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IPC Cardiology 2 > Venous Thromboembolism VTE Prophylaxis (Treatment) > Flashcards

Venous Thromboembolism VTE Prophylaxis (Treatment) Flashcards

1
Q

Treatments for arterial clots
* CAD
* PAD
* Stroke

A

Antiplatelets

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2
Q

Treatment for Venous Clots
* DVT
* PE

A

Anticoagulants

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3
Q

VTE prophylaxis(Treatment Goal)

A
  • Treatment goal–> Prevent VTE from occuring in patients at high risk(usually the hospitalized ones)
  • Treatment–> Low dose anitcoagulants AND/OR mechanical prophylaxis
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4
Q

Hospitlalized patients

Calculate PADUA score

A

* Score< 4
1. Low risk of VTE
2. Generally does not require thromboprophylaxis
* Score >/- 4
1. Thromboprophylaxis is recommended for non-pregnant patients without contraindications(major bleeding,low platelets) who are > 18years

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5
Q

PADUA Sore and risk factors

A

* 3 Points
1. Active cancer
2. Previous VTE
3. Reduced Mobility
4. Known genetic hypercoaguable condition
* 2 Points
1. Recent trauma/ surgery (within 1 month)
*** 1 Point
**
1. >/- 70 years old
2. Cardiac or respiratory failure
3. Acute MI or ischemic stroke
4. Acute infection or rhematologic disorder
5. Obesity(BMI >/_ 30)
6. Hormonal Treatment

Score is TOTAL of the points (magic number for prophylaxis is 4!!)

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6
Q

Non-Pharmacologic Treatment for VTE

A
  1. Ambulation
  2. Graduated Compression stockings
  3. Sequential Compression Devices(SCDs)
  4. Inferior Vena Cava Filter
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7
Q

Pharmacologic Treament for VTE

A
  1. Heparin(SQ)—> 5,000 units q8-12H(BMI >/_ 40 Kg/m2: 7,500 units Q8-12H)
  2. Enoxaparin(SQ)–> 30 units BID OR 40 units daily
  3. Fondaparinux(SQ)–> 2.5mg daily

Approved for orthopedic surgery
* Rivaroxaban–> 10mg QD
* Apixaban–>2.5mg BID
* Dabigatran —->220mg QD

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8
Q

Special Populations:Malignancy

Applies ONLY to OUTPATIENTS

A
  • Int-High w/strong evidence—>Thromboprophylaxis should NOT be offered to all cancer outpatients
  • Int-High w/ Moderate evidence—-> High risk outpatienets with (Khorana score >/ 2) MAY offer thromboprophylaxis with apixaban, rivaroxaban,LMWH provided there are no sig risk factors for bleeding and no DIs
  • Int w/strong evidence—>Patients with multiple myeloma receiving **thalidomide-or lenalidomide-based regimens **w/ chemotherapy and/or dexamethasone should be offered pharmacologic thromboprophylaxis w/ either **aspirin or LMWH **for lower-risk patients and LMWH for higher risk patients
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9
Q

Khorana score

Used in cancer out patients ONLY

A

2 Points
1. Stomach and Pancreatic cancers
1 Point
1. Sites of cancer(lung, lymphoma,gynecologic,bladder,testicular,renal)
2. Prechemotherapy platelet count >/_ 350,000
3. Hemoglobin <10g/dL or use red cell growth factors
4. Prechemotherpay leukocyte count >11,000
5. BMI >/_ 35

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10
Q

What is appropriate for DVT treatment?

