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Cardiovascular System > VENOUS THROMBOEMBOLISM > Flashcards

VENOUS THROMBOEMBOLISM Flashcards

1
Q

What are the two types of Venous Thromboembolism?

A

Pulmonary Embolism - blockage of artery in the lungs

Deep Vein Thrombosis - blood clot in the body, usually legs

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2
Q

What is the treatment for Venous Thromboembolism?

A
  • Antiplatelets - aspirin, clopidogrel etc
  • Anticoagulants - warfarin, apixaban etc
  • Thrombolytics - alteplase
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3
Q

Who must be assessed for risk of VTE?

A

ALL patients admitted to hospital have to be assessed for their risk of VTE and bleeding on admission

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4
Q

Which patients are in high risk of VTE?

A
  • Substantial reduction in mobility
  • Obesity / overweight
  • Malignant disease (cancer)
  • History of VTE
  • Thrombolytic disorder
  • Patients over 60 years of age
  • Pregnancy
  • Dehydration
    *HRT and combined hormone contraception (oestrogen)
  • Family history
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5
Q

When should mechanical and pharmacological prophylaxis be given?

A

Mechanical prophylaxis - to patients due for surgery and continue wearing day and night until patient is mobile. E.g. anti-embolism stockings

Pharmacological prophylaxis - to patients undergoing orthopaedic surgery whose risk of VTE outweighs risk of bleeding

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6
Q

Who should not be offered stockings for thromboembolism prophylaxis?

A

Patients with:
- Acute stroke
- Peripheral arterial disease
- Peripheral neuropathy
- Severe leg oedema
- Local conditions e.g dermatitis, gangrene

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7
Q

When should pharmacological prophylaxis be given?

A

Asap or within 14 hours of admission

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8
Q

How long should pharmacological prophylaxis be given for?

A

Until the patient is mobile

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9
Q

What kind of heparin is preferred in patients with renal failure?

A

Unfractionated heparin

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10
Q

What kind of heparin can be used used in all types of general and orthopaedic surgery?

A

Low weight molecular heparins (LWMH)

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11
Q

Which patients should receive unfractionated heparin?

A

Pt with renal impairment or increased risk of bleeding

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12
Q

What is the preferred heparin for prophylaxis in surgical patients?

A

LMWH Heparins as first line
Then unfractionated heparin.

But if patient has renal impairment or high risk of bleeding then unfractionated heparin first

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13
Q

What creatinine clearance level classifies as renal impairment?

A

crcl: 15-50ml/min

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14
Q

Which drugs are given for VTE Prophylaxis?

A
  • Offer fondaparinux sodium to patients undergoing hip or knee surgery, G.I bariatric surgery, or day surgery procedures

Continue for 7 days after surgery or until patient is fully mobile.

  • DOACs - for elective hip/knee replacement surgery after LMWH or low dose aspirin
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15
Q

What’s the treatment for PE/DVT?

A

For confirmed DVT or PE: Rivaroxaban, Apixaban

Alternative - LMWH for at least 5 days followed by Dabigatran or Edoxaban
OR LMWH given concurrently with a vitamin K antagonist for at least 5 days or until INR is at least 2.0

For patients with renal impairment:
- Apixaban
- Rivaroxaban
- LMWH for at least 5 days followed dabigatran (if crcl is more than 30ml/min) or Edoxaban

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16
Q

Can heparins be taken when pregnant?

A

Heparins are safe in pregnancy as they do not cross the placenta.

However LWMH is preferred as it carries a lower risk of osteoporosis and heparin-induced thrombocytopenia (low blood platelets).

But they are eliminated more rapidly in pregnancy so a dose alteration is required

17
Q

Examples of LMWH heparin?

A

Dalteparin, Enoxaparin, Tinzaparin

18
Q

How long do patients have to keep taking anticoagulant treatment?

A

Confirmed proximal DVT or PE - at least 3 months
(3-6 months for active cancer)

Provoked DVT or PE (has a cause e.g. contraceptive, pregnancy etc) - 3 months
(3-6 months for active cancer)

Unprovoked DVT or PE - more than 3 months
(more than 6 months for active cancer)

19
Q

What should be done in VTE if a haemorrhage (a side effect of heparin) occurs?

