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Year 3 - CR > Venous Thrombo-embolism Prevention > Flashcards

Venous Thrombo-embolism Prevention Flashcards

1
Q

What is a venous thromboembolism

A
  • Blood clot that starts in the calf- they may remain localise or they may go across the vein to occlude it and grow proximally
  • can embolism and move around and spread to other areas of the body
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2
Q

What are the consequences of venous thromboembolism

A
  • DVT
  • PE
  • Post thrombotic syndrome
  • leg ulcers
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3
Q

What is the 3rd most common cause of cardiovascular death

A

PE

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4
Q

what is the second most common cause of death in cancer and commonest cause of preventable hospital related death and most common cause of maternal mortality

A

PE

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5
Q

Why is VTE important

A

Common - 1 in 1000 per year

- treatments effective but significant risks - major and fatal bleeding

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6
Q

If you get a VTE what are you at risk of in the future

A
  • Post thrombotic syndrome

- Chronic thromboembolic pulmonary hypertension (CTEPH)

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7
Q

What are most death from PE due to

A
  • diagnostic failure rather than treatment failure - most patients die as the diagnosis is not suspected
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8
Q

What is your chances of dying from a DVT and PE

A

VTE – natural history
30-day case fatality PE vs DVT
– 7%v2%(OR3.8, 95% CI 1.6-9.2)
– ≈ 50% of above deaths from PE (approx. 4% v 1%)

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9
Q

What is pulmonary embolism the most common cause of

A
  • Most common cause of missed or delayed diagnosis
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10
Q

After you stop anticoagulants after 3 months what is the risk of developing another VTE

A
  • Overall 5% per year initially
    • 20% at 5 years
    • 30% at 10 years
    – Higher (≈10% in first year) if unprovoked than if provoked by temporary risk factor
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11
Q

What is post thrombotic sydnrome

A
  • complicates 40% of DVT cases
  • develops within 2 years of DVT diagnosis
  • variable severity
  • reduced quality of life
  • cost to individual and society
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12
Q

What are the symptoms of post-thrombotic syndrome

A
  • pain
  • swelling
  • skin induration/discolouration
  • ulceration
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13
Q

what 3 risk factors lead to VTE/PE development

- virchows triad

A
  • blood flow
  • blood coagulability
  • vessel wall damage
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14
Q

What are the major risk factors for VTE

A
  • Fracture of hip/pelvis
  • Hip or knee replacement surgery
  • Major general surgery especially for malignancy
  • Major trauma
  • Spinal cord injury
  • Hospitalisation with acute medical illness
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15
Q

What are the moderate risk factors for VTE

A 
• Previous VTE
• Malignancy/chemotherapy
• Pregnancy and post-partum period
• Combined oc pill or hormone therapy
• Central venous line
• Thrombophilia
Risk factors
• Other medical conditions e.g. nephrotic syndome, inflammatory bowel disease, Behçets syndrome
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16
Q

What are weak but common risk factors for VTE

A
  • Age
  • Travel-related thrombosis
  • Obesity
  • Varicose veins
  • Diet
  • Smoking
  • Air pollution
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17
Q

describe how hospital admission leads to VTE risk

A 
VTE following hospital discharge
Worcester DVT study (2007)
• 74% presented as outpatients
– 37% recent hospitalisation +/- surgery
– 23% recent major surgery +/- hospitalisation – 29% recent cancer diagnosis
– 20% previous VTE diagnosis
– 70% ≥1 VTE risk factors
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18
Q

why do cancer patients have an increased risk of VTE

A

– Cancer is prothrombotic
– Immobility
– Chemotherapy
– Central venous lines

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19
Q

of patients presenting with unprovoked VTE…

A

5% have a new cancer diagnosed within 3 years

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20
Q

What is the 2nd leading cause of death in cancer patients

A

VTE

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21
Q

When you are pregnant what increases your risk of developing a VTE

A
  • Obesity
  • Maternal age > 35 years
  • Caesarean section (especially emergency)
22
Q

What is trousseau syndrome

A
  • the connection between VTE and cancer
23
Q

Describe how the risk of VTE change in pregnancy

A
  • mostly level during pregnancy but increases before delivery
  • after delivery it massively increases in the first 6 weeks after delivery
24
Q

What are the NICE guidelines for VTE

A
  • All patients on admission receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria
  • patients are offered verbal and written information on VTE prevention as part of the admission process
  • patients provided with anti-embolism stockings have them fitted and monitored
  • patients are re-assessed within 24 hours of admission for risk of VTE and bleeding
  • patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance with NCIE guidelines
  • patients are offered verbal and written information on VTE prevention as part of the discharge process
  • patients are offered extended VTE prophylaxis
25
Q

Name thrombosis risk

A
  • Active cancer or cancer treatment
  • age over 60
  • dehydration
  • known thrombophiliais
  • obesity
  • one or more significant medical co-morbidities - e.g. heart disease, metabolic, endocrine or respiratory pathologies, acute infectious diseases
  • personal history or first degree relative with a history of VTE
  • use of hormone replacement therapy
  • use of oestrogen containing contraceptive therapy
  • varicose veins with phlebitis
  • pregnancy or less than 6 weeks post partum

admission related

  • significantly reduced mobility for 3 days or more
  • hip or knee replacemetn
  • hip fracture
  • total anaesthetic and surgical times greater than 90 minutes
  • surgery involving pelvis or lower limb with a total anaesthetic and surgical time greater than 60 minutes
  • acute surgical admission with inflammatory or intra-abdominal condition
  • critical care admission
  • surgery with significant reduction in mobility
26
Q