A

Anticoagulation

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11
Q

Guideline recommendations for DVT treatment choices

A
  • 2B–> pts w/ VTE and no cancer, we suggest dabigatran, rivaroxaban,apixaban, or edoxaban over vitamin K antangonist(VKA) therapy
  • 2C–> pts w/ VTE and no cancer who are not treated with dabigatran, rivaroxaban,apixaban, or edoxaban, we suggest VKA therapy over LMWH
  • 2B–> In pts with an **unprovoked proximal **DVT or PE who are stopping anticoagulant therapy and do not have a contraindication to aspirin, we suggest aspirin to prevent recuurent VTE
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12
Q

Guideline Recommendations :Treatment duration

A
  • 1B–>Patients with proximal DVT or PE: 3 months of anticoagulant therapy
  • 1B-2B–>In pts w/ an **unprovoked **VTE
    1. Low-moderate bleeding risk: **extended **anticoagulant therapy (no scheduled stop date)
    2. High bleeding risk: 3 months of anicoagulant therapy
  • 1B-2B–>In pts w/ DVT of the leg or PE and active cancer, we recommend **extended anticoagulant therapy ** (no scheduled stop date)
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13
Q

Bleed risk Assement(risk factors)

A
  • Age >65, >75
  • Previous bleeding
  • Cancer
  • Metastatic cancer
  • Renal failure
  • Liver failure
  • Thrombocytopenia
  • Previous stroke
  • Diabetes
  • Anemia
  • Antiplatelet therapy
  • Poor anticoagulant control
  • Comorbidity and reduced functional capacity
  • Recent surgery
  • Frequent falls
  • Alcohol abuse
  • NSAID use

  • Low risk: 0 risk factors
  • Moderate risk:1 risk factor
  • High risk: >/ risk factors
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14
Q

Distal DVT(Recommendations)

A

2C—> In pts w/ acute isolated distal DVT of the leg, we suggest **serial imaging of the deep veins for 2 weeks **unless there are w/ severe symptoms or risk factors for extension, then we suggest anticoagulation
* 1B—> In pts managed w/ anticoagulation, we recommend using the same anticoagulation as for patients with acute proximal DVT
* 1B-2C–> In pts w/ acute isolated distal DVT of the leg who are managed with serial imaging, we recommend no anticoagulation if the thrombus does not extend, suggest anticoagulation if the thrombus extends

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15
Q

Treatment recommendations for cancer patients w/ DVT

A
  • High, strong—> Initial anticoagualtion: may involve LMWH,UFH, fondaparinux, rivaroxaban, or apixaban. For pateints intiating treatment with parental anticoagulation,LMVH is preffered over UFH for the initial 5 to 10 days
  • High,strong–> Long-term anticoagulation: LMWH, edoxaban, or rivaroxaban for at least 6 months are preferred because of improved efficacy over vitaminK antagonists(VKAs). There is an increase in major bleeding risk with DOACs, particularly observed in GI and potentially genituurinary malignancies
  • Low, weak-Moderate–> Anticoagulation beyond the intial 6 months should be offered to select patients w/ active cancer, such as those w/ metastatic disease or those recieving chemotherapy
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16
Q

Pulmonary Embolism Treatment based on Classification

A
  • Low risk–> Therapeutic anticoagulation
  • Intermediate risk–>Anticoagulation, thrombectomy or catheter-directed thrombolytics, then therapeutic anticoagulation
  • High risk–>IV thrombolytics then therapeutic anticoagulation
17
Q

Thrombolytics

A
  • Alteplase–> non-specific w/ a half life of 5 mins, and dosing of bolus followed by infusion.
  • Tenecteplase–> specific to clot bound fibrin w/ half life of 90-130 minutes and dosing of 1 bolus.
18
Q

What are catheter directed thrombolytics?

A
  • CDT are used to break up clots
    These work by inserting catheter into clot(holes in catheter deliver medications and break up clot)

Medications used are: heparin and alteplase

19
Q

Types of CDT

A
  • Unifuse(w/out ulatrasound)
  • EKOS(w/ ultrasound)
20
Q

What is an EKOS?

EkoSonic endovascular system

A
  • Device to deliver catheter directed thrombolytics + ultrsound waves
  • MAY be more efficient at breaking up clots than CDT alone(w/out ultrasound)
21
Q

Guideline recommendations: treatment choices for PE

A

The SAME as DVT

22
Q

Guideline recommendations for treatment duration for PE

A

The SAME as DVT

IPC Cardiology 2 (6 decks)

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