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Cardiovascular > Thromboembolisms And Blood Clotting > Flashcards

Thromboembolisms And Blood Clotting Flashcards

1
Q

Venous Thromboembolism(VTE):
What are the two types of VTEs??

A

There are TWO types of thromboembolisms-
1) Deep vein thrombosis(DVT) :A blood clot occurring in a deep vein, usually calf of one leg or pelvis - unilateral localised pain or swelling
2) Pulmonary embolism(PE) - Detachment of clot which travels to the lungs and blocks the pulmonary artery = SOB or chest pains

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2
Q

VTE RISK ASSESSMENT - when do we assess patients for vte risk?? - what kind of risk factors?- what test is used??

A

When do we use a VTE risk assessment vs a Risk of bleeding assessment? - for hospital patients

VTE RISK ASSESSMENT:
- Immobility
- Obesity and bmi above 30
- Surgery
- Trauma
- Contraceptives - coc and HRT - WEAR STOCKINGS
- Malignant diseases
- 60+years
- Personal history of VTE
- Thrombophilic disorders
- 1st degree relative with VTE
- Varicose veins with phlebitis
- Pregnancy
- Critical care
- Significant co- morbidities

D- dimer test for diagnosis
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3
Q

Risk of bleeding- 7 factors

A
  • Thrombocytopenia (low platelet)
    • Acute stroke
    • Bleeding disorders
    • -Acquired liver failure
    • Inherited haemophilia,Von willebrands disease
    • Anticoagulants
    • Systolic hypertension
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4
Q

VTE Prophylaxis

A

Mechanical prophylaxis: Compression stockings, for patients scheduled for surgery continued until sufficiently mobile
Pharmacological Prophylaxis: For high risk patients undergoing general/orthopaedic surgery OR admitted to hospital as general medical patients

If contraindicates ,offer mechanical prophylaxis
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5
Q

The use of anticoagulants:
Why do we use anticoagulants? What’s the pint- who under go VTE risk assessments? What should high risk patients be offered??( what about high risk vte patients??? What are LMW heparins given for? Who gets unfractionated? Who gets fondaarinux? Who gets dabigatran and rivaroxaban? How long is prophylaxis continued for??

A
  • To prevent thrombus formation or extension of existing thrombus
    • All hospital patients admitted need to undergo risk assessment of VTE - high risk patients with low mobility , obese, history or over 60
    • Patients scheduled for surgery - mechanical prophylaxis required - stockings and should continue until pt is mobile
    • HIGH RISK PATIENTS SHOUD BE OFFERED PHARMACOLOGICAL PROPHYLAXIS
    • LMW heparin for general/orthopaedic surgery
    • Unfractionated heparins for patients with renal failure
    • Fondaparinux for hip/knee surgery or day surgery
    • Dagibartan/rivaroxiban for thromboprophylaxis after knee/hip surgery
    • Pharmacological prophylaxis continued for 5-7 days after surgery or until mobility is re-established 9major surgery needs longer time)
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6
Q

Low Molecular Weight Heparin- what kind of duration of action do they have in comparison to normal heparin?? Which patients do we prefer using it with?? It’s proffered to what because it has a lower risk of what? Dose adjustment need for which 2?

A
  • Initiates anticoagulation rapidly but has a shorter duration or action (unfractionated/normal)
    • LMW heparin have longer duration of action than normal heparin
    • Can be used with VTE patients in pregnancy - does not cross placenta
    • LMW heparin proffered - less risk of osteoporosis and heparin induced thrombocytopenia
    • Eliminated during pregnancy quite quickly - dosage adjustment need for enoxaparin and daltaparin
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7
Q

What do we give during a haemorrhage whilst on heparin?

A
  • Heparin should be withdrawn
    Protamine Sulphate given as an antidote for rapid reversal of heparin effects
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8
Q

Hyperkalaemia:
What does heparin do that warrants this? Caution with which patients?

A
  • Inhibition of aldosterone secretion by unfractionated or LMW heparin can cause hyperkalemia
    • Patients with Diabetes,CKD,acidosis,raised plasma K concentration should be measured before starting and during treatment
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9
Q

LMW heparin:
Examples? What are they preferred over because they reduce the risk of what? Why is it more convenient? What is it used in?