Name the bleeding risks

A

Patient related

  • active bleeding
  • acquired bleeding disorders
  • concurrent use of anticoagulatns known to increase the risk of bleeding
  • acute stroke
  • thrombocytopaenia
  • uncontrolled systolic hypertension - 230/120 or higher
  • untreated inherited bleeding disorder

Admission related

  • neurosurgery, spinal surgery or eye surgery
  • other procedure with high bleeding risk
  • lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
  • lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours
27
Q

Name the mechanical methods of thromboprophylaxis

A
  • Anti embolism stockings

- intermittent pneumatic compression

28
Q

Name the pharmacological methods of thromboprophyalxis

A

– Unfractionated heparin
– Low molecular weight heparin
– Fondaparinux
– New direct oral anticoagulants (DOACs)

29
Q

describe parenteral thromboprophylaxis

A

– Unfractionated heparin 5000 u sc bd or tds

– Low molecular weight heparin
• Enoxaparin 40 mg sc od
• Dalteparin 5000 u sc od
• Tinzaparin 4500 u sc od

– Fondaparinux - synthetic pentasaccharide - 2.5 mg sc od

30
Q

describe oral thromboprophylaxis

A

– Direct thrombin inhibitor
• Dabigatran

– Factor Xa inhibitor
• Rivaroxaban
• Apixaban
• Edoxaban (not yet licensed for VTE prevention)

31
Q

How does heparin work

A
  • binds to naturally ocucring anti thrombin III
  • and this speeds up the inhibition of the activated clotting factors
  • particulary factor IIa and Xa
32
Q

How does LMWH work

A
  • shorter chains

- inhibits factor Xa but some are not long enough to inhibit thrombin therefore you only get some thrombin inhibition

33
Q

How does fondaparinux work

A
  • inhibition of Xa and no inhibition of thrombin
34
Q

What does dabigatran inhibit

A

thrombin

35
Q

What does apixaban, edoxaban, rivaroxaban inhibit

A

Factor Xa

36
Q

When do you get a peak of DOACs

A

around 2 hours later

37
Q

What is the half life of DOACs

A

12 hours

38
Q

Where are the DOACs eliminated

A
  • dabigatran - renal

- others not the renal

39
Q

What patients should not recieve graduated compression stockings

A
  • Known peripheral vascular disease
  • Leg or buttock pain on exercise
  • Previous or planned revascularisation surgery
  • Massive leg oedema where stockings are unable to be fitted
  • Leg conditions in which stockings would interfere eg dermatitis, recent skin graft, gangrene
40
Q

What is the standard approach to VTE

A

• Anticoagulant therapy
– Prevent extension and recurrence (not thrombolytic)

Standard approach
• Immediate therapy with treatment-dose heparin (LMWH)
• Overlap with warfarin until INR in therapeutic range (5 days minimum)
• Then stop LMWH, continue warfarin for 3 months (monitor in anticoagulant clinic) and review duration

41
Q

What does warfarin inhibit

A

Vitamin K antagonists

• Factors II, VII, IX, and X (and protein C and protein S)

42
Q

What is the half life of warfarin

A

36 hours

43
Q

Where is warfarin metabolised

A

in the liver

44
Q

What are the side effects warfarin

A

– Risk of major bleeding – 1-2% per year
– Avoid in pregnancy – teratogenic and bleeding
– Safe for breast feeding

45
Q

How do you monitor warfarin

A
  • INR (derived from the prothrombin time - extrinsic and common pathway)
46
Q

What DOACs require a heparin lead in

A

Dabigatran and Edoxaban

- heparin lead in required 5-10 days

47
Q

describe an updated VTE plan

A

Acute (5-10 days)
- IV heparin, LMWH, Fondaparinux, DOCA

Short term (3-6 months )

  • warfarin
  • LMWH
  • DOAC

long term (beyond 3-6 months)

  • Warfarin
  • LMWH
  • DOAC
  • ASA
  • nothing
48
Q

How long should you have warfarin in a provoked v an unprovoked VTE

A

Venous thromoboembolism = length of warfarin treatment

  • provoked (e.g. recent surgery): 3 months
  • unprovoked: 6 months
49
Q

What can D dimer be elevated in

A
  • DVT
  • pregnancy
  • cancer
  • hospitalised
  • elderly patients
50
Q

What test do you do after a D dimer is positive

A
  • do a CT pulmonary angiography
51
Q

What advice is given to people on warfarin

A
  • Shouldn’t take it if pregnant
  • can take it whilst breastfeeding
  • avoid cranberry juice
  • warfarin is also affected by alcohol
52
Q

What is the general information that someone taking anticoagulants should be old

A
  • avoid injuring yourself as it can make you prone to bleeding
  • should not take aspirin, herbal remedies such as St John’s Wart
  • some medicines can effect anticoagulants such as antibiotics, antidepressants, corticosteroids, NSAIDs

Year 3 - CR (44 decks)

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