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Y3 - Haem > Thrombosis > Flashcards

Thrombosis Flashcards

1
Q

What is thrombosis?

A

Blood clotting

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2
Q

What are venous thromboembolic clots rich in?

A

Red cells and fibrin

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3
Q

What is the pathophysiology of venous thrombosis?

A

Deterioration of venous valves causes stasis

Activation of coagulation cascade produces a fibrin clot

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4
Q

Are platelets involved in venous thrombosis?

A

No

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5
Q

What site do venous thromboses most commonly form in?

A

Deep veins of the lower legs

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6
Q

What are the pathophysiological causes of venous thrombosis?

A

Virchow’s triad:

  • stasis
  • hypercoagulability
  • vessel wall damage
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7
Q

What are risk factors for venous stasis?

A 
Previous venous thrombosis
Immobility (age, obesity, pregnancy)
Venous obstruction (pregnancy, tumour)
Polycythaemia (excess red cell - blood is thicker and move more slowly)
Varicose veins
Congestive heart failure
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8
Q

What are risk factors for endothelial injury?

A 
Surgery
Piccs/lines
Trauma
Thrombophlebitis/cellulitis
Hypertension
Smoking
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9
Q

What are risk factors for hypercoagulability?

A 
Factor V Leiden mutation
Prothrombin gene mutation
Protein C/S deficiency
Malignancy
Sepsis
Trauma/major surgery
Inflammatory disease
Drugs - e.g. oestrogen therapy (COCP, HRT)
Pregnancy and post-partum
HIT - heparin-induced thrombocytopenia
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10
Q

What is thrombophilia?

A

Ant inherited or acquired tendency towards thrombosis

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11
Q

When should you consider a thrombophilia?

A 
Recurrent VTE
Recurrent miscarriage
VTE under age 40
Strong family history of VTE
VTE in unusual place - mesenteric or cerebral veins
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12
Q

What are examples of thrombophilias?

A 
Inherited:
- Factor V Leiden
- Prothrombin 20210 mutation
- Protein C/S deficiency
- Anti-thrombin deficiency
Acquired:
- Anti-phospholipid syndrome
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13
Q

What is Factor V Leiden?

A

Inherited disorder where clotting factor V works normally in clot formation but isn’t switched off as easily by proteins C and S

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14
Q

What is anti-phospholipid syndrome?

A

Autoimmune condition affecting primary and secondary haemostasis causing recurrent arterial and venous thromboses and recurrent miscarriage

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15
Q

What antibodies can be detected in anti-phospholipid syndrome?

A

Lupus anticoagulants

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16
Q

What is the treatment for venous thrombosis?

A

Anticogulation

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17
Q

What are the different types of anticoagulation?

A

Heparin
Warfarin
DOAC

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18
Q

What is the mechanism of heparin?

A

Potentiates antithrombin by binding to the anti-thrombin and thrombin complex (undfractionated) or the anti-thrombin and factor X complex (LMWH)

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19
Q

What is the difference in the clotting factors that unfractionated and low molecular weight heparin inhibit?

A

Unfractionated - II, IX, X, XI, XII

LMWH - Xa

20
Q

What are the indications for heparin?

A

Treatment of VTE and acute coronary syndrome

Prophylaxis in pregnancy or pre/post-surgical

21
Q

What are the contraindications for heparin?

A

Bleeding disordes
History of peptic ulcer disease
Severe uncontrolled hypertension
Caution in renal disease - give lower dose

22
Q

How is heparin monitored?

A

Unfractionated heparin monitored with APTT

LMWH can be monitored with anti-Xa but no need apart from complicated patients (renal failure or pregnancy)

23
Q

What are the complications of heparin?

A

Bleeding
Heparin-induced thrombocytopenia (with thrombosis)
Osteoporosis

24
Q

What is the management for bleeding caused by heparin?

A

Stop heparin

If severe - protamine sulphate

25
Q

What is heparin-induced thrombocytopenia?

A

Heparin can induce antibodies that cause thrombosis
More likely in unfractioned heparin
Rare

26
Q

What is the management for heparin-induced thrombocytopenia?

A

Switch to different anticoagulant

27
Q

What is the mechanism of warfarin?

A

Inhibition of vit K
Vit K carboxylates clotting factors II, VII, IX, X so warfarin’s inhibition reduces the synthesis of these clotting factors

28
Q

How does warfarin affect protein C and S, and how does this affect management?

A

Protein C and S are involved in switching off secondary haemostasis
When warfarin is introduced they will also drop, and will drop before the other clotting factors
So initially you are more likely to get a clot
For this reason heparin is always given with warfarin for the first 5-7 days to cover this period

29
Q

What are contraindications for warfarin?

A 
Pregnancy
Non-compliance
Non-thromboembolic strokes
Severe uncontrolled hypertension
Severe liver or renal disease
Peptic ulcer or GI bleeds
30
Q

In which stages is warfarin introduced?

A
  1. Initiation
    - rapid in acute thrombosis
    - slow in the community, lessening the effect on protein C and S, may be able to avoid heparin use
  2. Stabilisation
    - find dose that suits the patient
  3. Maintenance
    - take dose at same time every day
31
Q

What is used to monitor warfarin?

A

INR

32
Q

What is the range that warfarin needs to be kept in?

A

2-3 usually

3-4 if extra anticoagulation needed - e.g. VTE, metallic heart valve, anti-phospholipid syndrome

33
Q

What are the complications of warfarin?

A

Bleeding
- mild: bruising, epistaxis, haematuria
- severe: GI, intracerebral, significant drop in Hb
Teratogenicity

34
Q

What are examples of interactions that potentiate the action of warfarin?

A 
Febrile illness
Hyperthyroidism			Cardiac failure
Liver/renal disease
Drugs: alcohol, omeprazole, erythromycin, ciprofloxacin, valproate
Cranberry juice
35
Q

What are examples of interactions that reduce the action of warfarin?

A

Pregnancy
Hypothyroidism
Drugs: phenytoin, carbamazepine, rifampicin

36
Q

What is the management for a patient on warfarin when INR is in normal range but there is minor bleeding?

A

No action

37
Q

What is the management for a patient on warfarin when INR is high but <6?

A

Stop warfarin

Restart when <5

38
Q

What is the management for a patient on warfarin when INR is >8 but only minor bleeding?

A

Stop warfarin
Give oral vit K
Restart when <5

39
Q

What is the management for a patient on warfarin when INR is >8 with severe bleeding?

A

Stop warfarin
Pothrombin complex concentrate or fresh frozen plasma
IV vitamin K

40
Q

How long before surgery should warfarin be stopped?

A

5 days

41
Q

What are examples of DOACs, and which clotting factor do each inhibit?

A

Apixaban - Xa inhibitor
Rivaroxaban - Xa inhibitor
Dabigatran - IIa inhibitor

42
Q

What is arterial thrombosis?

A

Clots formed in arterial circulation

43
Q

What is the pathophysiology of arterial thrombosis?

A

Damage to endothelium
Recruitment of ‘foamy’ macrophages that are rich in cholesterol
Forms plaque rich in cholesterol
When plaques rupture platelets are recruited
Platelets adhere to subendothelial collagen and aggregate

44
Q

What are arterial thrombotic clots rich in?

A

Platelets

45
Q

What are risk factors for arterial thrombosis?

A

Hypertension
Smoking
High cholesterol
Diabetes mellitus

46
Q

What is done to reduce risk of arterial thrombosis?

A 
Stop smoking
Treat hypertension
Treat diabetes
Lower cholesterol
Anti-platelet drugs

Y3 - Haem (9 decks)

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