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CARDIOVASCULAR TOPIC PRE-REG > Thromboembolism > Flashcards

Thromboembolism Flashcards

1
Q

What are the two types of thromboelbolism

A

Lung and extremities (legs)

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2
Q

What are the symptoms of thromboembolism

A

SOB
Hot to touch
Painful
Usually unilateral (one leg)
Coughing

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3
Q

What is a VTE

A

A blood clot in the vein and obstructs blood flow
DVT- legs or pelvis- unilateral localised pain or swelling
PE- lungs- chest pain or SOB

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4
Q

What are the risk factors of VTE

A

Surgery
Trauma
Significant immobility
Malignancy
Obesity
Pregnancy
Hormonal therapy (COC or HRT)

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5
Q

What tests need to be done to conform a VTE

A

D-dimer test

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6
Q

What are the 2 methods of thromboembolism prophylaxis

A

Mechanical- graduated compression stockings
-wear until the patient is sufficiently mobile

Pharmacological- anticoagulants
-start within 14 hours of admission
-patients with risk factors for bleeding should only receive pharmacological prophylaxis’s when their risk of VTE outweighs the risk of bleeding

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7
Q

What is the treatment protocol for VTE in surgery

A

Mechanical prophylaxis
Prophylaxis should continue until the patient is sufficiently mobile or discharged from hospital

Pharmacological prophylaxis
Considered when the risk of VTE outweighs the risk of bleeding
A low molecular weight heparin is suitable in all types of general and orthopaedic surgery
-unfractionated heparin is preferred in renal impairment
- fondaparinux sodium for patients with lower limb immobilisation or pelvis fragility fractures
- continue for at least 7 days post surgery or until sufficient mobility has been re-established
— 28 days after major cancer surgery in the abdomen
— 30 days in spinal surgery

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8
Q

What is the treatment protocol for VTE in surgery continued

A

In elective hip replacement either:
- low molecular weight heparin for 10 days and then 75mg aspirin for 28 days
-LMWH for 28 days + stockings on discharge
-Rivaroxaban

Elective knee replacement either
- 75mg aspirin for 14 days
-LMWH for 14 days and stockings until discharge
-rivoraxaban

General medical patients with a high risk of VTE should be given pharmacological prophylaxis for at least 7 days or mechanical prophylaxis until mobile

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9
Q

What is the treatment protocol for VTE in pregnancy

A

If risk of VTE that outweighs the risk of bleeding
- LMWH during hospital admission
Pregnant women: prophylaxis until no risk of VTE or until patient is discharged
- some who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks - start LMWH 4-8 hours after the event - continue for a minimum of 7 days

Additional mechanical prophylaxis if immobilised- until sufficiently mobile or discharged from hospital

Treatment of VTE: LMWH, unfractionated if patient is at high risk of haemorrhage

Give unfractionated if need quick response as it has a short half life

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10
Q

What is the treatment for VTE

A

If you have conformed DVT or PE: apixaban or rivaroxaban
If unsuitable offer:
- LWMH for at least 5 days followed by dabigatran or edoxaban
-LMWH + warfarin for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings followed by warfarin alone

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11
Q

What is the duration of treatment for VTE

A

Distal DVT (calf) : 6 weeks
Proximal DVT /PE: at least 3 months (3-6 months for those with active cancer)
Provoked DVT/PE: stop at 3 months if the provoking factor has been resolved
Unprovoked DVT/PE: 3 months+
Recurrent DVT/PE: long term

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12
Q

What are the monitoring requirements of warfarin

A

Maintain INR of 2.5: VTEs, AF, cardioversion, MI, Cardiomyopathy
Maintain INR of 3.5: VTEs or mechanical heart valves

Major bleed: stop warfarin- IV phytomenadione (vitamin K) and dried prothrombin
INR > 8, minor bleed: stop warfarin - IV phytomenadione
INR >8 , no bleed: stop warfarin and oral phytomenadione
INR 5-8, minor bleed: stop warfarin and IV phytomenadione
INR 5-8, no bleed: withhold 1-2 doses of warfarin

Restart warfarin when INR is <5

INR should be monitored every 1-2 days in early treatment and then every 12 weeks

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13
Q

What is the correlation between blood and INR

A

The higher the INR the runnier your blood is

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14
Q

What is the MHRA warning about warfarin

A

Skin necrosis and calciphylaxis
-painful skin rash

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15
Q

What are the side effects of warfarin

A

-Haemorrhage: prolonged bleeding
Vitamin k1antidote

Pregnancy: avoid in the first and third trimester
-use contraception

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16
Q

What are the interactions of warfarin

A

Vitamin k rich foods: avoid major changed in diet with leafy greens
-reduce efficacy of warfarin

Pomegranate and cranberry juice
-increases patients INR

Miconazole (OTC daktarin oral gel)
-increases patient INR

CYP450 enzyme inhibitors and inducers
-increases or decreases warfarin concentration

17
Q

What is the protocol of warfarin and surgery

A

Minor procedures with low risk of bleeding:
Performed with an INR of less then 2.5
Restart warfarin within 24 hours of procedure

Procedure where there is a risk of severe bleeding
Stop warfarin 3-5 days before
Give vitamin k if INR is >1.5the day before the surgery
Patients at high risk of thromboembolism: bridge with LMWH- stop LMWH 24 hours before surgery- restart LMWH 48 hours after

Emergency surgery:
If can be delayed by 6-12 hours : IV vitamin k
If can’t be delayed by 6-12 hours : IV vitamin k + dried prothrombin complex

18
Q

What are DOACs direct oral anticoagulants

A

They are newer generation anticoagulants which requires no monitoring:
-apixaban
-dabigatran
-edoxaban
-rivaroxaban

19
Q

What are the dose of DOACs

A

Apixaban: 10mg BD for 7 days- 5mg BD

Rivaroxaban: 15mg BD for 3 weeks- 20mg OD
-should be taken with food

Dabigatran:150mg BD aged 18-74, 100-150 BD aged 75-79, 110mg BD for aged 80+
Only start once patient has had 5 days of LMWH

Edoxaban: 60mg OD 30mgOD if patient weighs under 61kg
Only start once patient has had 5 days of LMWH

These are the strengths for the TREATMENT of thromboembolism only

20
Q

Parental anticoagulants- Heparins vs LMWH

A

All heparins:
-avoid in heparin induced thrombocytopenia
Can cause hyperkalaemia- not to be given with NSAIDs and ACE-i and other drugs that cause hyperkalemia
Haemorrhage- treat with protamine sulphate ( used for unfractionated heparins)

Heparins unfractionated
- quick initiation and elimination- ideal in high bleeding risk (monitor APTT)- short half life
Higher risk of heparin induced thrombocytopenia than LMWH
-preferred in renal impairment

LMWH:
Preferred in pregnancy

21
Q

What is the MHRA warning in DOACs

A

Dose adjustment of DOACs in patients with renal impairment

CARDIOVASCULAR TOPIC PRE-REG (9 decks)

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