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724: Medical Lectures > Pulmonary Venous Thromboembolism > Flashcards

Pulmonary Venous Thromboembolism Flashcards

1
Q

Pulmonary embolism (PE) is the ____ leading cause of death among hospitalized patients

A

3rd

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2
Q

Less than __% of patients with fatal emboli have received specific treatment for the condition

A

10

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3
Q

What substances can embolize to the pulmonary circulation?

A
  • air
  • amniotic fluid
  • fat
  • foreign bodies
  • parasite eggs
  • septic emboli
  • tumor cells
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4
Q

What is the most common embolus?

A

thrombus

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5
Q

Where do thrombi most commonly originate?

A

In the deep veins of the LEs

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6
Q

__% of calf thrombi propagate proximally to the popliteal and ilieofemoral veins, at which point they may break off and embolize to th pulmonary circulation

A

20

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7
Q

Pulmonary emboli with develop in __-__% of patients with proximal DVT

A

50-60

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8
Q

Approximately __-__% of patients who have symptomatic pulmonary emboli will have LE DVT when evaluated

A

50-70

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9
Q

The risk factors for PE are the risk factors for thrombus formation within the venous circulation. What are these 3 risk factors? What are they referred to as?

A
  • venous stasis
  • injury to the vessel wall
  • hypercoagulability

Virchow’s triad

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10
Q

What does venous stasis increase with?

A
  • immobility
  • hyperviscosity
  • increased central venous pressures
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11
Q

What 3 things can cause injury to the vessel wall?

A
  • prior episodes of thrombosis
  • orthopedic surgery
  • trauma
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12
Q

What can cause hypercoagulability?

A
  • medications
  • disease
  • inherited gene defects
  • defieincies or dysfunction of protein C, protein S, and antithrombin
  • prothrombin gene mutation
  • hyper-homocysteinemia
  • the presence of antiphsopholipid antibodies (lupus anticoagulant and anticariolipin antibody)
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13
Q

What is the most common inherited cause in white populations?

A

Resistance to activated protein C, aka factor V Leiden

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14
Q

Factor V Leiden is present in approximately _% of healthy American men and in __-__% of patients with idiopathic venous thrombosis

A

3

20-40

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15
Q

Physical obstruction of the vascular bed and vasoconstriction from neurohumoral reflexes both increase what?

A

Pulmonary vascular resistance

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16
Q

Massive thrombus may cause _____ _____ failure

A

right ventricular

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17
Q

Vascular obstruction _____ physiologic dead space and leads to what?

A

increases

hypoxemia

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18
Q

What symptoms of PE are fairly sensitive?

A
  • dyspnea (75-85%)

- pain (65-75%)

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19
Q

What is the only sign reliably found in more than half of patients?

A

tachypnea

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20
Q

97% of patients in the original prospective investigation of pulmonary embolism diagnosis (PIOPED I) proved pulmonary emboli have one or more of what 3 findings?

A
  • dyspnea
  • chest pain with breathing
  • tachypnea
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21
Q

ECG is abnormal in __% of patients with PE

A

70

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22
Q

What are the most common ECG abnormalities? These abnormalities are seen in __% of patients

A
  • sinus tachycardia
  • nonspecific ST and T wave changes

40%

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23
Q

What do arterial blood gases usually reveal?

A

acute respiratory alkalosis due to hyperventilation

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24
Q

What lab fidnings are highly suspicious for PE?

A

Profound hypoxia with a normal chest radiograph in the absence of preexisting lung disease

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25
Q

Plasma levels of D-dimer are ____ in the presence of thrombus

A

elevated

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26
Q

A D-dimer less than ___ ng/mL provides strong evidence against venous thromboembolism

A

500

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27
Q

What are 6 imaging and special examination studies performed to help diagnose PE?

A
  • chest radiograph
  • CT
  • ventilation-perfusion (V/Q) lung scanning
  • venous thrombosis studies
  • pulmonary angiograph
  • MRI
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28
Q

When are chest x-rays the most suggestive of PE?

A

When normal in the setting of hypoxemia

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29
Q

Chest radiographs are normal in __% of patients with confirmed PE

A

12

29
Q

What are the 3 most frequent radiograph findings?

A
  • atelectasis
  • parenchymal infiltrates
  • pleural effusions
30
Q

What is used as the initial diagnostic study in North America for suspected PE?

A

Helical CT pulmonary angiography

32
Q

__% of patients with DVT will have PE on angiography

A

50

33
Q

What are 3 commonly available diagnostic venous thrombosis studies?

A
  • venous US
  • impedance plethysmography
  • contrast venography
34
Q

What venous thrombosis study is the test of choice to detect proximal DVT?

A

venous ultrasonography

35
Q

What is diagnostic of first-episode DVT?

A

inability to compress the common femoral or popliteal veins in symptomatic patients

36
Q

How does impedance plethysmography work?

