Venous Thromboembolismus (VTE) disease

Question 1

DVT vs PE

Answer 1

-Thrombus inside the deep veins (often in the leg or pelvis) -> clot breakage results in traveling to other parts (such as lungs -> Pulmonary embolism)

-Pulmonary embolism (PE): thrombus with the vessels of the lungs -> typically secondary to a DVT-breaking part

Question 2

Symptom of DVT

Answer 2

-Unilateral pain and swelling of the leg (bilateral is possible) (blood clots can be seen with ultrasound)

-unilateral leg warmth

Question 3

Symptoms of PE

Answer 3

-sudden SOB
-+/- hypoxia (low O2 saturation)

Question 4

What are the types of Pulmonary Embolism?

Answer 4

Low risk: treat with Anticoagulants: Warfarin, Heparin, Lovenox, Apixaban

Submassive and massive: blockage of the heart -> Ischemia, hypoxia -> treat with thrombolytics

Question 5

Factors contributing (provoking) to clots

Answer 5

Virchow Triad

-Endothelial injury: Surgery, trauma

-Hypercoagulability: smoking, cancer, contraceptives, pregnancy, post-partum, inherited thrombophilia, diabetes

-Abnormal blood flow: long travel, immobility

Question 6

What is the dose of Apixaban for DVT and PE?

Answer 6

loading dose: 10 mg PO BID x 7d
-> then 5 mg PO BID
(2.5 mg BID in reduced-intensity anticoagulant phase)

Question 7

What is the dose of Rivaroxaban for DVT and PE?

Answer 7

loading dose: 15 mg PO BID x 21d
-> then 20 mg PO daily
(10 mg daily in reduced-intensity anticoagulant phase)

Question 8

PICO format

Answer 8

-a format that asks about
-Population
-Intervention
-Comparison
-Outcome

fe: does the class (population), who has class on Monday 4 PM (change time, intervention), retain more information (outcome) on Friday at 4 PM (comparison)

Question 9

Low-risk PE patients can be treated outpatient. True or False?

Answer 9

True

low-risk PE: no significant changes in oxygenation, do not require oxygen to maintain respiratory support

Question 10

Which drug class is recommended by the guidelines for patients with DVT and PE?

Answer 10

DOACS for patients with new VTE, DVT

Dabigatran (BRIDGING)
Edoxaban (BRIDGING)

Why does Dabigatran need bridging despite having a short onset of 1h???
could you use Apixaban or Xarelto for bridging??? -> it has never been studied

Apixaban
Rivaroxaban

Question 11

Which drug is preferred for treatment-phase therapy (cancer) with VTE?

Answer 11

Oral Xa inhibitors (Apixaban, Rivaroxaban) over LMWH (Enoxaparin, lovenox)

Question 12

Which drug should be used in patients with antiphospholipid syndrome?

Answer 12

Warfarin
INR goal: 2-3

(antiphospholipid syndrome: coagulopathy, immune response to phospholipids -> antibodies causing clots )

Question 13

What is the recommended duration of treatment for patients with VTE, DVT, and PE?

Answer 13

3 months of anticoagulant -> DOACS
(the greatest risk for the clot to occur is within 3 months)

after 3 months, consider extended-phase treatment

Question 14

What is recommended in patients diagnosed with VTE with no provocation (unprovoked clot)?

Answer 14

offer an extended-phase treatment (doesn’t have to treat)

in unprovoked DVT we don’t really know what caused it, so we don’t know if the risk factor is still present to cause another clot -> so we extend the therapy

no provocation: no factors that contribute to a clot: immobility, surgery, long travel, cancer, pregnancy, contraceptives

Question 15

Which drugs are recommended for extended-phase treatment? What dose?

Answer 15

-Apixaban (Eliquis) and Rivaroxaban (Xarelto)

reduce the full-treatment dose of Apixaban/Rivaroxaban to:

-Apixaban: 2.5 mg PO daily
-Rivaroxaban: 10 mg PO daily

Question 16

Which of the DOAC can be used in dialysis despite being cleared by the kidneys?

Answer 16

Apixaban

Question 17

Which of the DOACs has the lowest risk of causing bleeding?

Answer 17

Apixaban