Thrombo embolic disease

Question 1

Normal clot formation - 2 types

Answer 1

1) Primary clotting

2) Secondary clotting

Question 2

Components of primary clot

Answer 2

-platelet plug

Question 3

Components of secondary clot

Answer 3

• coagulation cascade

- negative feedback

Question 4

The clotting cascade components

Answer 4

1) Intrinsic
2) Extrinsic
3) Common
enzymes (proteases) = most of the factors
coenzymes = V & VIII
cofactors = calcium , phopholipids

Question 5

Coagulation cascade

Answer 5

X

Question 6

Negative feedback mechanisms

Answer 6

1. Anticoagulants
   - antithrombin (inhibits proteases)
   - TFPI (inhibits proteases, mainly VIIa/TF)
2. Fibrinolysis

Question 7

why called D-dimers

Answer 7

-2 D globulins and one E subunit

Question 8

Classification of diseases of clotting

Answer 8

1) Which vessels they occur in
- venous thromboembolism (VTE)
- arterial thrombosis
- capillary thrombosis

Question 9

Why venous system is high risk of clotting

Answer 9

-Stuff is sitting there for awhile

Question 10

Common cause arterial thrombosis

Answer 10

Atherosclerosis

Question 11

Cause Capillary thrombosis

Answer 11

Mainly due to microangioathic hemolytic anemias

Question 12

Types of VTE diseases

Answer 12

1. Superficial vein thrombosis (SVT)
2. Migratory SVT
3. Deep vein thrombosis (DVT)
4. DVT complicatins

Question 13

SVT causes

Answer 13

-from IV, catheters etc

Question 14

Complications from SVT

Answer 14

Are rare

Question 15

What are migratory SVT a sign of

Answer 15

Malignancy

Question 16

DVT common complications

Answer 16

• pulmonary embolism

- postphlebitic syndrome

Question 17

Etiology /Risk of VTE- acquired VTE

Answer 17

• immobility
• age
• pregnancy (to compensate for excess breathing in birth)
• obesity
• trauma
• surgery
• malignancy
• meds -birth control pill
• inflammation (autoimmune disorders)
• hyperviscosity (blood get thicker occuring in rare disorders -i.e. get lots of RBCs)
• antiphospholipid antibody syndrome (APLAS)- make autoantibody to phospholipids

Question 18

Etiology/Risk of VTE - hereditary

Answer 18

• factor V leiden
• prothrombin gene mutation
• protein C deficiency
• protein S deficiency
• antithrombin-3 deficiency
• increased factor 8
• increased homocysteine

Question 19

Virchows triad

Answer 19

1) Stasis
2) Vascular injury
3) Hypercoag

Question 20

What risks propagate clotting through vascular injury

Answer 20

1) Surgery
2) Trauma
3) Malignancy
4) Inflammation
5) Homocysteine

Question 21

What risks propagate clotting through stasis

Answer 21

• immobility
• age
• pregnancy
• obesity

Question 22

What risks propagate clotting through hypercoag

Answer 22

• hereditary thrombophilias
• pregnancy
• age
• malignancy
• hyperviscosity
• meds -OCP

Question 23

Risks with multiple mechanisms leading to clotting

Answer 23

• pregnancy
• age
• malignancy

Question 24

Unknown mechanisms of clotting

Answer 24

• hyperhomocysteinemia ( does it cause the clot or is it consequence)
• antiphopholipid antibody syndrome (APALS)

Question 25

Classification of hereditary thrombophilias

Answer 25

1. Loss of anticoagulant function - antithrombin 3 deficiency - protein C deficiency - protein S deficiency 2. Gain of factor function - factor V leiden - prothrombin gene - elevated Factor VIII

Question 26

Accumulative risk

Answer 26

2 or more risk factors - risk of clot goes up exponentially

Question 27

Postphlebitic synrome MOA

Answer 27

Chronic venous insufficiency leads to venous hypertension which then causes edema, hypoxia, inflammation

Question 28

Signs of DVT

Answer 28

- swelling, painful | - red, warm (inflmmation signs)

Question 29

Signs of PE

Answer 29

typical: SOB, chest pain, hemoptysis Atypical: abdominal pain, syncope, fever, cough, seizure

Question 30

Postphlebetic syndrome

Answer 30

- swelling - pain - ulcers - rash

Question 31

Radiological testing

Answer 31

1) Ultrasound | 2) CT

Question 32

Lab testing

Answer 32

1. DDimers - high sensitivity - low specificity 2. Etiologic testing

Question 33

DD dimers high sensitiivity

Answer 33

If negative, excludes VTE

Question 34

DD dimer low specificity

Answer 34

If positive, can be due to thrombosis, infection, trauma, surgery

Question 35

Etiologic testing

Answer 35

Figure out what could be the trigger for the clot What ??(tests for) a) is it hereditary? b) is it acquired? When to do these panel of testing 1) unprovoked +/-recurrent VTE 2) Strong family history 3) Purpura fulminans in neonates and children (requires urgent protein C and S testing)

Question 36

When not to test for hereditary factors

Answer 36

1) provoked (obvious trigger) 2) not recurrent 3) Arterial thrombosis

Question 37

General guideline when to test for hereditary disorder

Answer 37

1) Change in management - duration of anticoagulant - prophylaxis required - alternative to OCP or HRT required

Question 38

Goal of treatment

Answer 38

To prevent further clot formation | dont want to bust clot because huge risk of emboli-travelling to the lungs

Question 39

Treatment

Answer 39

-heparin + coumadin (warfarin) -5 day overlap because: heparin acts more rapidly (increases AT-3 activity) but is given IV -Coumadin is PO but acts slower and has potential transient procoagulant state (inhibts vitamin K dependent factors + protein C&S)

Question 40

How long continue treatment

Answer 40

``` Typically 6 months on coumadin 3 months (with transient risk factor) Indefinite (for recurrent DVT) ```