Venous Thromboembolic Disease Flashcards
What is a thrombus(i)?
Clot that forms in the vein and remains stationary
What is an embolus(i)?
Cloth that breaks off and travels and lodges in another part of the venous system
What does VTE include?
Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Thrombus or embolism involving any other vein…
What are the key points in VTE epidemiology?
Incidence increases with age
- Women > men in childbearing years, then switches
Blacks slightly higher
Sudden death is the presenting symptom in 25% of cases
What is Virchow’s Triad?
Venous stasis
Endothelial injury
Hypercoagulability
What are some provoking factors for a provoked VTE?
Surgery - especially orthopedic and general
Trauma
Prolonged immobility
Pregnancy or OCP
Medications
Infection (COVID)
What maybe included in the presentation of VTE?
Can be asymptomatic
Ipsilateral LE edema
LE erythema, pain, and warmth
What should be included in a physical exam for VTE?
+/- calf tenderness
+/- palpable cord (more sensitive than Homan’s test)
+/- superficial venous dilation
+/- Homan’s sign
What is Homan’s sign?
Passive dorsiflexion of the ankle with knee at 30 degrees - calf pain (often not reliable but often on test questions)
What is the work-up for VTE?
D-dimer
Duplex venous ultrasound (test of choice)
Contrast venography (gold standard but not routine)
When is a d-dimer useful?
When a patient has low risk probability of DVT, it is only helpful when negative to rule out DVT. If positive, then proceed to US because it is not specific.
What is a pulmonary embolism?
Blood clot in the pulmonary artery system most likely caused by an embolism from a DVT
What is the worst location for a PE?
Saddle, at the bifurcation of the PA. Occlusion of both Rand L pulmonary arteries.
What location of PE is more likely to cause lung infarct or pleuritis?
Sub-segmental
What sided heart failure can be associated with a saddle PE?
Right heart sided
The presentation of PE’s are largely variable based on size and location, but what are some possible symptoms?
Major Most Common
Tachycardia
Tachypnea
Other Symptoms
Dyspnea
Pain with inspiration
Cough
Leg or chest pain
Hemoptysis
Wheezing
Cyanosis
Hypoxia
What should be the initial work-up for PE?
Labs (CBC, CMP, Pregnancy, Coag. studies, Troponin, BNP, D-dimer [only if low risk])
EKG
Duplex US
POCUS Echo
CXR
What is Fleischner’s sign?
Enlarged PA
What is Westermark sign?
Lack of distal pulmonary vasculature
What is Hampton’s hump?
Wedge shaped pulmonary infarct
What sign’s can be seen on CXR, although all are rare?
Fleischner’s sign
Westermark sign
Hampton’s Hump
What are some common findings in EKG in working-up PE?
Pattern of Right Heart Strain –> RBBB, right axis deviation, right atrial deviation, inverted T-waves leads II and V1 (closest to right side)
What are you specifically looking for in echocardiograph when working-up PE?
Assessing for right ventricular dilation
What is the preferred diagnostic test for PE?
CT-pulmonary angiography (CTPA)
Is a CT-pulmonary angiography (CTPA) still the preferred test in working up PE in a pregnant patient?
Yes, still preferred if high suspicion or elevated D-dimer
What is a critical requirement prior to ordering a ventilation-perfusion scan (VQ scan) to work-up a PE?
Normal CXR
What is the treatment for VTE?
For most, anticoagulation
If massive PE or unsuccessful treatment with anticoags then embolectomy
For parenteral treatment, what is the preferred treatment?
LMWH (Lovenox) preferred over UFH because there is no monitoring, more predictable and once/twice daily
Who can’t receive Lovenox?
Patients with renal disease or failure, should be treated with UFH (Heparin)
What is the treatment for VTE in pregnant patients?
LMWH is most preferred
Coumadin (Warfarin) is HIGHLY CONTRAINDICATED (teratogenic)
What DOAC’s are available for the treatment of VTE?
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Dabigatran (Pradaxa)
Edoxaban (Lixiana)
What are the contraindications to DOAC’s?
Thrombophilia
Certain chemo drugs or other drug interactions
Failure (recurrent thrombosis despite tx)
What is the duration of treatment for a major transient provoked attack?
3 months + prophylaxis for subsequent exposures
What is the duration of treatment for a cancer related VTE?
3-6 months or as long as the cancer is active
What is the duration of treatment for an unprovoked VTE?
Minimum of 3-months, possible indefinite if no bleeding risk
What is the duration of treatment for a recurrent unprovoked VTE?
Indefinite
What is the duration of treatment for an underlying hypercoaguable state?
Indefinite
What is thrombophlebitis?
Clot leading to inflammation of a deep vein, DVT or if superficial then superficial thrombophlebitis
What are thrombophlebitis most commonly secondary too?
PICC lines, IVs
If a patient presents with symptoms of thrombophlebitis with fever and chills what are you suspicious for?
Septic phlebitis (staph aureus most common pathogen)
