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PHRM844 > VTE > Flashcards

VTE Flashcards

1
Q

Venous thrombi

A

Composed of RBC, fibrin, and some platelets
Mostly RBCs

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2
Q

VTE symptoms present when

A

Flow is obstructed
Vasc tissue is inflammed

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3
Q

DVTs and PEs

A

All PEs come from DVTs
Not all DVTs lead to PEs

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4
Q

Virchow’s triad

A

Conditions that increase clotting risk
Hypercoagulable state
Endothelial injury
Circulatory state

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5
Q

Hypercoagulable state

A

Abnormal clotting components
Ex. pregnancy, cancer

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6
Q

Endothelial injury

A

Abnormal surfaces in contact with blood flow
Ex. post-op, traumatic injury

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7
Q

Circulatory stasis

A

Abnormal blood flow
Ex. long period of immobility, hospitalization

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8
Q

Coagulation cascade overview

A

Cascade initiates -> increases production of thrombin -> results in clot formation

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9
Q

Factor II

A

Prothrombin

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10
Q

Factor IIa

A

Thrombin

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11
Q

Postthrombotic syndrome

A

Long-term complication of DVT
Caused by damaged venous valves
Pigmentation and skin hardening

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12
Q

DVT risk factors

A

Age > 40 years
HF, MI
Obesity
Pregnancy
Immobilization > 10 days

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13
Q

DVT non-pcol treatment

A

Bed rest w anticoag prn
Elevate feet
Pain management
Compression stockings

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14
Q

PE non-pcol treatment

A

Oxygen
Mechanical ventilation
Compression stockings

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15
Q

Ideal anticoagulant

A

Oral
Once daily dosing
Quick onset
Limited monitoring and drug interactions
Available and effective antidote
Wide therapeutic index
Low cost

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16
Q

UFH

A

Rapid parenteral anticoag
Variable response -> incr aPTT monitoring

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17
Q

Heparin associated thrombocytopenia (HAT)

A

Non-immune mediated
Mild platelet decrease
48-72 hours post-admin
Don’t need to d/c heparin

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18
Q

Heparin induced thrombocytopenia (HIT)

A

Immune mediated
7-14 days post-admin
Platelet decrease > 50% or to < 100,000 mm3

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19
Q

HIT management

A

Stop all heparin products
Give alt anticoag
Don’t give platelet infusions
Don’t give warfarin until platelet > 150,000

20
Q

LMWH vs UFH

A

LMWH usually preferred
Better bioavailablility
Predictable dose response
Longer half life -> less freq dosing
Less risk HIT

21
Q

Injectable FXa inhibitors and DTIs

A

Fondaparinux : prophylaxis and tx
- Don’t use if renal dysfunction
- Can be used in HIT
Lepirudin: HIT tx
Bivalirudin: HIT tx, alt to UFH during PCI
Argatroban: HIT tx

22
Q

Warfarin available forms

A

Coumadin, Jantoven, warfarin
1, 2, 2.5, 3, 4, 5, 6, 7.5, 10mg tablets

23
Q

Warfarin MOA

A

Inhibit vitamin K formation and dependent clotting factors (FII, VII, IX, X, Protein C and S)

24
Q

Test before warfarin if

A

Warfarin naïve AND
Results available before sixth dose AND
Pt at high risk of bleeding w high INR

25
Q

Drugs that incr INR w warfarin

A

Erythromycin
Anabolic steroids
Metronidazole
Bactrim
Ciprofloxacin
Acute alcohol use

26
Q

Drugs that decr INR w warfarin

A

Rifampin
Carbamazepine
Chronic alcohol ingestion
Extreme Vit K ingestion

27
Q

Antiplatelets in VTE

A

Limited role
ASA if CHA2DS-VASc score = 1
Dipyridamole w warfarin if prosthetic heart valves
Adjunct w anticoags and incr bleeding risk

28
Q

Bleeding management

A

Discontinue meds
Manual compression
Maintain BP
Surgical or radiological intervention
BP products ± PCC ± targeted antidote

29
Q

Bleeding targeted reversal

A

UFH, LMWH: protamine sulfate
Dabigatran: idarucizumab
FXa inhibitors: andexanet alfa

30
Q

Bleeding w warfarin

A

INR 4.5-10 + no bleeding -> avoid vit K
INR > 10 + no bleeding -> PO vit K
Major bleeding -> PCC pref to FFP

31
Q

VTE prophylaxis

A

UFH, LMWH, FXa inhibitors, Vit K antagonists

32
Q

VTE: low risk

A

< 10%
No specific pcol tx recommended

33
Q

VTE: moderate risk

A

10-40%
Most non-orthopedic surgeries
- UFH, LMWH, fondaparinux
Acute illness
- UFH, LMWH, fondaparinux, rivaroxaban, betrixaban

34
Q

VTE: high risk

A

40-80%
Orthopedic surgery
- LMWH, fondaprinux, rivaroxaban, apixaban, dabigatran (hip), UFH, vit K antagonist
Major trauma or spinal cord injury

35
Q

CHA2DS2-VASc measures

A

Risk factors for stroke or systemic VTE
ONLY w afib pts

36
Q

HAS-BLED measures

A

Risk factors for bleeding

37
Q

CHA2DS2-VASc factors

A

CHF: 1
HTN: 1
Age ≥ 75 years: 2
Diabetes: 1
Stroke: 2
Vascular disease: 1
Age 65-74 years: 1
Female: 1

38
Q

HAS-BLED factors

A

HTN: 1
Abnormal renal/liver funct: 1 or 2
Stroke: 1
Bleeding risk: 1
Labile INR: 1
Age > 65 years: 1
Drugs or EtOH: 1 or 2

39
Q

Dabigatran approved indications

A

Hip prophylaxis
Non-valvular afib
DVT/PE tx

40
Q

Rivaroxaban approved indications

A

Post-op prophylaxis
Non-valvular afib
DVT/PE tx - 1st line
Secondary prevention of repeat DVT/PE
VTE prophylaxis - usually in-pt use

41
Q

Apixaban approved indications

A

Post-op prophylaxis
Non-valvular afib
DVT/PE tx - 1st line
Secondary prevention of repeat DVT/PE

42
Q

Edoxaban approved indications

A

Non-valvular afib (adjust w renal impair)
DVT/PE tx

43
Q

Warfarin dosing

A

Initial dose: 5mg po q1d
Healthy outpt dose: 10mg po q1d x2d
Bridge w UFH/LMWH/Xa for ≥ 5 days AND until INR is therapeutic (~2-3)

44
Q

Recommended INR goals

A

2.5-3.5
- Mechanical heart valve (mitral, caged ball, high risk)
2-3
- VTE prophylaxis
- VTE/PE tx
- Systemic embolism prophylaxis
- Mechanical heart valve (aortic)
1.5-2
- Mechanical On-X

45
Q

Five D’s when interviewing pt

A

Drugs
Diseases
Doses
Diet
Drinking

46
Q

Bridging procedure w warfarin

A

Done w invasive procedures
Stop warfarin 5 days before surgery
Give LMWH or UFH until surgery
- Stop LMWH 24 hrs before
- Stop UFH 4-6 hrs before
Resume warfarin 12-24 hrs post-op

PHRM844 (16 decks)

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