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HAEM5001 Haemostasis and Thrombosis > Module 7 > Flashcards

Module 7 Flashcards

1
Q

What is the treatment of choice for catheter related thrombosis?

A

anticoagulation for at least 3 months, regardless of whether the catheter is removed

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2
Q

What is the mechanism of action of heparins?

How is fondaparinux different?

A

Potentiates antithrombin inhibition of thrombin and factor Xa

Fondaparinux only targets Xa and is completely synthetic

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3
Q

What are the target anti-Xa levels for UFH vs LMWH?

A

UFH 0.3-0.7

LMWH 0.5-1.1

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4
Q

Under what circumstances do we monitor the anti-xa activity for LMWH?

A

renal insufficiency
extremes of weight
pregnancy
non-compliance

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5
Q

What are the half lifes of UFH, LMWH and dalteparin?

A

1 hour
4 hours
17 hours

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6
Q

What clinical circumstances favour warfarin over DOAC for long term anticoagulation?

A 
triple positive APLS
mechanical valves
Cr Cl <30
heart failure
non-compliance (longer half life)
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7
Q

Which agent preferentially prolongs the PT vs the APTT?

Which agent preferentially prolongs the APTT vs the PT?

A

PT over APTT: rivaroxaban, less so apixaban

APTT over PT: dabigatran

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8
Q

How do we manage bleeding in setting of DOACs?

A
  • withhold agent
  • supportive measures
  • local haemostasis
  • FFP as plasma expander
  • platelets to normalise
  • idracizumab for dabigatran
  • prothrombinex but minimal evidence for this
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9
Q

How long to w/h apixaban/dabigatran/rivaroxabanpre-op?

When do we restart?

“PAUSE study”

A

HIGH RISK

  • w/h for 2 days prior to OT
  • restart on post-op D2

LOW RISK

  • w/h for 1 day prior to OT
  • restart on post-op D1
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10
Q

What are the 8 A’s that interact with warfarin?

A
  • Antibiotics
  • Antifungals
  • Anti-depressants
  • Antiplatelets
  • Amiodarone
  • Anti-inflammatories
  • Acetaminophen
  • Alternative remedies
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11
Q

What are the factors in prothrombin complex concentrates?

A

II, IX and X

or

II, VII, IX and X

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12
Q

What is the management plan for patients with

  • INR >1.5 with critical bleeding
  • INR >2 with non-critical bleeding
  • any INR with minor bleed
A 
FIRST 2 CASES
Cease warfarin therapy
Vit K 5-10mg IV and
Prothrombinex 50 IU/KG IV and
FFP 150-300ml IV
If PTX unavailable, FFP 15ml/kg

ANY INR, MINOR BLEED
Omit therapy, repeat INR next day
Consider Vit K 1-2mg orally or 0.5-1mg IV if INR >4.5 or high risk

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13
Q

What are the elimination routes for

  • argatroban
  • bivalrudin
  • danaparoid
A

argatroban: hepatic

Bivalrudin and danaparoid: renal

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14
Q

What are the mechanisms of action and monitoring for

  • argatroban
  • bivalrudin
  • danaparoid
A

Argatroban: direct, selective thrombin inhibitor

Bivalrudin: direct thrombin inhibitor

Monitor both with aPTT

Danaparoid: FXa and Thrombin inhibitor by binding to antithrombin

Monitor anti-Xa if clinically indicated

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15
Q

What are the considerations when using warfarin with respect to HITTS?

A

avoid prior to platelet count recovery due to risk of warfarin-induced skin necrosis
if receiving warfarin at time of diagnosis of HITTS, reverse wth Vit K

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16
Q

Which are the cancer subtypes with the highest prevalence of cancer thromboses?

A

breast, prostate, lung, Colorectal, pancreatic, clear cell ovarian, glioblastoma multiforme

17
Q

What are the treatments advised for cancer-related thromboses?

