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Cardio MT2 > MT2_12_DVT/PE > Flashcards

MT2_12_DVT/PE Flashcards

1
Q

What are the signs and symptoms of DVT?

A
  • calf pain and tenderness
  • swelling
  • erythema
  • warmth
  • dilation of superficial veins
  • pain behind knee
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2
Q

How to diagnose DVT?

A

ultrasound (CT venography and DDimer sometimes..)

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3
Q

How to diagnose PE?

A
  • CT angiography in stable patients

- V/Q scan in unstable patients,

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4
Q

When treating DVT, Pt without severe symptoms or severe risk factors get imaging ___weeks over initial coagulation, repeat every ____days if patient is ___

(if no extension in the first 2
weeks, extension is less likely)

If pt has severe symptoms, initiate IV anticoagulant, unless high risk for bleeding

What counts of high risk?

A

2
5-7
high risk (+DDimer)

  • high risk:
    • DDimer
  • thrombosis that is proximal
  • cancer
  • hx of VTE
  • inpatient
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5
Q

For treatment, when is IV UFH preferred?

A
  • renal failure
  • thrombolytic therapy is planned
  • quick and reversible
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6
Q

What is the dosing for UFH?

for normal pt and stroke pt?
monitor?

Reversal agent?

A
  • Normal risk: 80u/kg , then 18u/hour. No LD if INR is greater than 1.5
  • Recent stroke? 70u/kg,then 15, then 1000U, avoid loading dose, avoid in the first 24 hours of a stroke
  • monitor aPITT, antifactor Xa 0.3-0.7
  • DOC for patients undergoing inpatient procedures
  • protamine…caution in over reversal causing rebreeding
  • SE: HIT, osteoporosis, necrosis, hypersensitivity
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7
Q

Dose for dalteparin?

Dose for enoxaparin? (outpatient vs inpatient) Xa goals?

A
  • DVT/PE: 200 IU/kg SQ QD
  • if patient is obese consider 100 Q12
  • outpatient DVT: 1mg/kg q12
  • inpatient DVT/PE: 1mg/kg Q12 or 1.5 SQ QD
  • Q12L 0.6-1.0
  • Q24: 1-2
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8
Q

When is factor 10a monitoring required? When to start dray after initiating fragments (dalteparin)?

A
  • pregnancy q3-4 weeks
  • obesity
  • bleeding
  • renal failure
  • 4-6 hours
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9
Q

How to convert between LMWH and UFH?

Advantage of LMWH?

A

UFH to LMWH, DC and start LMWH in one hour

LMWH to UFH: DC LMWH, start UFH 1-2 hours prior to time of the next dose

recheck levels 4 hours after

  • HIGH BA, more predictable anticoagulant response for LMWH
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10
Q

What are the limitations of LMWH?

BBW

A
  • Obesity
  • renal insufficiency: do not use dalteparin, use enox
  • must wait ~5 hours before invasive procedure due to long half life
  • partial reversibility w protamine
  • BBW: epidermal/spinal hematoma
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11
Q

For Fonda (Factor 10a, indirect) What is the dose?

Limitations? CI in renal…

Reversal

Hold

BBW

A
  • less than 50kg,5mg SQ QD
  • 50-100: 7.5 mg SQ QD
  • over 100: 10mg SQ QD

Limitations; increased bleeding in renal insufficient. (CrCl less than 30)

  • no antidote
  • long half life, hold 5 days
  • BBW: spinal/epidermal hematoma
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12
Q

What are the direct thrombin inhibitors? (bivalirudin, argatroban,) When is it reserved for and limitations?

A
  • bivalirudin
  • argatroban
  • reserved for HIITs
  • no antidode, $$, renal and hepatic clearance, increase in iNR
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13
Q

What to if patient is on warfarin and they have HIT?

What to give in oncologic patients?

A
  • STOP warfarin and heparin
  • add vitamin K
  • LMWH, abigatrin, rivaroxaban, apixaban, endoxaban
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14
Q

For rivaroxaban (10a), what is the dose for VTE treatment? Reversal agent? BBW? DDI? Caution?

