24
Q

S1-Q3-T3

A

Look at slide 25 if your forgot

25
Q

Wells criteria?

A

Score given for PE probabilty

Slide 26

26
Q

Well’s criteria - VTE risk scores?

A

= 4 - PE unlikely get a d-dimer

D-dimer <500 (low) ruled out VTE

> 4 - PE likely - get a imaging study

27
Q

If you have a wels criteria VTE risk of >4 you should not?

A

Order a d-dimer - doesnt change anything

28
Q

HX warning signs for VTE?

A

Virchow’s triad risk factors

  • hx of immobilization
  • surgery
  • obesity
  • fam hx
  • lower extremity trauma
  • malignancy
  • OCPs or HRT
  • pregnant
  • stroke
29
Q

VTE PE?

A

Pay special attention to the vascular system

Chest
Heart
Abdominal organs and skin

30
Q

VTE labs?

A 
CBC
Coag studies (PT/PTT)
ECG
Renal function
ABGs (resp alkalosis)
Hypercoagulable workup
d-dimer
31
Q

Imaging for DVT?

A

Compression venous US

32
Q

Imaging for PE?

A

CXR - r/o other shit
CT pulmonary angiography
ventilation-perfusion lung scan
- ( if ct not available)

33
Q

Tx for VTE?

A

Anticoagulation

  • LMW Heparin
  • unfractionalte IV heparin

BRIDGE with WARFARIN

34
Q

How to bridge warfarin for VTE?

A

Heparin + oral warfarin/coumadin x 5 days until INR of 2 or more has been achieved x 24hrs

35
Q

Alternates to heparin tx?

A

Factor Xa inhibitors
— no warfarin bridge
- Rivaroxaban
- Apixaban

36
Q

Risks and benefits of factor Xa inhibitors?

A

Risks: bleeding and is irreversible (maybe not anymore)
- cannot monitor compliance (must trust pt)

Benefits: NO INR monitoring or daily inj

37
Q

1st episode and reversible (provoked) VTE therapy?

A

3 months of LMWH

38
Q

Cancer VTE tx?

A

LMWH x 3-6 months
Then
LMWH indefinitely until cancer free

Coumadin is not effective in neoplasm induced VTE

39
Q

1st episode idiopathic (unprovoked ) VTE tx?

A

3 months therapy
But
Case-by-case, they may need lifelong

Get a hypercoagulability evaluation

40
Q

Recurrent VTE and irreversible risk factors therapy?

A

Life long tx

41
Q

What is the pulmonary embolism severity index (PESI)

A

Assesses the 30 day mortality outcomes to triage into:

  • outpatient
  • inpatient
  • ICU level

Slide 37

42
Q

PESI score risk categories

A

< 65 : outpatient

66-85 : consider outpatient

86-105 : consider inpatient

106-125 : inpatient management

> 125 : ICU management

43
Q

Malgnancy and VTE?

A

Malignancy increases risk of VTE

VTE may be initial presentation of malignancy

44
Q

Warning signs for Malignancy?

A

Unprovoked VTE

Recurrent VTE wile on anticoagulants

Multi-site VTE

Recurrent unprovoked superficial thrombosis

45
Q

Low, moderate, and high suspicion for malignancy testing?

A

Low: no further testing

Moderate: CT of abdomen and pelivs

High: routine chem, CBC, CT, mammography, gynecology consult, PSA

46
Q

Pretty much all cancer pts should be?

A

On LMWH

At least for first 3-6 months but prob longer

47
Q

Who to screen for inherited thrombophilia?

A
  • Family hx of unprovoked VTE
  • unprovoked VTE <45 y/o
  • recurrent VTE
  • recurrent pregnancy loss
48
Q

Thrombophilia testing post anticoagulant

A

You should check at least 2 wks post completion of initial oral anticoagulant

  • it can alter the results
49
Q

Donating blood

A

Is a great excuse to eat the way i do every other day

Senior - Heme-Onc (6 decks)

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