A

LMWH for 4 weeks
Alternatively, can use DOAC (rivaroxaban or apixaban) , however increased bleeding with GI and GU cancers

note we don’t treat INCIDENTAL thromboses

18
Q

Which of the antiphospholipid antibodies are associated with the highest and lowest risk of thrombosis ?

A

Highest: LAC
Lowest: anti-cardiolipin

19
Q

What is the management of a patient who is triple positive APLS presenting with first thrombosis?

A 
IV Heparin or LMWH 
Bridge to warfarin aim INR 2-3
Always bridge if temporary cessation
If arterial thrombosis, consider adding aspirin
CVD risk modification
Can add hydroxychloroquine if SLE
20
Q

What is the management for patients with no thromboses but persistent anti-phospholipid positivitiy on 12 week testing?

A

NO EVIDENCE for primary prophylaxis

  • Aspirin if CV risk high, hydroxychlorophine with SLE
  • Address reversible risk factors
  • Consider short term anticoagulation during high risk situations eg. surg
21
Q

What are the diagnostic features of catastrophic APLS and how do we treat?

A

FEATURES

  • thrombosis in 3 or more organs
  • rapidly progressive
  • common precipitants: subtherapeutic anticoagulation, infection malignancy
  • MOFS
  • SIRS

TREATMENT

  • early high dose steroids
  • plasma exchange
  • continue anticoagulation
  • IVIg
  • if refractory, rituximab/complement inhibition
22
Q

What are the actions of α2 antiplasmin?

A

Crosslinked into clot by XIIIa, makes thrombi resistant to plasmin
Inactivates plasmin in circulation

23
Q

How do thrombolytics work eg. streptokinase/urokinase/alteplase/tenecteplase?

A

Bind to fibrinogen forming complex that leads to plasminogen conversion into plasmin

24
Q

What are the broad indications for thrombolysis?

A

STEMI: where primary PCI cannot be offered
Acute PE: for those with catastrophic RHF
Acute ischaemic/thrombobtic stroke
Acute iliofemoral venous thrombosis

25
Q

What differentiates tenecteplase from the other thrombolytics?

A

Same as alteplase, is genetically engineered plasminogen activator

More fibrin-specific

Has a longer half life, can be given as single bolus

26
Q

What are the assessment components of the Pulmonary Embolism Severity Index? (11)

How do the scores reflect risk/mortality?

A 
Age (years)
Male sex +10
Cancer +30
Heart failure +10
COPD +10
HR >110 +20
BP <100 +30 
RR >30 +20
Temp <36 +20
Delirium +60
Sats <90 +20

Low risk <65 1.9% mortality

Intermediate risk 86-105 18.5% mortality

High risk >125
25% mortality

27
Q

How does the PESI score help determine management?

A

PESI low risk : anticoagulation, consider discharge home

PESI intermediate and above: anticoagulate and hospitalise

PESI intermediate or high with RV dysfunction, consider rescue reperfusion

28
Q

What are the absolute indications for IVC filter insertion?

A
  • contraindication to anticoagulation
  • complication of anticoagulation
  • failure of anticoagulation eg. recurrent PE or inability to achieve adequate anticoagulation
29
Q

Describe some rescue therapies used in PE?

A

IV thrombolysis
- increased bleeding complications and intracranial haemorrhage

Catheter directed therapy
- no increased bleeding events

Pulmonary embolectomy/surgical thrombectomy

30
Q

What would be the indication for thrombectomy with DVT?

A

for iliofemoral DVT with contraindication to thrombolysis

31
Q

What would be an indication for persistent anticoagulation for VTE post the 6 month mark?

A
  • UNPROVOKED Proximal DVT or PE
  • APLS
  • active cancer

can persist with DOAC at reduced dose in unprovoked proximal DVT or PE eg. apixaban 5mg or rivaroxaban 10

32
Q

Under what circumstances would you only anticoagulate for 6 weeks?

A

provoked distal DVT with resolved major risk factors, no persistent risk factors

HAEM5001 Haemostasis and Thrombosis (9 decks)

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