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Pulmonary > Venous Thromboembolism > Flashcards

Venous Thromboembolism Flashcards

1
Q

Prevention of Fatal PE

A
  1. Recognize patients at risk of VTE and institute prophylactic treatment
  2. Recognize and treat DVT to prevent PE
  3. Recognize first episode of PE and initiate therapy to prevent recurrent, fatal PE
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2
Q

DVT and PE

A
  • Most episodes of DVT begin in calf veins
  • Without anticoagulation, ~1/4 of calf vein DVTs progress to proximal (above the knee) DVT
  • Without anticoagulation, almost 1/2 of proximal DVTs progress to PE
  • Without Rx, ~1/3 of episodes of PE are fatal
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3
Q

Factors Leading to Venous Thrombosis

A

• Virchow’s Triad

– Venous trauma (endothelial injury)

– Stasis (abnormal blood flow)

– Hypercoagulability

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4
Q

Risk Factors for VTE

A

– History of VTE

– Hypercoagulability

– Immobility

– Congestive Heart Failure

– Cancer

– Advanced age

– Recent surgery

– Trauma

– Pregnancy

– OCA and estrogen (HRT) use

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5
Q

VTE Prophylaxis

A
    1. Early ambulation
    1. Sequential compression devices (SCDs)
    1. Anticoagulation

– Subcutaneous unfractionated heparin, low molecular weight heparin, or fondaparinux

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6
Q

Physical Examination

A
  • Only a difference in calf diameters was of potential value for ruling in DVT
  • Accordingly, further diagnostic testing is required to confirm or exclude the diagnosis of DVT

-ultrasound

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7
Q

Why is Diagnosis of PE so difficult?

A
  • The two most common symptoms of PE: dyspnea and chest pain have multiple other more common causes.
  • A given episode of PE may present as one of three different clinical syndromes
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8
Q

Three Steps to Diagnose PE

A
  • Step one: Suspect PE – In patients with chest pain, dyspnea or syncope: Are the clinical findings suggestive of one of the syndromes of PE?
  • Step two: Estimate probability of PE

– Apply one of the clinical prediction models: Wells or Geneva Model

• Step three: Confirm or R/O PE

– If D-Dimer is negative and probability is low or moderate: PE ruled out

– If chest CT is positive: Treat for PE

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9
Q

Syndromes of Acute PE

A
    1. Acute cor pulmonale*
    1. Acute, unexplained dyspnea
    1. Pulmonary infarction

*Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system.

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10
Q
A

Cor Pulmonale

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11
Q

Syndromes of Acute PE Acute Cor Pulmonale

A
  • Symptoms: shock, collapse, syncope
  • Exam: hypotension, distended neck veins
  • EKG: S1Q3T3 or incomplete RBBB
  • CXR: normal
  • ABGs: decreased pO2, decreased pCO2
  • Echocardiogram: severe right ventricular dysfunction
  • Differential DX: Acute Myocardial infarction (AMI)
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12
Q
A
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13
Q

Syndromes of Acute PE Acute Unexplained Dyspnea

A

• Symptoms

-Dyspnea +/- anxiety

• Physical Exam

-Tachypnea, clear lungs

• EKG

-Usually normal

• Chest X-ray

-Normal

• Blood gases

-Decreased pO2/pCO2

•Differential DX:

-CHF, hyperventilation

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14
Q

Syndromes of Acute PE Pulmonary Infarction

A

• Symptoms

– Acute pleuritic pain

– Dyspnea, +/- hemoptysis

• Physical Exam

– Tachypnea

– Crackles, wheezes or rub

• CXR

– consolidation in periphery of lung; may have pleural effusion

• EKG

  • normal

• ABG

  • pO2 and pCO2 may be decreased or may be “normal”

•Differential DX: Pneumonia

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15
Q
A
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16
Q

D-dimer For The Exclusion of PE

A
  • D-Dimer (fibrin fragments) measured by quantitative rapid ELISA test
  • Positive = > 500 ng/ml
  • Sensitivity for PE = 97%
  • Specificity for PE = 41%
17
Q

Diagnostic Pathways For Suspected PE

A
  • High probability by Wells or Geneva criteria: Proceed to chest CT
  • Low or moderate probability: Obtain D- dimer If D-dimer positive: chest CT If D-dimer negative: no therapy
18
Q

Ventilation/Perfusion (VQ) Scans As Substitute For Chest CT

A
  1. Pregnant or women in child-bearing age
  2. Patients with normal or near-normal chest x-ray
  3. Abnormal renal function—risk of contrast media with chest CT-angiogram
19
Q

Treatment of Acute PE

A

“Prophylactic” Treatment

  • Anticoagulation
  • Inferior vena caval interruption Definitive Treatment
  • Thrombolytic therapy
  • Pulmonary embolectomy
  • Patients with acute PE who are hemodynamically stable will survive if further episodes of PE are prevented.
  • They require prophylactic therapy with anticoagulants (or IVC interruption if unable to anticoagulate)
20
Q

Treatment of Acute PE Anticoagulant Therapy

A

• LMW heparin or fondaparinux

– 5 days of therapy followed by warfarin

• February 2016 guidelines

– NOACs preferred over warfarin

– Dabigatran, rivaroxaban, apixaban, edoxaban

21
Q

New Oral anticoagulants Direct Thrombin Inhibitors (DTIs) and Factor Xa Inhibitors

A

• Advantages over warfarin

– Monitoring not needed

– Fixed dose

– More rapid onset/offset

– Wider therapeutic index/Less intracranial hemorrhage

• Disadvantages

– More expensive

– Antidotes? (idarucizumab, andexanet)

– Degree of anticoagulation

22
Q

Treatment of Acute PE Duration of Oral Anticoagulant Therapy

A

• Three Months

– Pts with a transient (reversible) risk factor for VTE

– “Provoked” versus “unprovoked” VTE

• Three Months or Long Term

– Patients with unprovoked (idiopathic) VTE

• Long Term

– Cancer patients (until cancer has resolved)

– Second episode of unprovoked VTE

23
Q

Contraindications To Thrombolytic Therapy

A
  • Major internal bleeding within 6 months
  • Intracranial disease
  • Recent operation or organ biopsy
  • Occult blood on stool examination
  • Severe uncontrolled hypertension
  • Severe hepatic or renal impairment
  • Pregnancy or lactation
24
Q

Treatment of VTE: IVC Filters

A

• Major indication

– Contraindication to anticoagulation

• Others indications controversial

25
Q

Treatment of PE Complicated by Shock

A

Approximately 5-10% of PE patients develop shock. Their mortality with anticoagulant therapy is approximately 30%. In addition to anticoagulation, PE patients in shock should receive one of the three following therapies:

  1. THROMBOLYTIC THERAPY with r-tPA (recombinant tissue plasminogen activator) may be considered in patients who have no contraindications to thrombolytic therapy. The major complication is severe bleeding. Intracerebral hemorrhage occurs in 2-3% of patients.
  2. PULMONARY EMBOLECTOMY - This can be considered in a hospital that is staffed to perform emergency cardiac surgery. The ideal candidate is a young patient without associated heart or lung disease who has a contraindication to thrombolytic therapy.
  3. CATHETER FRAGMENTATION OF EMBOLI - there are case reports that this may be beneficial in some patients. Some combine this with thrombolytic therapy.

Pulmonary (29 decks)

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