A
  • 15mg PO BID for 21 days, then 20mg QD
  • no bridging!
  • andexanet, for rivaroxaban, and apixaban
  • BBW: DC increases thrombotic risk, spinal/epidermal hematoma
  • DDI:avoid in combined PGP and 3A4 inhibitors/PGP inhibitors
  • caution in renal impairment and moderate CYP3A4 inhibitors , anticoagulant, thrombolytics
  • avoid in hepatic impairment and increased risk of stroke in patients transitioning to warfarin
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15
Q

VTE treatment dose for apixaban? (factor 10a)

DDIs

A
  • 10mg BID for one week, then 5mg BID
  • no bridging!
  • 3A4 and PGP, avoid in concomitant anticoagulant, thrombolytics, caution in anti-platelets
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16
Q

What is the BBW for andexanet?

A

(reversal agent for rivaroxaban and apixaban)

- thrombosis, cardiac arrest, sudden death

17
Q

For endoxaban (factor 10) dosing for VTE? Avoid in..

BBW for afib?

Reversal?

avoid with pgp inducers (rifampin), and use with anticoagulant

A
  • 60mg beginning 5-10 days after initiating therapy with a parenteral anticoagulant
  • avoid in CrCl less than 15ml/min
  • endoxaban, avoid if CrCl is greater than 95 due to increased risk of ischemic stroke , avoid in liver
  • FEIBA or Kcentra
18
Q

For dabigatrin, what is the VTE dose?

What is the reversal agent?

Limitations?

BBW?

A
  • 150mg po BID 5-10 days of parenteral anticoagulation
  • praxbind (idarucizumab) binds to dabigatrin to then neutralize it
  • increased risk of GIB
  • avoid rifampin ( PGP induced)

DC = thrombotic events, spinal/epidermal hematoma

19
Q

When to initiate overlap with Coumadin?

A
  • for DVT/PE initiate on day 1 w an overlap of at least 5 days and INR grater than 2 for 24 hours
20
Q

warfarin dose for healthy outpatients ? 5mg?

A

10mg for the first 2 days

5mg for elderly, impaired nutrition, liver disease, CHF, bleed, DDIs

21
Q

What is the reversal agent for vitamin K?

A
  • Kcentra, and vitamin K

- warfarin’s initial effect takes 2-3 days!!

22
Q

What is the duration of anticoagulant therapy for DVT/PE? What if patient needs long term therapy for a recurrent VTE?

A

3 months

- LMWH!

23
Q

For warfarin, how to monitor?-

A
  • outpatient every 1-3 days
  • ## q12 weeks for stable INR
24
Q

What to use in pregnancy?

A

LMWH , continue at greater than or equal to 6 weeks

25
Q

For an inferior vena cava filter, when is it indicated?

A
  • pt can’t under anticoagulant therapy

- it is a filter that can removed when safe to start anticoagulant therapy..do NOT use WITH an anticoagulant

26
Q 
Considerations
cancer/pregnancy
avoidance of IV therapy
liver disease
severe renal disease
CAD
GI bleed
Reversal agent needed
Thrombolytic use considered
A
  • LMWH
  • rivaroxaban, apixaban
  • LMWH
  • VKA, apixaban
  • avoid dabigatran
  • VKA, apixaban
  • UFH, VKA, ?rivarox/apix
  • UFH
27
Q

For thrombolytic therapy, what is the dose for TPA and how long should it be infused?

A
  • dose is 100mg IVPB over 2 hours, the 2 hour infusion achieves a more rapid blood clot .
  • if TPA ineeds to be given, just hold the heparin when PTT is less than2X normal
28
Q

Agents used for DVT PROphylaxis? non pharm treatment options?

A
  • UFH, LMWH, Fonda, Dabi, Rivarox

- non pharm includes sequential compression device, intermittent pneumatic compression, compression stockings

29
Q

For hospitalized patients, what to recommend?

A

LMWH
UFH 5000U BID, TID
Fonda (not for critically ill)

  • if low risk, do not use agent
  • DC prophylaxis as soon as pt can walk
  • if high risk of bleed, use a mechanical ppx, when risk decreases, switch to mechanical

Cardio MT2 (12 decks)

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