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Pulmonary Embolism DVT Flashcards

1
Q

FDA approved thrombolytics in Acute PE

A

AUS-Alteplase,Urokinase,Streptokinase

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2
Q

Dose of thrombolytics in PE

A

ALTEPLASE-100 mg ivm over 2 HOURS ( first 10 mg bolus)

UK-4400u/KG over 10 minutes, then 4400/KG/HR for 12 hours

STK—2.5LAKH over 30 mts then 1 LAKH /hr for 24 hrs( In MI unit is in millions but here in lakhs)

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3
Q

When will u start heparin after thrombolysis

A

Once APTT is Less than twice upper limit. No bolus..If it is more than 2 times rpt APTT every 4 hours

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4
Q

—-% of pts with unprovoked proximal VTE develop recurrent VTE with in 1 yr of stopping anticoagulants

A

Around 10%

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5
Q

HERDOO2 Predictors of VTE

A

At 5-12 months of anticoagulation after first proximal DVT..

  1. Hyperpigmentation,Edema,Redness (post-thrombotic signs)
  2. D-dimer 250 ug/L or more( usual cut off value for DVT is 500)
  3. Obesity-BMI of 30 or more
  4. Old age-65 or more

Score of 2 or more is high risk of recurrence

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6
Q

Conclusion of REVERSE II trial

A

“Men continue HERDOO2” at 5-12 months after first Proximal DVT

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7
Q

The ISTH (The International Society of Thrombosis and Hemostasis) suggests that it is safe to stop anticoagulants if risk of recurrent thrombosis at 1 yr off therapy is less than

A

5% ; given the risk of serious bleeding and a serious bleed is 2-3 times more likely than a VTE to be fatal

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8
Q

Second most common cardiovascular disorder

A

Venous thromboembolism

And the 3 Dr common cause of cardiovascular death

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9
Q

Main criticisms of REVERSE II trial

A

Only one year follow up. Risk may catch up by 3-4 years as shown in a 2015 French study after PE

2.With NOAC availability is there a big concern on continued anticoagulation

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10
Q

Target aPTT in PE pts on UFH

A

1.5-2.5

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11
Q

Pts on Heparin should be monitored for

A

Osteoporosis and Thrombocytopenia

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12
Q

Warfarin target INR in PE

A

2.5

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13
Q

May Thurner syndrome is

A

compression of Left common iliac vein by Right common iliac Artery

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14
Q

Some common causes of recurrent VTE despite anticoagulation

A

Malignancy
May Thurner
Anti phospholipid syndrome
Inherited thrombotic disorders

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15
Q

Should IVC filter be removed

A

If contraindication for anti coagulation has resolved, remove filter and initiate anticoagulants

Anti coagulation is the optimal therapy for VTE

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16
Q

If recurrence occurs with adequate anticoagulation inVTE what to do

A

Change Warf to LMWH/ or increase LMWH/ or add IVC filter

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17
Q

Early complication of PE is mainly

A

1-2 weeks- Recurrence. Rpt imaging to be done

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18
Q

Late complications of PE

A
  1. Recurrence
  2. CTEPH- chronic thromboembolic PH- suspect with progressive dyspnea Particularly in first 2 years of diagnosis- 5% pts develop
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19
Q

The NOAC to be taken with food

A

Rivaroxaban

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20
Q

Most common cause for PE recurrence

A

Sub therapeutic anticoagulation

21
Q

Risk of recurrence of VTE after a first unprovoked episode ( after cessation of anti coagulation)

A

First yr-10%
First 5 yrs-30%

Anti coagulation reduces recurrence by 90%
Low intensity anti coagulation reduces recurrence by 60%
Aspirin reduces risk by 30%

22
Q

Max period NOAC used in VTE recurrence prevention

A

2 years - Rivaroxaban

23
Q

Safety and efficacy of indefinite anticoagulation in VTE is established in ——————-&—————

A
  1. UNPROVOKED PROXIMAL dvt
  2. UNPROVOKED SYMPTOMATIC pe

RECURRENT UNprovoked distal dvt/ any VTE also most would suggest indefinite anticoagulants

24
Q

CI to anti coagulation in Prox DVT

A

Platelet- Less than 50,000
Past h/o IC bleed
Active bleeding

These are the CONTRAINDICATIONS

25
Q

The NOAC which showed a higher rate if ACS when given for prevention of recurrent dvt

A

Dabigatran

26
Q

Post IVC filter if contraindications for anticoagulants is resolved, what to do

A

Give full anticoagulation for 3 months

Then consider removal

27
Q

First unprovoked VTE in high bleeding risk Pt what to do after 3 months

A

Discontinue-ACCP Guidelines

Uptodate 2018

28
Q

Popliteal vein thrombosis is Proximal or distal

A

Proximal

P=P

29
Q

Aspirin reduces recurrence of DVT by

A

1/3rd

Anti coagulation reduces risk by 90%

30
Q

Risk of recurrence after a single provoked DVT

A

1-5% at 1 year & 3-15% at 5 years

31
Q

Risk of DVT recurrence after 2 unprovoked DVT

A

15% at 1 year and 45% at 5 years

32
Q

In my patient with first provoked (non surgical) PE with low bleeding risk NOAC should be—————after the first 3 months

A

Not sure.
Looks like a weak recommendation to discontinue

To confirm

33
Q

Distal dvt means involvement of “calf veins “ which are

A

Peroneal, Anterior And Posterior tibial veins and Muscular veins

34
Q

Late second episode of VTE means

A

More than 1 year after the first episode

35
Q

One factor in favor of stopping anticoagulants in DVT is (regarding indefinite anti coagulation

A

A normal D-dimer within 3 months of anticoagulant withdrawal

36
Q

One situation where Warfarin is preferred over NOAC in DVT treatment

A

Creatinine clearence < 30 ml/minute

37
Q

Rate of bleeding with anticoagulation in VTE in different risk groups in first 3 months

A

Low- no RF-1.6%
Intermediate risk-( One RF)- 3.2%
High risk group-(2 RF)- 12.8%

Annual Rate of bleeding after first three months is about Half of the above in each group

38
Q

Initial anti coagulation in VTE means upto

39
Q

One of the non hematologic risk with prolonged LMWH

A

Osteoporosis

40
Q

Anti coagulation 3 months after surgery provoked VTE

41
Q

The relative risk of major bleeding with anti coagulation

A

2.6 Times roughly

42
Q

General definition of major blood loss

A

2gm Hb drop or needing 2 units of blood or in a critical site

43
Q

Decision of anti coagulation after 3 months is same for Non Surgical provoked VTE and —————-

A

Unprovoked Distal DVT

LOW/ INTERMEDIATE risk- weak recommendation to DIScontinue ( But for unprovoked Prox DVT/PE- weak recommendation to continue)

HIGH risk- STOP for both

44
Q

3 situations where indefinite anti coagulation may benefit in patients in grey zone

A

Malignancy
APLA
“High risk” thrombophilias ( def of PC,PS,AT III or Homozygous V,II mutations)

45
Q

Highest chance of VTE recurrence is ————- after the event

A

6 months- 1 year after the event

46
Q

3 major risk factors for VTE

A

Major surgery >30 mts
IMMOBILITY 3 days or more
LSCS

47
Q

Contraindications to anti coagulation in VTE-3

A
  1. Platelet count<50,000
  2. Prior ICH
  3. Active bleeding.

Consider IVC Filter

48
Q

Progestin only contraception and VTE

A

Oral prepn are ok in general

Injectable depot Medroxy progesterone has increased risk

49
Q

HRT in VTE

A

Estradiol by non oral route( patch) appears to be ok

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