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Cardiovascular > Venous thromboembolic disease > Flashcards

Venous thromboembolic disease Flashcards

1
Q

What is a DVT?

A

Formation of a thrombi within the lumen of the vessels that make up the deep venous system

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2
Q

Where are DVTs commonly formed?

A

Venous valve pockets and other sites of stasis

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3
Q

Are DVTs platelet or fibrin rich clots?

A

FIbrin rich

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4
Q

WHat is a distal vein thrombosis?

A

DVT of the calves below the poptiteal vein

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5
Q

What is a proximal vein thrombosis?

A

DVT of the popliteal or femoral vein

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6
Q

Do distal DVTs require treatment?

A

No but proximal ones do

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7
Q

What ercentage of those with a proximal DVT develop post thrmbotic syndrome?

A

30%

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8
Q

What are the largest risk factors for DVT?

A

1) Major surgery
2) Day surgery
3) Active malignancy
4) Pregnancy
5) Thrombophilia

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9
Q

What is virchows triad and which conditions contribute to it?

A

Hypercoaguable state
Malignancy, pregnancy, oestrogen therapy, IBD, sepsis, thrombophilia
Turbulence/stasis
left ventricular dysfunction, immobility, paralysis, venous insufficiency/varicose veins, venous obstruction (tumour, pregnancy, obesity)
Endothilial injury
Venous disorders, venous vascular damage, trauma, surgery, indwelling catheters, PWID

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10
Q

What is a provoked DVT?

A

Transient risk factor- surgery or hospitalisation

Continuing risk factor- cancer, obesity, thrombophilia

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11
Q

What is an unprovoked DVT?

A

No identifiable cause

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12
Q

What type of DVT has the highest rate of recurrence?

A

unprovoked DVT

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13
Q

What are the consequences of venous thromboembolism?

A 
Fatal PE
Increased risk of recurrent VTE
Post thrmbotic syndrome 
Chronic thromboembollic pulmonary hypertension CTEPH
Decreased QoL
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14
Q

What is post thrombotic syndrome?

A

Pain: severe, nerve like, effects daily activities
Oedema
Hyperpigmentation: browning of skin- blood pooling and blood entering the skin
Eczema
Varicose collateral veins
Vein ulceration

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15
Q

What is the treatment for post thrombotic syndrome?

A

Limited

Compression stockings but cannot be used in peripheral arterial disease

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16
Q

What is CTEPH?

A

Chronic thromboembolic pulmonary hypertension

serious complication of PE occurring in 5% of patients

17
Q

WHat are the symptoms of CTEPH?

A

initially assymptomatic then progressive dyspnoea and hypoxia
Right sided heart failure- cor pulmonale
Progressive condition withmortality of 4-20%

18
Q

How is CTEPH treated?

A

Pulmonary endartectomy

19
Q

What are the investigations for DVT?

A

Pretest probability scores- Wells score

D-dimer- product of the breakdown of fibrin. High negative predictive value

20
Q

How is the Wells score for DVT used?

A

low score- do d dimer

High score- need imaging regardless of D dimer

21
Q

What are the pretest probability scores for PE?

A 
Modified wells score. 
Score <4 makes PE unlikely. 
Score >4 makes PE likely 
Geneva score for PE. 
Score 0-3 = low risk => do d dimer
Score 4-10 = intermediate risk +. do d dimer and imaging?
Score >10 = high risk => Imaging
22
Q

How do you image DVT?

A

Compresability U/S- can you fully compress the vein

Dopler U/S- visualise veins and flow direction with colour to show turbulence/stasis.

23
Q

How do you image fore PE?

A

V/Q scanning used to show mismatched ventilation perfusion defects. Useful in small PEs and pregnancy. Limited by inconclusive results and skilled people
CXR- normally normal acutely but may show a wedged shaped infarct later
CT pulmonary angiography is the gold standard test

24
Q

What are the pharmacological treatments for VTE?

A

Anticoagulation, thrombolysis and analgesia

25
Q

What are the mechanical interventions for VTE?

A

Compression stockings

IVC filters

26
Q

Would you screen routinely for cancer and thrombophilia following a VTE?

A

No- take a good history

27
Q

How long should you anticoagulate for a provoked or unprovoked VTE or active cancer?

A

Provoked = 3 months
Unprovoked = 3 months and asess the risk of continuing
Active cancer 3-6 mmonths of LMWH (or fragmin) and reassess

28
Q

What are the advantages and disadvantages to warfrin?

A

+ can be used in severe renal failure and can be reversed
- high risk of bleeding, slow onset, narrow TI, many drug/food interactions, needs INR monitoring, interindividual variability

29
Q

What are the advantages and disadvantages of Direct oral anticoagulants DOACs?

A

+ lower risk of bleeding, predctable, fewer interactions, no need for INR monitoring, easier long term and safer
- No available antidote or long term data

30
Q

Which DOACs are commonly used in DVT/PE?

A

Apixaban (doesn’t increase risk of major bleeding in comparison to placebo)
Rivaroxaban

31
Q

How would you treat a PWID with a VTE event?

A

Normally give rivaroxaban for 3 months
Risk of bleeding if people continue to inject while on anticoagulants
Do not give fragmin as it has a street value

32
Q

What is phlegmasia?

A

Severe form of DVT due to extensive thrombotic oocclusion of major and collateral veins of extremities- rare. often results in death

33
Q

WHich patients are given thrombolysis for DVT?

A

Symptoms for >14 days and good functional status, life expectancy > 1 year and low risk of bleeding

34
Q

Which patients are given thrombolysis for PE?

A

Haemodynamic instability (perfusion failure, circulatory shock, heart failure)

35
Q

What are class 2 European standard compression stockings used for?

A

Prevention of post thrombotic syndrome

36
Q

When should compression skockings be warn?

A

ASAP follow diagnosis once swelling has reduced. Worn for > 2 years. ONly worn on affected leg as it will effect arterial circulation and may cause ischemia

37
Q

When are IVC filters used?

A

Only in DVT and needing major surgery so don’t want to anticoagulate then too much. Can be removed post surgery but 1 in 20 get stuck.
Often have complications and can thrombose easily generating more clot

38
Q

What are IVC filters?

A

Mechanical devie that sits in the IVC to catch clots

Cardiovascular (24 decks)

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