Venous Thromboembolism Flashcards by Lauren Ames

virchow’s triad

venous stasis
venous endothelial injury
hyper-coagulability

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gold standard for diagnosis VTE. Only test that can detect proximal and distal

venography

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this test is only sensitive for proximal DVT. It is non-invasive and measures blood flow following occlusion

impedance plethysmography

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this test is non-invasive and measures the rate of blood flow from the reflection of sound waves off RBCs

doppler U/S

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combines doppler with real time B-mode U/S to give better sensitivity and specificity of detecting proximal DVTs

duplex U/S

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this test has high sensitivity but low specificity. You can rule out DVT if normal, but cant rule-in if elevated

d-dimer

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If non-invasive tests are negative and you suspect a PE, what should you do?

V/Q scan

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objectives for DVT treatment

prevent development of PE
prevent postphlebitic syndrome
reduce mortality
minimize adverse events and costs

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this drug blocks the synthesis of thromboxane A2 from arachidonic acid by inhibiting cyclooxygenase

aspirin

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ADRs include bronchospasm and GI hemorrhage

aspirin

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contraindications include children under 12, breast feeding, hemophilia, PUD, and known hypersensitivity rxn

aspirin

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this drug is combined with aspirin to make aggrenox

dipyrdamole

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this drug causes inhibition of phosphodiesterase that hydrolyzes cAMP. Increase in cAMP causes decreases tA2 synthesis and thus platelet aggregation

dipyrdamole

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used to prevent thrombosis

aggrenox

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used with prosthetic mechanical valves in combo with warfarin and is an alternative to exercise in thallium myocardial perfusion imaging

dipyrdamole

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ADRs- HA, GI bleed, hypotension

dipyrdamole

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caution in pts with hypotension and in pts with serious CAD

dipyrdamole

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this drug block ADP-induced platelet-fibrinogen and platelet-platelet binding

ticlopidine

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indicated for prevention of repeat stroke or TIA and in coronary artery stinting

ticlopidine

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contraindicated in pts with severe liver dysfunction, thrombocytopenia, neutropenia, PUD, and internal bleeding

ticlopidine

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interacts with cimetidine, digoxin, theophylline, and red clover

ticlopidine

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ADRs include bleeding, N/V/D, thrombocytopenia, neutropenia, pancytopenia, nephrotic syndrome, and dark colored urine

ticlopidine

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this drug inhibits activation of glycoprotein IIb/IIIa receptor on the surface of platelets, which is required for aggregation to occur

clopidogrel

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indicated for secondary prevention of CV and cerebrovascular events and in patients allergic to aspirin

clopidogrel

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ADRs include hemorrhage, abdominal discomfort, and N/V

clopidogrel

this drug is safer than ticlopidine and is often added to ASA to obtain better platelet inhibition

clopidogrel

an antibody fragment directed toward the GP IIb/IIIa receptor of platelets. Binding and blocking the receptor prevents platelet aggregation

abciximab

indicated to prevent ischemic cardiac complications in patients undergoing percutaneous coronary intervention. Short term prevention of MI in patients with unstable angina

abciximab

these two drugs work like abciximab but are peptide fragments. They are potentially antigenic and should only be used once

tirofiban and eptifbatide

work by inhibiting the action of coagulation factors or interfere with the synthesis of coagulation factors

anticoagulants

binds to antithrombin III and accelerates inactivation of coag factors. AT III is an anticoagulant (inhibits binding of fibrinogen to thrombin)

heparin

binds to thrombin, inactivating its activity

heparin

binds and inhibits factor Xa (which converts prothrombin to thrombin)

heparin

this drug complexes with antithrombin III and inactivates factor Xa but does not bind as well to thrombin

LMWH

indicated for DVT, PE. Coronary artery pr-thrombosis after thrombolytic therapy

heparin

can be used in pregnancy- does not cross placenta

heparin

indicated for DVT/PE, unstable angina, and MI

LMWH

in order to treat someone with this, make sure they have a stable proximal DVT or PE, normal vital signs, low bleeding risk, no renal insufficiency, and monitoring system

heparin and LMWH

contraindicated in hemophilia, thrombocytopenia, PUD

heparin/LMWH

ADRs: bleeding (esp in those >70, recent surgery or trauma, use of ASA or NSAIDs, and renal failure)

heparin/LMWH

antidote for heparin (and sort of for LMWH)

protamine

this can occur in 3% of UFH treated patients. It is associated with arterial or venous thrombosis and causes a drop in platelet count >50%

heparin induced thrombocytopenia (HIT)

complications of this include DVT, PE, MI, stroke, TIA, and end organ damage

HIT

treat HIT

D/C UFH use DTIs (argotroban or lepirudin) initiate warfarin once platelets are okay

