Lecture 8 - Hypercoagulable States Flashcards
3rd leading cause of death in hospital pts?
Pulmonary embolism
Abbrox 40% of PE pts will develope?
proximal DVT
Verchows triad
Vessel wall damage/trauma
Venous stasis
Hypercoagulabiity
What causes venous stasis?
Immobility
Hyperviscosity (polycthemia_
Increased central venous pressures
- preggo/CHF
While only 1% of the population ___ accounts for 50-60% of enous thromboembolism (VTE)
Inherited hypercoagulabilty
Inherited hypercoagulabilty conditions?
- Factor V leiden mutation
- Antithrombin III deficiency
- protein C deficiency
- protein S deficiency
- prothrombin gene mutation
- antiphospholipid antibody syndrome (APS)
What is included in antiphospholipid antibody syndrome (APS)?
Lupus anticoagulant
Anticardiolipin antibody
Anti-beta2-glucoprotein
Acquired hypercoagulability conditions?
Advanced age Immobilization Inflammation Pregnancy Oral contraceptive use Hormonal replacement therapy Obesity DM Cancer
Can VTE be idiopathic?
Yeah it can be
VTE is rare right?
No its pretty common
1% incidence after age 60
VTE includes?
DVT
PE
Post thrombotic syndrome
Classic VTE hx?
Prolonged immobilization
- coach class syndrome
- hospitalization
Recent surgery or trauma
- especially ortho
Hx of cancer
Cardiac symptoms that may be VTE?
Chest pain Dypsnea Limb ischemia Stroke Acute renal failure
DVT and PE together?
70% Pts with PE have DVT
50% of pts with DVT have PE
S/X of DVT
Unilateral lower extremity
- edema
- erythema
- warmth
- ttp
Decreased extremity pulses/cyanosis
“Heavy legs”
Palpable venous cord
Homan’s sign
Bad signs with DVT?
Calf diameter >2cm difference
Cyanotic hue
Homan’s sign?
Unreliable
Calf pain on foot dorsiflexaion
Post-thrombotic syndrome (PTS) is a ?
Long term sequelae of DVT 2/2 chronic venous insufficiency
Approx 50% of pts 6mo post DVT
What causes PTS?
Reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction
PTS S/S
- Extremity pain
- Venous dilation
- Edema
- Pigmentation
- Skin changes
- Venous ulcers
Acute PE S/S?
- sudden SOB
- pleuritic chest pain
- tachypnea
- hemoptysis
- syncope
ECG changes
MC ECG findings for PE?
Sinus tach
Nonspecific ST and T wave changes
S1-Q3-T3 usually means?
Massive acute PE
Cor pulmonale
S1-Q3-T3
Look at slide 25 if your forgot
Wells criteria?
Score given for PE probabilty
Slide 26
Well’s criteria - VTE risk scores?
= 4 - PE unlikely get a d-dimer
D-dimer <500 (low) ruled out VTE
> 4 - PE likely - get a imaging study
If you have a wels criteria VTE risk of >4 you should not?
Order a d-dimer - doesnt change anything
HX warning signs for VTE?
Virchow’s triad risk factors
- hx of immobilization
- surgery
- obesity
- fam hx
- lower extremity trauma
- malignancy
- OCPs or HRT
- pregnant
- stroke
VTE PE?
Pay special attention to the vascular system
Chest
Heart
Abdominal organs and skin
VTE labs?
CBC Coag studies (PT/PTT) ECG Renal function ABGs (resp alkalosis) Hypercoagulable workup d-dimer
Imaging for DVT?
Compression venous US
Imaging for PE?
CXR - r/o other shit
CT pulmonary angiography
ventilation-perfusion lung scan
- ( if ct not available)
Tx for VTE?
Anticoagulation
- LMW Heparin
- unfractionalte IV heparin
BRIDGE with WARFARIN
How to bridge warfarin for VTE?
Heparin + oral warfarin/coumadin x 5 days until INR of 2 or more has been achieved x 24hrs
Alternates to heparin tx?
Factor Xa inhibitors
— no warfarin bridge
- Rivaroxaban
- Apixaban
Risks and benefits of factor Xa inhibitors?
Risks: bleeding and is irreversible (maybe not anymore)
- cannot monitor compliance (must trust pt)
Benefits: NO INR monitoring or daily inj
1st episode and reversible (provoked) VTE therapy?
3 months of LMWH
Cancer VTE tx?
LMWH x 3-6 months
Then
LMWH indefinitely until cancer free
Coumadin is not effective in neoplasm induced VTE
1st episode idiopathic (unprovoked ) VTE tx?
3 months therapy
But
Case-by-case, they may need lifelong
Get a hypercoagulability evaluation
Recurrent VTE and irreversible risk factors therapy?
Life long tx
What is the pulmonary embolism severity index (PESI)
Assesses the 30 day mortality outcomes to triage into:
- outpatient
- inpatient
- ICU level
Slide 37
PESI score risk categories
< 65 : outpatient
66-85 : consider outpatient
86-105 : consider inpatient
106-125 : inpatient management
> 125 : ICU management
Malgnancy and VTE?
Malignancy increases risk of VTE
VTE may be initial presentation of malignancy
Warning signs for Malignancy?
Unprovoked VTE
Recurrent VTE wile on anticoagulants
Multi-site VTE
Recurrent unprovoked superficial thrombosis
Low, moderate, and high suspicion for malignancy testing?
Low: no further testing
Moderate: CT of abdomen and pelivs
High: routine chem, CBC, CT, mammography, gynecology consult, PSA
Pretty much all cancer pts should be?
On LMWH
At least for first 3-6 months but prob longer
Who to screen for inherited thrombophilia?
- Family hx of unprovoked VTE
- unprovoked VTE <45 y/o
- recurrent VTE
- recurrent pregnancy loss
Thrombophilia testing post anticoagulant
You should check at least 2 wks post completion of initial oral anticoagulant
- it can alter the results
Donating blood
Is a great excuse to eat the way i do every other day