A

It relies on changes in electrical impedance between patent and obstructed veins to determine the presence of thrombus

37
Q

What does contrast venography reveal?

A

a filling defect and the “railroad sign”

38
Q

What imaging technique is the reference standard for the diagnosis of PE?

A

Pulmonary angiography

39
Q

What angiography finding establishes a definitive diagnosis of PE?

A

intraluminal filling in more than one projection

40
Q

What secondary angiograph findings are highly suggestive of PE?

A
  • abrupt arterial cutoff
  • asymmetry of blood flow
  • prolonged arterial phase with slow filling
41
Q

What limits the use of MRI in the diagnosis of PE?

A

Artifacts introduced by respiration and cardiac motion

42
Q

Most American centers use what kind of diagnostic algorithm?

A

A rapid D-dimer and helical CT pulmonary angiogram

43
Q

A clinical prediction rule score greater than 4.0 indicates what? What does a score less than or equal to 4.0 indicate?

A

PE is likely

PE is unlikely

44
Q

The incidence of proximal DVT in untreated patients undergoing hip fracture is __-__%.

A

10-20%

45
Q

The incidence of PE in untreated patients undergoing hip fracture is __-__%.

A

4-10%

46
Q

The incidence of fatal PE in untreated patients undergoing hip fracture is __-__%.

A

0.2-5%

47
Q

What are 2 treatment options for PE?

A
  • Anticoagulation drugs

- Thrombolytic therapy

48
Q

What anticoagulation drug is used as a secondary prevention method?

A

Heparin

49
Q

How does heparin work?

A

It beinds to and accelerates the ability of antithrombin to inactivate thrombin, factor Xa, and factor IXa, which retards additional thrombus formation

50
Q

The appropriate duration of anticoagulation therapy needs to take what 4 things into consideration?

A
  • patient’s age
  • potentially reversible risk factors
  • likelihood and potential consequences of hemorrhage
  • preferences for continued therapy
51
Q

Continued anticoagulant therapy result in a lower rate of recurrence at the cost of an increased risk of what?

A

hemorrhage

52
Q

It is recommended that anticoagulation therapy should last how long after a first episode provoked by a surgery or a transient nonsurgical risk factor?

A

3 months

53
Q

When is extended (6-12 months) therapy recommended?

A

For unprovoked or recurrent episode with a low to moderate risk of bleeding

54
Q

Describe anticoagulant therapy in cancer patients

A

Extended therapy with low molecular weight heparin is recommended regardless of bleeding risk

55
Q

It is reasonable to continue therapy for how long after a first episode when there is a reversible risk factor?

A

6 months

56
Q

It is reasonable to continue therapy for how long after a first-episode of idiopathic thrombosis?

A

12 months

57
Q

It is reasonable to continue therapy for how long in patients with nonreversible risk factors or recurrent disease?

A

6-12 months

58
Q

What is the major complication of anticoagulation therapy?

A

hemorrhage

59
Q

What risk factors increase the risk for hemorrhage?

A
  • concomitant drugs such as aspirin that interferes with platelet function
  • increased patient age
  • previous GI hemorrhage
  • coexistent chronic kidney disease
60
Q

What are the 3 drugs used for thrombolytic therapy?

A
  • streptokinase
  • urokinase
  • recombinant tissue plasminogen activator (rt-PA; alteplase)
61
Q

How does thrombolytic therapy work?

A

Those 3 drugs increase plasmin levels and thereby directly lyse intravascular thrombi

62
Q

What are the major disadvantages of thrombolytic therapy compared with heparin?

A

Its more expensive and there is a significant increase in major hemorrhagic complications

63
Q

When should thrombolytic therapy be used?

A

In PE patients at high risk for death in whom the more rapid resolution of thrombus may be lifesaving

64
Q

What are the absolute contraindications to thrombolytic therapy?

A

active internal bleeding and stroke within the past 2 months

65
Q

What are the major contraindications to thrombolytic therapy?

A
  • uncontrolled hypertension

- surgery or trauma within the past 6 months

66
Q

What are 2 other additional measures that can be taken to treat PE?

A
  • Inferior vena cava filter

- Mechanical or Surgical extraction of thrombus

67
Q

Under what 3 circumstances is an inferior vena cava filter recommended?

A
  • for recurrent thromboembolism despite adequate anticoagulation
  • for chronic recurrent embolism with a compromised pulmonary vascular bed
  • with the concurrent performance of surgical pulmonary thromboendarterectomy
68
Q

PE is estimated to cause more than _____ deaths annually

A

50,000

69
Q

What contributes to this high mortality rate?

A

PE is not recognized antemortem or death occurs before specific treatment can be initiated

70
Q

The outlook for patients with diagnosed and appropriately treated PE is generally ____

A

good

71
Q

Death from recurrent thromboemboli develops in approximately _% of patients

A

3

724: Medical Lectures (42 decks)

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