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Cardiovascular > Thromboembolic Disease and Stroke > Flashcards

Thromboembolic Disease and Stroke Flashcards

1
Q

how do clots form pulmonary embolisms

A

thromboemboli detach and travel through the right side of the heart to block vessels in the lungs

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2
Q

where do clots usually form in the veins

A

venous valve pockets and other areas of stasis

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3
Q

define a DVT

A

Formation of thrombi within the lumen of the vessels that make up the deep venous system

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4
Q

where does a distal VT (vein thrombosis) form

A

in the calves

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5
Q

where does a proximal VT form

A

popliteal vein or femoral vein (closer to the heart)

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6
Q

what is the significance of the location of a DVT

A

proximal closer to heart so more likely to cause PE

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7
Q

what does VTE stand for

A

venous thromboembolism

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8
Q

what are the three components of virchow’s triad

A

hypercoagulable state

circulatory stasis

endothelial injury

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9
Q

what can cause a hypercoagulable state

A

Malignancy

Pregnancy and peripartum period

Oestrogen therapy

Inflammatory bowel disease

Sepsis

Thrombophilia

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10
Q

what can cause circulatory stasis

A

Left ventricular dysfunction

Immobility or paralysis

Venous insufficiency or varicose veins

Venous obstruction from tumour, obesity or pregnancy

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11
Q

what can cause endothelial injury

A

Venous disorders

Venous valvular
damage

Trauma or surgery

Indwelling catheters

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12
Q

the risk factors for VTE are predisposing and exposing. describe the exposing risk factors

A

(acute conditions or trauma)

surgery, trauma, acute illness, acute heart failure, acute resp failure, central venous catheterisation, cancer, inflammatory disease

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13
Q

what are the predisposing risk factors for VTE

A

(patients characteristics)
history of VTE, chronic heart failure, advanced age, varicose veins, obesity, Immobility or paresis,
Myeloproliferative disorders,
Pregnancy/peripartum period, Inherited or acquired thrombophilia,
Hormone therapies,
Renal insufficiency, CANCER AND INFLAMMATORY DISEASES

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14
Q

what factors lead to a provoked VTE

A

transient/ reversible or continuing/ irreversible factors

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15
Q

what is a thrombus

A

clot that stays in situ

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16
Q

what is an embolus

A

clot that has dislodged

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17
Q

what is the difference between venous and arterial clots

A

arterial platelet rich, veins fibrin rich due to stasis of blood

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18
Q

what are the symptoms of a PE

A

breathlessness, cough, haemoptysis, sharp stabbing chest pain, dizzyness/fainting

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19
Q

what causes an unprovoked VTE

A

no identifiable cause- idiopathic

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20
Q

what are the consequences of a VTE

A

fatal PE, risk of recurrent VTE, post thrombotic syndrome (PTS), chronic thromboembolic pulmonary hypertension, SOB, right sided heart failure, reduced quality of life

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21
Q

what is post thrombotic syndrome characterised by

A

pain, oedema, hyperpigmentation, eczema, varicose collateral veins, venous ulceration

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22
Q

how is post thrombotic syndrome treated

A

with compression stockings

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23
Q

describe the progression of chronic thrmoboembolic pulmonary hypertension

A

asymptomatic,

progressive dyspnoea , SOB and hypoxaemia,

right sided heart failure

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24
Q

what causes chronic thromboembolic pulmonary hypertension

A

original embolic material is replaced over time with fibrous tissue that is incorporated into the intima and media of the pulmonary arteries. this may occlude the pulmonary artery, leading to pulmonary artery resistance and, ultimately, right heartfailure.

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25
Q

how is chronic thromboembolic pulmonary hypertension treated

A

pulmonary thromboendarterectomy- surgery to remove clots from pulmonary arteries
and
anticoagulants

