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Cardiovascular Nafisa > Thromboembolism > Flashcards

Thromboembolism Flashcards

1
Q

What is deep vein thrombosis? DVT

A

A blood clot occurs in a deep vein, usually in calf of one leg

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2
Q

What is pulmonary embolism? PE

A

The detachment of a blood clot which travels to the lungs and blocks the pulmonary artery

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3
Q

For all patients admitted to hospital what two risks must we compare?

A

Their risk of developing a VTE versus their risk of bleeding

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4
Q

What are some factors that increase the risk of VTE?

A
  • immobility
  • obesity, BMI >30
  • malignant disease
  • 60+ years
  • personal history of VTE
  • thrombophilic disorders (means have disorder which means have increased tendency of developing blood clots)
  • a first degree relative of theirs has VTE
  • HRT/ combined contraceptive (due to their effect on the body’s clotting factors and blood flow
  • pregnancy
  • varicose veins with phlebitis (enlarged veins that have become inflamed and painful.
  • pregnancy
  • critical care
  • significant co- morbidities
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5
Q

What is VTE?

A

Venous thromboembolism is a broader term that encompasses two related conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE).

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6
Q

What factors increase the RISK OF BLEEDING in a patient?

A
  • thrombocytopenia (low platelet)
  • acute stroke
  • bleeding disorders
  • Acquired: liver failure
  • Inherited: haemophilia, von willebrands disease
  • anticoagulants
  • systolic hypertension
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7
Q

What is haemophilia

A

Hemophilia is a rare genetic bleeding disorder characterized by a deficiency or dysfunction of specific clotting proteins called clotting factors

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8
Q

What is von willebrands disease?

A

von Willebrand disease (vWD) is a genetic bleeding disorder characterized by a deficiency or dysfunction of von Willebrand factor (vWF), a protein that plays a crucial role in blood clotting.

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9
Q

What is an example of mechanical VTE prophylaxis?

A

compression stockings

exert pressure on the leg vein

Improving Blood Flow: Compression stockings are specially designed to pr

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10
Q

When do we use mechanical VTE prophylaxis

A

For pts scheduled for surgery

Compressions stockings are continued for these pts until they are sufficently mobile

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11
Q

When do we provide pharmacological VTE prophylaxis to patients?

A

For HIGH RISK VTE patients undergoing general/ orthopaedic surgery OR admitted to hospital as general medication patients

If contraindicated offer mechanical prophylaxis

(orthopaedic= bones, joints, ligaments, tendons and muscles)

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12
Q

What are parenteral anticoagulants we can give as pharmacological VTE prophylaxis?

A

Low molecular weight heparin
or
unfractionated heparin in renal failure
or
fondaparinux

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13
Q

When do we give NOACs?

A

prophylaxis after knee/ hip replacement surgery
edoxaban: treatment and prevention of recurrent VTE

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14
Q

What is the duration of VTE prophylaxis for GENERAL SURGERY?

A

5-7 days or until sufficient mobility

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15
Q

What is the duration of VTE prophylaxis for MAJOR CANCER SURGERY in ABDOMEN or PELVIS?

A

28 days

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16
Q

What is the duration of VTE prophylaxis for KNEE/ HIP surgery?

A

extended duration

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17
Q

How do we treat VTE?

A

LMHW
(or unfractionated heparin in renal failure- but make sure to monitor *APTT if unfractionated heparin given)

For at least 5 days
AND
until INR at 2 or more for at least 24 hours

AND AT THE SAME TIME start an oral anticoagulant, usually warfarin

*Activated Partial Thromboplastin Time (aPTT) monitoring is a laboratory test used to assess the clotting ability of a patient’s blood

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18
Q

How do we treat VTE in pregnancy?

A

LMHW is the preferred choice

as lower risk of osteoporosis and heparin- induced thrombocytopenia

Stop at labour- onset. Seek specialist advice on continuing after birth

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19
Q

What does unfractionated heparin activate?

A

antithrombin

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20
Q

What does low molecular weight heparin INACTIVE?

A

factor Xa

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21
Q

What is unfractionated heparin?