A
  • Dalteparin,enoxaparin,tinzaparin
    • Usually preferred over unfractionated as lower risk of heparin induced thrombocytopenia
    • Longer duration of action and one daily dose - more convenient
    • Used in prophylaxis of DVT,treatment of DVT, Pulmonary embolism and MI
    • Dalteparin is licensed for extended treatment and prophylaxis of VT in patients with solid tumours
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10
Q

DOACs: Direct oral anticoagulants warfarin does what? 2-2.5 or 2.5 to 3.5

A

eg, warfarin - act by antagonising the effects of vitamin K
- Take 28-72 hours for full effect
- INR should be monitored regularly and patients should be given warfarin book

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11
Q

Haemorrhages is the main adverse reaction to the use of what??

A
  • Main adverse effect of all oral anticoagulants
    Anti- coagulant should be stopped and INR should be measured to ensure that it is dropping
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12
Q

Combined anti- platelet and anticoagulant therapy:

A
  • Increased risk of bleeding
    • Risk of bleeding with aspirin and warfarin is lower than risk of clopidogrel and warfarin
    • If possible - withhold antiplatet therapy until warfarin therapy is complete or vice versa
      Cautions:
    • Avoid in severe hepatic impairment especially is prothrombin time already prolonged
    • Avoid with severe renal impairment
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13
Q

Warfarin!!!!!!

A

Warfarin is an oral anticoagulant that was used first-line for many years in both the management of venous thromboembolism and reducing stroke risk in patients with atrial fibrillation. It has now been largely superseded by the use of direct oral anticoagulants (DOACs) which do not require the same level of monitoring as warfarin.

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14
Q

Warfarin MoA

A

• inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
• this in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.

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15
Q

Warfarin indications

A

• mechanical heart valves
○ target INR depends on the valve type and location
○ mitral valves generally require a higher INR than aortic valves.
○ second-line after DOACs:
§ venous thromboembolism: target INR = 2.5, if recurrent 3.5
§ atrial fibrillation, target INR = 2.5

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16
Q

Warfarin monitoring

A

Monitoring
• patients are monitored using the INR (international normalised ratio), the ratio of the prothrombin time for the patient over the normal prothrombin time.
• warfarin has a long half-life and achieving a stable INR may take several days
• there are a variety of loading regimes and computer software is now often used to alter the dose

17
Q

Warfarin - Factors that may potentiate warfarin

A

Factors that may potentiate warfarin
• liver disease
• P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
• cranberry juice
• drugs which displace warfarin from plasma albumin, e.g. NSAIDs
• inhibit platelet function: NSAIDs

18
Q

Warfarin side effects:

A

• haemorrhage
• teratogenic, although can be used in breastfeeding mothers
• skin necrosis
○ when warfarin is first started biosynthesis of protein C is reduced
○ this results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration
○ thrombosis may occur in venules leading to skin necrosis
○ purple toes

19
Q

Thromboemoblism prophylaxis-

A

Mechanical:
- Graduated compression stockings:
- Wear until patient is sufficiently mobile

Pharmacological - anti coagulants- 
- Start within 14 hours of admission 
- Patients with risk factors for bleeding should only receive pharmacological prophylaxis  When their risk of VTE out weighs their risk of bleeding
20
Q

RISK Of bleeding

A

Hasbled or orbit

E – The ORBIT score is based on age (over 75), a reduced haemoglobin (< 13 mg/dL in men, < 12 mg/dL in women, a history of bleed, an eGFR under 60 mg/dl/1.73m2, as well as treatment with an anti-platelet.

21
Q

VTE IN SURGERY

A

Mechanical - ALL patients should continue with this until sufficiently mobile or discharged from hospital

Pharmacological prophylaxis -
- Consider when 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 proffered in renal impairment
- If you have someone who is at risk of VTE but we need to stop their blood from running within th Ernest two hours then we would offer low molecular weight heparin
- Fondaparinux sodium offered to patients with lower limb immobilisatition or pelvis fragility fractures
- Continue for at leat 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

22
Q

Elective hip replacement:
What do we give and for how many days? Then what do we give for 28 days?? What else can we give? And what would we recommend until discharge?

A

LMWH FOR 10 DAYS, then low dose aspirin for 28 days
LMWH For 28 days in + stockings until discharge
Rivaroxiban

23
Q

Elective knee surgery:
What do we give for 14 days? How long do we give lmwh for? What stockings do we use till discharge? What douche can we use? General medical patient with high risk of VTE have to be given what for at least 7 days?