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26
Q

what does D-dimer show

A

breakdown product of cross linked fibrin, released when clot forms

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27
Q

how is used to investigate a DVT

A

ultrasound

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28
Q

what does a doppler ultrasound show

A

how blow flows through a vessel

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29
Q

what does the ability to compress a vein suggest

A

that there is not a clot above it as pressure is not too high to compress

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30
Q

what is venography and when is it used

A

uses contrast dye and X ray ( or magnetic resonance imagine) to image vascular system

used when ultrasound negative but patients symptoms are positive

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31
Q

what other than a clot can raise D-dimer

A

recent surgery/illness

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32
Q

what does the wells score show

A

calculates the pre-test probability of a DVT

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33
Q

what action plan should follow a low wells score

A

check D-dimer, no imagine if negative

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34
Q

what action plan should follow a mod/high wells score

A

imaging regardless of D-dimer

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35
Q

what does negative imaging and positive D-dimer require

A

repeat imaging

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36
Q

what factors are considered for a wells score

A

active cancer, calf/leg swelling, collateral superficial veins, pitting oedema, localised pain, paralyses, recently bedridden

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37
Q

what factors are considered for a wells score for PE

A

clinical signs of DVT, PE most likely diagnosis, HR>100, immobilisation, previous DVT/PE, haemoptysis, malignancy

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38
Q

what does the revised geneva score indicate

A

probability of PE in patients

39
Q

what factors are considered in the geneva score

A

age, previous DVT/PE, surgery, active cancer, unilateral limb pain, haemoptysis, HR, pain on lower limb deep venous palpation AND unilateral oedema

40
Q

what is considered the gold standard of imagine

A

CT pulmonary angiogram

angiogram (X-ray of blood vessels)

41
Q

what are other imaging methods used for DVT/PE

A

chest X-ray (can show pleual effusions and sometimes infarct)

V/Q scan (ventilation/perfusion) Demonstrates mismatched perfusion defects

42
Q

how are DVTs and PEs treated (drugs)

A

anticoagulants, thrombolysis, analgesia

low molecular weight heparin, warfarin

Direct oral anticoagulants; dabigatan, apixaban, rivoraxaban, edoxaban

43
Q

how are DVTs and PEs treated (medical interventions)

A

compression stockings, IVC filters

44
Q

what conditions are screened for DVT/PEs

A

cancers, thrombophilia

45
Q

what are factor Xa inhibitors and what do they do

A

anticoagulant drugs that stop thrombin being formed by blocking factor Xa

46
Q

what is fragmin

A

anticoagulant (administered via infection)

47
Q

what anticoagulant tends to be favoured in cancer

A

fragmin

48
Q

what is phlegmasia

A

Arterial compromise secondary to extensive DVT

49
Q

what treatment should be used to treat venous clots

A

fibrinolysis (as fibrin rich clots) e.g. tissue plasminogen activator (tPA), streptokinase (SK)

50
Q

what treatment should be used for PE and clots causing stroke/ atrial fibrillation- or patients who have deterioated haemodynamically in hospital

A

thrombolysis (break down clots) e.g. tissue plasminogen activators

51
Q

when should pharmacological systemic thrombolytic not be given

A

when patients with PR are haemodynamically stable

52
Q

what do compression stockings prevent

A

post thrombotic syndrome

53
Q

how long post thrombosis should compression stockings be worn

A

2 years

54
Q

what is the only treatment for post phlebitic syndrome

A

compression stockings

55
Q

what are IVC filters

A

mechanical devices which sit in the inferior vena cava and aims to catch any clots that pass dislodge

56
Q

what are the complications of the IVC filters

A

can thrombose and rip through walls of IFC into the aorta causing a fistula

57
Q

what is the burden on VTE as a disease

A

substantial negative impact on quality of life, lower levels of physical functioning, worse perceptions of health, disability, death

58
Q

what is a stroke

A

acute onset of focal neurological symptoms and signs due to disruption of blood supply

59
Q

what is stroke a complication of

A

poor vascular health

60
Q

what do the specific stroke symptoms experienced by a patient let you determin

A

the area of brain affected

61
Q

what is the biggest impact a stroke has on a patient

A

rarely kills but 2/3rds leave hospital with a disability

62
Q

what are the two types of stroke

A

haemorrhagic (15-20%) and ischaemic (80-85%)

63
Q

describe ischaemic stroke

A

when a clot blocks blood flow to an area of the brain

64
Q

describe haemorrhagic stroke

A

when blood vessel tears and bleeding occurs inside or around the brain tissue

65
Q

what causes a haemorrhagic stroke

A

raised blood pressure, weakened blood vessel wall due to (structural aneurysm, ateriovenous malformation) or inflammation of the vessel wall (vasculitis)

