Therapy and prevention of thrombophilia

Question 1

What is a good treatment for a DVT?

Answer 1

treat with LMWH and bridged to warfarin, target INR 2.5 +- 0.5 and continue for 3-6 months

Question 2

What is the purpose of anticoagulation in DVT patients?

Answer 2

• prevent extension of clot from calf to thigh
• prevent PE
• prevent recurrence
• prevent emboli from a-fib of the heart to cause stroke of the brain

Question 3

What is the problem with giving heparin SC?

Answer 3

need huge volumes which is usually painful

Question 4

Does heparin last long in the body?

Answer 4

No it has a short half life so it must be given often (IV)

Question 5

How is dosing adjusted for heparin?

Answer 5

frequent PTT (every 6 hrs) or anti-X assay. Thus, hospitalization necessary

Question 6

What is the therapeutic range for heparin?

Answer 6

0.3-0.7 units/ ml

Question 7

The only time monitoring of LMWH is necessary is:

Answer 7

• kidney dysfunction
• extreme wgt (fat or skinny)

monitor with anti Xa assay not PTT

weight based dosage (1mg/kg 2x daily)

Question 8

What is a main disadvantage to LMWH?

Answer 8

no antidote (protamine only partially effective) and long half life

Question 9

Does LMWH prolong PTT?

Answer 9

No.

Question 10

When is LMWH contraindicated?

Answer 10

renal failure (renal metabolism)

Question 11

How is the effect of Warfarin monitored?

Answer 11

INR

Question 12

What is the appropriate prophylaxis for DVT range of Warfarin?

Answer 12

2.5 +/- 0.5

Question 13

What is the appropriate protection of mechanical heart valve range of warfarin?

Answer 13

3.0 +/- 0.5

Question 14

Antidotes for warfarin toxicity?

Answer 14

• vitamin K- first line
• prothrombin complex concentrate
• FFP

Question 15

T or F. Do not take anticoagulants IM shots during warfarin toxicity

Answer 15

T. Only SC

Question 16

What anticoagulant can be given during pregnancy?

Answer 16

Heparin only

Side effect: long term treatment drops bone density so osteopenia is common

Question 17

What is an appropriate prophylaxis for DVT?

Answer 17

LMWH (reduces risk of clot by 65%) or Fondaparinux for anyone undergoing hip replacement (and most surgeries) even if there is no past history

Question 18

What patient population is most at risk for DVT?

Answer 18

• spinal cord injury
• major trauma
• stroke
• hip or knee replacement
• critical care

Question 19

T or F. A Person less than 60 y/o getting a colonoscopy does not need DVT prophylaxis

Answer 19

T. Anyone undergoing other surgery even in the absence of prior DVT would require prophylaxis

Almost everyone over 60 requires it

Question 20

What is the prophylaxis dose of LMWH for DVT/VTE?

Answer 20

0.4mg/kg 1x daily within 6-24 hrs after the procedure

Question 21

What are some contraindications for DVT/VTE prophylaxis?

Answer 21

• acute hemorrhage from wounds
• intracranial hemorrhage within prior 24 hrs
• HIT
• severe head trauma
• platelets less than 30K

Question 22

What is an appropriate therapy for a-fib to prevent VTE?

Answer 22

depends on CHADS2 score

Question 23

What is the CHADS2 score?

Answer 23

criteria for selection of patients for chronic anticoagulation to prevent VTE in atrial fibrillation

Question 24

What are the criteria for CHADS2?

Answer 24

heart failure-1
age 75+- 1
hypertension-1
diabetes-1
prior ischemia stroke-2

Question 25

Anyone with a 0 CHADS2 score can be treated with what?

Answer 25

aspirin alone

Question 26

Anyone with a 1-2 CHADS2 score can be treated with what?

Answer 26

warfarin used mostly, aspirin some

Question 27

Anyone with a 3+ CHADS2 score can be treated with what?

Answer 27

must use warfarin or dabigatran

Question 28

What does the acute management of arterial thrombosis consist of?

Answer 28

• thrombectomy (if indicated) mechanical
• stent placement (if indicated)
• thrombolysis (if indicated)
• follow up with anti-platelet and anticoag drugs

Question 29

What are the guidelines for acute ST-segment elevation MI (STEMI) at a reperfusion therapy at a PCI-capable hospital?

Answer 29

primary PCI should be performed with STEMI patients of less than 12 hrs

• aspirin should be given before primary PCI and continued indefinitely
• loading dose of ADP inhibitor should be given and continued for 1 yr
• UFH should be given during the PCI

Question 30

What are the guidelines for acute ST-segment elevation MI (STEMI) at a reperfusion therapy at a Non-PCI-capable hospital?

Answer 30

In absence of contraindications, fibrinolytic therapy should be given to STEMI patients when it is anticipated that primary PCI cannot be performed within 2 hrs of first medical contact

Question 31

Indications for thrombolytics?

Answer 31

MI, CVA, PE high risk, DVT-ilio-femoral only

Question 32

Contraindications for thrombolytics?

Answer 32

massive trauma or CPR, age 75+, recent GI bleed, active intracranial process

Question 33

Acetaminophen (Tylenol) works on what?

Answer 33

Cox3 in the brain so it only controls pain, not bleeding

Question 34

T or F. Aspirin is contraindicated with warfarin

Answer 34

T. Exacerbates bleeding risk

Question 35

Cox 2 inhibitors (Ibuprophen/Refacoxib) increases risk of heart disease

Answer 35

Cox 2 inhibitors (Refacoxib) increases risk of heart disease

Question 36

Best treatment to prevent recurrent ischemic stroke?

Answer 36

Aspirin with Clopidogrel