A
  • 75mg aspirin for 14 days
    • LMWH for 14 days in + stockings until discharge
    • Rivaroxaban
      General medical patients with high risk of VTE should be given pharamcological prophylaxis for at leat 7 days or mechanical prophylaxis until mobile
24
Q

VTE prophylaxis in pregnancy:

A

If risk of VTE outweighs risk of bleeeeeeding bisssssshhhhhhh
LMWH during hospital admission
Pregnant women: prophylaxis until no risk of VTE or till the patient is discharged!!!
Women 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 - until sufficiently mobile or discharged from hospital

Treatment of VTE - Unfractionated if patient is at high risk of haemorrhage

25
Q

The treatment of confirmed DVT - what if docs unsuitable? Duration of treatment?

A

The treatment:
- Confirmed proximal DVT or PE - give apixaban or rivaroxaban
If unsuitable - offer:
- LMWH for at least 5 days followed by Dabligatran or edoxaban
- LMWH + warfarin for at least 5 days or until the inr is at least 2 for 2 consecutive readings ,followed warfarin alone
Duration of treatment-
- Distal DVT - CALF = 6 WEEKS
- PROXIMAL DVT/PE- At leat 3 months (3 to 6 months for those with active cancer)
- Provoked DVT/PE stop 3 months if provoking factor resolved
- Unprovoked DVT/PE - 3 months
- Recurrent DVT/PE- long term

Provoked - there is a reason that can be reversed

26
Q

Warfarin- one targets? Bleeding!!!

Major bleed
INR more than 8 and minor bleeding
INR MORE THAN 8 - no bleeding
INR 5-8 +Minor bleeding -
INR 5-8, NO BLEED

A

Maintain INR 2.5 +-0.5 - vte,cardioversion,mi,cardiomyopathy
Maintain INR 3.5 - Recurrent vte or mechanical heart valves

Major bleed - Stop warfarin- IV Phytomenadione and dried prothrombin
INR more than 8 and minor bleeding = stop warfarin - IV phytomenidoine
INR MORE THAN 8 - no bleeding = Stop warfarin - oral phytomenidoine
INR 5-8 +Minor bleeding - stop warfarin - IV Phytomenidoine
INR 5-8, NO BLEED - Withold 1-2 doses of warfarin

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

Restart warfarin when INR is greater than 5

27
Q

MHRA

A

MHRA - Skin necrosis and calciphylaxis - painful skin rashh

28
Q

Haemorrhage - prolonged bleeding

A

Vitamin K phytomenidoine - antidote

29
Q

Pregnancy and warfarin

A

avoid in 1st/ third trimester - use contraception

30
Q

Interactions

A

Vitamin K is the antidote - so leafy greens stop because high in vitamin K
Pomegranate and cranberry juice can reduce Inr
Miconazole OTCBAKTARIN
- Increases patient INR
- Warfarin+ tramadol= raised inr = bruising and bleeding = fatal

CYP450 ENZYME INHIBITORS AND INDUCER
- INCREASE or decreases warfarin concentration respectively

31
Q

Surgery and warfarin: minor

A
  • Minor procedures with low risk of bleeding- Performed with an INR of less than 2.5
    • Restart warfarin within 24 hours of the procedure
32
Q

Procedure where there is a severe risk of bleed:
What do we do with warfarin?

A

Stop warfarin 3-5 days before
Give vitamin K if inr is greater than or equal to 1.5 the day before surgery
Patients high risk of thromboembolism: bridge with LMWH - Stop LMWH 24 hours before surgery - restart LMWH 48 Hours after

33
Q

Emergency surgery:
If it can be salted by 6-12 hours?
If it can’t?

A
  • If CAN BE DELAYED BY 6-12 HOURS - IV VITAMIN K
    • IF it can’t be delayed by 6-12 hours then IV vitamin k and dried prothrombin complex
    Newer generation of anti coagulants which require no monitoring
34
Q

Parenteral Anticoagulants - Heparin vs LMWH -
All heparin’s are avoided in what? What can they cause?
What do we treat heparin haemorrhage with?

What’s good about unfactionated heparin? Who is it ideal for? Is there a higher risk of thrombocytopenia with heparin than lmwh? When is it preffered

LMWH? Used when

A

All heparins: Avoid in heparin induced thrombocytopenia
- Can cause Hyperkalaemia
- Haemorrhage - treat with protamine sulphate(used for Unfractionated heparin)
-
- Heparin - Unfractionated
- Quick initiation and elimination - ideal high bleeding risk (monitoring process APTT)
- Higher risk of heparin induced thrombocytopenia than lmwh
- Proffered in renal impairment
-
- LMWH:
- Preferred in pregnancy

Cardiovascular (10 decks)

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