A

Withdraw the heparin.

20
Q

What can be used to reverse the effects of heparin?

A

Protamine sulphate.

But it only partially reverses the effects of LWMH.

21
Q

What’s the mechanism of action for Tranexamic acid?

A

Inhibits fibrinolysis

22
Q

What are the indications for Tranexamic acid??

A
  • Local fibrinolysis
  • Management of menorrhagia
  • Hereditary angioedema, epistaxis (nose bleed)

Helps blood to clot - used for nose bleed and heavy periods

23
Q

What are the doses for tranexamic acid?

A

Menorrhagia - 1g THREE times a day for up to 4 days. Must be started when menstruation starts.
MAX 4g per day

Fibrinolysis - 1-1.5g 2-3 times a day

Epistaxis - 1g 3 times a day for 7 days

Can be taken with or without food

24
Q

What are the side effects, monitoring, patient advice and contraindications for tranexamic acid?

A

Side effect - Diarrhoea (if so, reduce the dose), nausea and vomiting

Monitoring: Regular liver function tests in long term treatment of hereditary angioedema

Advice: increase risk of DVT if taken with contraceptive pill

Contraindications: Epilepsy, DVT, PE, Irregular periods, renal problems, pregnancy

25
Q

What do beta blockers do?

A

They block beta adrenoreceptors in the heart, bronchi, pancreas, liver and peripheral vasculature.

And therefore slow the heart rate and depress the myocardium

26
Q

What are the different types of beta blockers?

A
  • Intrinsic sympathomimetic activity (ISAs)
  • Water soluble beta blockers
  • Cardio-selective beta blockers
27
Q

Explain ISA beta blockers?

A

ISA Beta Blockers have the ability to stimulate AND block adrenergic receptors.
ISAs cause less bradycardia and less
coldness of the extremities

28
Q

Examples of ISA beta blockers?

A

Acronym CAPO:

  • CELIPROLOL
  • ACEBUTOLOL
  • PINDOLOL
  • OXPRENOLOL
29
Q

Explain water soluble beta blockers?

A

Water soluble beta blockers are less likely to enter the brain, therefore, cause less sleep disturbance and less nightmares/vivid dreams.

30
Q

Examples of water soluble beta blocker?

A

Acronym CANS:

  • CELIPROLOL
  • ATENOLOL
  • NADOLOL
  • SOTALOL
31
Q

Explain cardio-selective beta blockers?

A

Cardio-selective beta blockers have less effect on the bronchial (B2) receptors, and therefore less effect on airway resistance.

32
Q

What are the cautions of beta blockers?

A
  • Diabetes
  • 1st degree AV block
  • In conjunction with diltiazem or verapamil (can cause heart block)
33
Q

Example of cardio-selective beta blockers?

A

Acronym BATMAN:

  • BISOPROLOL
  • ATENOLOL
  • METOPROLOL
  • ACEBUTOLOL
  • NEBIVOLOL
34
Q

What do B1 receptors and B2 receptors affects?

A

B1 receptors - heart
B2 receptors - lungs

Remember by 1 heart and 2 lung

35
Q

What are the conditions are beta blockers used for?

A
  • Hypertension
  • Angina
  • Myocardial Infarction
  • Arrhythmias
  • Heart Failure
  • Anxiety
  • Migraine Prophylaxis (propranolol)
  • Glaucoma (timolol, betaxolol)
  • Thyrotoxicosis
36
Q

What are the contraindications of beta blockers?

A
  • Asthma, COPD, bronchospasm
  • Marked bradycardia
  • 2nd and 3rd degree AV block
  • Uncontrolled heart failure
37
Q

What should be given for the initial treatment of VTE?

A
  • Use LWMH (such enoxaparin, dalteparin, tinzaparin) for the initial treatment.

Unfractionated heparin can be used as an alternative

  • Start oral anticoagulant (usually warfarin) at the same time as heparin.
38
Q

What are the red flags for tranexamic acid?

A

Colour vision change or visual impairment - DISCONTINUE IMMEDIATELY

Signs of VTE - Legs or arms painful and swollen; red and warm to touch, shortness of breath, sharp pain in chest

Coughing or coughing up blood

Anaphylactic reaction

Cardiovascular System (9 decks)

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