A

standard heparin

SHORTER duration of action

Preferred choice if:
- high risk of bleeding
- renal impairment

Monitor: APTT

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22
Q

What are examples of low molecular weight heparin

A

TINZEPARIN

ENOXAPARIN

DALTEPARIN

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23
Q

What is low molecular weight heparin?

A

Longer duration of action

Generally preferred choice as HAS LOWER RISK OF:
- osteoporosis
- heparin induced thrombocytopenia

USED IN PREGNANCY!

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24
Q

What are the side effects of heparin?

A

Haemorrhage

Hyperkalaemia: as heparin inhibits aldosterone secretion which means, potassium cant be excreted and is built up

Osteoporosis

Heparin- induced thrombocytopoenia

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25
Q

What to do if a patient on heparin develops the side effect: HAEMORRHAGE?

A

withdraw heparin

if rapid reversal required= antidote protamine

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26
Q

how to prevent pt on heparin developing HYPERKALAEMIA

A

KNOW that this risk is higher in diabetes mellitus and chronic kidney disease

monitor POTASSIUM levels before treatment AND if treatment lasts >7 days

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27
Q

When does heparin- induced thrombocytopenia occur and what are the clinical signs? And how do we monitor

A

occurs 5-10 days after treatment

CLINICAL SIGNS:

  • 30% reduction in platelets
  • skin allergy
    -thrombosis

MONITORING:
before treatment and if > 4 days use

28
Q

What are examples of other parenteral anticoagulants?

A

heparinoid
argatroban
hirudin
heparin flushes
epoprostenol
fondaparinux

29
Q

What is warfarin?

A

an ORAL anticoagulant
a HIGH risk drug

It antagonises actions of vitamin K in blood clotting
Takes 48 to 72 hours to work

strengths: 0.5, 1mg, 3mg, 5mg

Warfarin acts as a vitamin K antagonist. It inhibits an enzyme called vitamin K epoxide reductase (VKOR), which is responsible for recycling and regenerating active vitamin K in the body. By inhibiting VKOR, warfarin reduces the availability of active vitamin K. With reduced active vitamin K available, the liver is less able to produce functional clotting factor

30
Q

What is the dose of warfarin?

A

5mg initially and monitor every 1-2 days
maintenance dose: 3-9mg at same time each day

31
Q

how is warfarin monitored?

A

INR every 3 months once stable

32
Q

how long does duration of treatment last for: ISOLATED CALF DVT?

A

6 weeks

Isolated calf deep vein thrombosis (DVT) refers to the development of a blood clot (thrombus) within the deep veins of the calf muscle, without involvement of the more proximal veins in the thigh or pelvis

33
Q

how long does duration of treatment last for: PROVOKED VTE (COCs, pregnancy, leg plaster cast)

COCs - combined oral contraceptives

A

3 months

Provoked venous thromboembolism (VTE) refers to the development of a blood clot (thrombus) in the deep veins of the body in response to a specific triggering event or provoking factor.

34
Q

how long does duration of treatment last for: UNRPOVOKED VTE (e.g. atrial fibrillation)

A

at least 3 months/ long- term

35
Q

what is target INR in VTE (within 0.5 units)?

A

2.5

AF, MI, cardioversion, bioprosthetic, mitral valve

36
Q

what is target INR in recurrent VTE (within 0.5 units)?

A

3.5

for recurrent VTE in patients receiving anticoagulant and INR>2

37
Q

How do you counsel patients on warfarin?

A

yellow treatment booklet: explains treatment. also a section for you to write down and keep a record of your warfarin dose.

anticoagulant alert card: patient safety card (also known as an alert card) which provides appropriate details of their treatment.

Tell patient to STOP and SEEK immediate medical attention if any sign of bleeding e.g. nose bleeds or blood in urine. Also pts told to report painful skin rash (calciphylaxis)

38
Q

What are some interactions of wafarin?

A

DIRECT ACTING antivirals to treat chronic hepaptitis

  • Risk of interaction with vitamin k antagonists and can cause changes in INR. Affects efficacy of warfarin. CLOSELY monitor INR

OVER THE COUNTER ORAL MICONAZOLE GEL

  • closely monitor patient if miconazole is prescribe. Miconazole is a POTENT ENZYME INHIBITOR. It increases anticoagulant effect of warfarin. Increases the INR- increased risk of bleeding
39
Q

what are some side effects of warfarin?