ADR includes osteoporosis

heparin (less with LMWH)

monitor: baseline aPTT, PT/INR, and CBC along with signs and symptoms of bleeding

heparin

monitor: aPTT, PT/INR, CBC, and SrCr along with anti factor Xa activity

LMWH

this drug prevents DVT following orthopedic surgery. It requires cofactor of antithrombin III for activity

fondaparinux

this drug is indicated in prevention of DVT in patients undergoing knee or hip replacement. Also used in stroke and systemic embolism prophylaxis in patients with non-valvular afib

rivaroxaban

indicated for DVT prophylaxis in patients post hip and knee replacement- dont give if CrCl <15 or severe liver failure

apixaban

reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fib. Can inhibit both free and clot-bound thrombin

dabigatran

binds selectively and reversibly to the catalytic site of thrombin as a competitive inhibitor- can inhibit clot-bound thrombin

argatroban

short half life. Used in heparin induced thrombocytopenia with and without thrombosis, ischemic stroke, hemodialysis, PCI. NO antidote

argatroban

derived from the leech, these two drugs inactivate thrombin

desirudin and lepirudin

indicated in patients with heparin induced thrombocytopenia. Prophylaxis of DVT in patients undergoing hip and knee replacement

hirudins

contraindicated in active bleeding and renal or hepatic impairment

hirudins

ADRs hemorrhage and hypersensitivity

hirudins

vitamin K antagonist. Blocks the reduction of vitamin K epoxide (necessary for clotting factors II, VII, IX, X)

warfain

half life for clotting factors

II- 60 hours VII- 6 hours IX- 24 hours X- 40 hours

used in acute MI, DVT, PE, afib, rheumatic disease, prosthetic heart valves, hip or knee replacement patients

warfarin

contraindicated in central thrombosis, peptic ulcer, pregnancy

warfarin

ADRs- bleeding and skin necrosis

warfarin

treat bleeding induced by warfarin

vitamin K

monitor PT/INR, aPTT, CBC, LFTs UA and fecal occult signs and symptoms of bleeding

warfarin

this class turns plasminogen into plasmin, which cleaves fibrin and lyses thrombi

thrombolytic agents

someone had an MI how do you administer throbolytic agent

intracoronary

used in acute MI, massive or submassive PE, heparin tx failures, extensive proximal DVT

thrombolytic agents

ADRs include hemorrhage and reperfusion arrhythmias

thrombolytic agents

contraindicated in recent surgery, CVA within 2 months, recent needle puncture, active bleeding, uncontrolled HTN, malignancy, pregnancy, CPR

thrombolytic

enzyme that catalyzes the conversion of tissue plasminogen to plasmin in the presence of fibrin. Fibrin specifically produces local fibrinolysis in the area of a recent clot with limited systemic proteolysis

alteplase

indicated for acute MI, PE, acute ischemic stroke

alteplase

ADRs include bleeding, arrhythmias, N/V, cardiac arrest, stroke, thromboembolism

alteplase

this drug forms a complex with plasminogen to convert the active enzyme plasmin, hydrolyzes fibrin plugs, and catalyzes the degradation of fibrinogen 7 clotting factors V and VII

streptokinase

indicated for life threatening DVT, PE, arterial thromboembolism, and acute MI

streptokinase

ADRs include N/V, bleeding, and antigenic reactions (allergic)

streptokinase

DVT/PE prevention: total hip replacement

LMWH, warfarin, factor Xa inh

DVT/PE prevention: total knee replacement

LMWH, warfarin, factor Xa inh, +/-IPC

DVT/PE prevention: hip fracture surgery

factor Xa inh, LMWH, warfarin, LDUH

DVT/PE prevention: trauma

LMWH, IPC or ES in LMWH C/I

DVT/PE prevention: general med (CHF, COPD) or bedrest and >1 RF

LDUH, LMWH, fondaparinux