66
Q

describe a thrombotic ischaemic stroke

A

clot blocking artery at the site of occlusion

67
Q

describe an embolic ischaemic stroke

A

clot blocking artery has travelled to artery it occludes from somewhere more proximal in the arteries/heart

68
Q

describe hypoperfusion ischaemic stroke

A

due to reduced flow of blood due to stenosed artery rather than occlusion of artery

69
Q

what is a stenosed artery

A

narrowing of artery due to atherosclerosis

70
Q

what is the mechanism of atherothrombotic stroke

A

atherogenesis (adhesion on monocytes and lymphocytes) -> plaque-> vessel stenosis OR plaque rupture -> platelet aggregation -> thrombosis -> ischaemia

vessel stenosis can also lead to ischaemia by reduced blood flow

71
Q

what are the non modifiable risk factors for stroke

A

age, family history of stroke/heart disease, gender, race, previous stroke

72
Q

what are the (potentially) modifiable risk factors of stroke

A

hypertension (most important), hyperlipidaemia, smoking, atrial fibrillation, diabetes, congestive heart failure, alcohol, obesity, physical inactivity, poor socioeconomic status

73
Q

what causes a transient ischaemic attack

A

artery blocked by small clot that endothelium is able to dissolve it and blood flows again

74
Q

what types stroke benefit from statin therapy

A

ischaemic not haemorrhagic

75
Q

where do venous clot usually travel

A

usually stay in venous system and travels to the lungs..

76
Q

what could allow a venous clot to enter the arterial system

A

atrial septal defect, patent foramen ovale

77
Q

what are the rarer cause in stroke (especially in younger patients)

A

homocysteinemia (makes vessels weaker), vasculitis, protein S, C, Antithrombin III deficiency, paradoxical embolism (from arterial side), genetic, cardioembolic, cervical artery dissection

78
Q

what is the immediate treatment for an ischaemic stroke

A

thrombolysis or thrombectomy (to remove clots and reverse disability)

79
Q

what are conditions that mimic stroke

A

hypoglycaemia, seizure, migrane, brain tumours, functional hemiparesis (pretending to have a stroke)

80
Q

how is a stroke diagnosed

A

history, examination, brain imaging (differentiating between types); CT, MRI +/- angiography

81
Q

in ischaemic stroke what investigations are completed to find the cause of the thrombosis or embolism

A

blood tests (glucose, lipids, thombophillia), asses for hypertension

82
Q

what is an atheroembolism

A

embolism from a thrombus forming on an athersclerotic plaque (platelet rich clots)

infarcts in same side as affected carotid artery

83
Q

what is a cardioembolism

A

embolism from a clot formed in the heart (usually in left atrium)

infarcts in more than one arterial territory (bilateral)

84
Q

where do clots affecting multiple areas come from

A

the heart (cardioembolism)

85
Q

what tests should be carried out on a suspected atheroembolism

A

carotid scanning, CT/MR angiography of aortic arch

86
Q

what tests should be completed on a suspected cardioembolism

A

ECG-AF?, LVH? (uncontrolled hypertension)

echocardiogram

87
Q

what should be considered if there is multiple haemorrhages

A

vascultitis

88
Q

what is used to investigate the cause of bleeding in a haemorrhagic stroke

A

imaging; hypertensive? underlying aneurysm?

89
Q

what is a complication of thrombolysis

A

bleeding in the brain

90
Q

what is used to prevent later stroke following a atheroembolic/thromus stroke

A 
antiplatelets (aspirin + dipryridamole)
statins for cholesterol 
diabetes management 
hypertension management 
lifestyle advice
91
Q

what is used to prevent later stroke following a atrial fibrillation stroke

A

anticoagulant (warfarin (vit k antagonist)

direct acting oral anticoagulants (Rivaroxaban, Dabigatran, Apixaban, Edoxaban)

92
Q

do antiplatelets work on the clot from the heart

A

no

93
Q

what are the surgical managements of a stroke

A

haematoma (clot within tissues) evacuation, relief of raised intracranial pressure, carotid endarterectomy (unblock the artery)

(70% stenosis in same side internal carotid artery as affected side of brain)

Cardiovascular (34 decks)

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