A

BLEEDING e.g. nose bleeds <10 minutes, bleeding gums, bruising. The ANTIDOTE is VITAMIN K

CALCIPHYLAXIS (risk factor for this side effect is end- stage renal disease)
Patients should be counselled to report painful skin rash. Consider stopping warfarin if calciphylaxis diagnosed

40
Q

What to do when patient on warfarin has MAJOR bleeding?

A

STOP warfarin
IV Vitamin K
Dried prothrombin complex or fresh frozen plasma

41
Q

What to do if pt is on wafarin and has INR 5-8 AND NO BLEEDING

A

withold 1-2 dose
reduce maintenance dose
measure INR after 2-3 days

42
Q

what to do if pt INR is 5-8 AND MINOR BLEEDING

A

omit warfarin

give IV vitamin K

repeat if INR still high after 24 hours

restart warfarin when INR <5.0

43
Q

what to do if pt INR is <8.0 and NO BLEEDING

A

omit warfarin

oral vitamin K

repeat i INR is still high after 24 hours

restart warfarin when INR< 5

44
Q

what to do if pt INR is >8 and minor bleeding

A

omit warfarin

IV vitamin K

repeat if INR still high after 24 hours

Restart warfarin when INR <5.0

45
Q

What to do with pt who takes warfarin BEFORE they have elective surgery?

A

make sure their warfarin is stopped 5 days before elective surgery

give oral vitamin K for one day if INR >1.5

restart warfarin on evening OR next day

46
Q

What to do with pt who takes warfarin before EMERGENCY surgery?

A

If surgery can be delayed: delay 6-12 hours

If cant be delayed give IV vitamin K and dried prothrombin complex

47
Q

If a patient on warfarin has HIGH RISK OF VTE and is about to have surgery?

A

bridge with LMWH (treatment dose) and stop 24 hours before surgery

A pt is thought to be at high risk of VTE if:
- VTE in last 2 months
- AF with previous stroke/ TIA
- mechanical valve

48
Q

if patient on warfarin has high risk of bleeding and is about to have surgery?

A

start LMWH 48 hours after surgery

49
Q

How do novel oral anticoagulant drugs work?

A

inhibits specific clotting factors ie thrombin or factor Xa

50
Q

What is the mechanism of action of dabigatran?

A

direct thrombin inhibitor

51
Q

How is dabigatran packaged and what is its expiry?

A

Special container

4 month expiry

52
Q

What are examples of drugs that are direct factor Xa inhibitors?

A

apixaban
edoxaban
rivaroxaban

53
Q

what are advantages of NOACs in comparison to warfarin?

A

rarely causes bleeding and no monitoring reqiored

54
Q

what does ischaemic mean

A

blood clot obstructs blood supply

55
Q

what does haemorrhagic mean?

A

weak blood vessel in brain bursts (intracerebral haemorrhage)

56
Q

How is transient ischaemic attack managed?

A

MR dypridamole and aspirin

give statins irrespective of serum cholestrol
treat hypertension, not with beta- blockers unless indicated for another condition

57
Q

how is ischaemic stroke managed?

A

clopidogrel

(in atrial fibrillation- related stroke, review for anticoagulant)’give statins irrespective of serum cholestrol
treat hypertension, not with beta- blockers unless indicated for another condition

58
Q

What do we avoid in a intracerebral haemorrhage?

A

Avoid aspirin, statin and anticoagulants (increases risk of bleeding, only give if essential

Treat hypertension and take care to avoid hypoperfusion

59
Q

What are antiplatelet drugs?

A

decrease platelet aggregation and inhibit thrombus formation in the arterial circulation

60
Q

how do we have secondary prevention of CVD/ event?

A

low dose apsirin: 75mg daily

61
Q

when do we give clopidogrel?

A

following acute coronary syndromes or PCI)

62
Q

when do we give dipyridamole?

A

secondary prevention of strokes

63
Q

when do we take dipyridamole?

A

take tablets 30-60 mins before food

64
Q

when is the expiry date for dyspirdamole?

A

persantin retard capsules - special container, 6 weeks expiry

65
Q
A

Cardiovascular Nafisa (9 decks)

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