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Haemotology > VTE + anticoagulation > Flashcards

VTE + anticoagulation Flashcards

1
Q

What is a distal DVT

A

Popliteal vein - behind knee or below

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2
Q

What is a proximal DVT

A

Above the popliteal

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3
Q

Sites of a PE

A

Central #Segmental
Sub segmental

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4
Q

COmplications of PE

A

Post thrombotic syndrome
Pulmonary HPTN -> cor pulmonale
Psychological - stress, anxiety et c

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5
Q

Risk factors PE

A

Cancer
Pregnancy + 6 weeks PP
Surgery - over 30 mins
Fracture, esp if immobile/cast
Flight >4 hours
Recent hospitalisation
Hormone therapy - COCP, HRT
Immobility>3 dyas

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6
Q

How to rule out DVT

A

Low wWells score + negative D dimer

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7
Q

What is the problem with D dimer

A

High prevalence groups may have negative D dimer and PE

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8
Q

When is active phase

A

4 weeks after initial
Treatment prevents -> PE or extension of clot

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9
Q

Contraindication for DOACs

A

Impaired renal function, extreme weights, elderly

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10
Q

What are LMWH particuarly good for

A

Stopping and starting - immediate effet
eg tinzaparin

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11
Q

What drug do you use for a goal INR of 3-4

A

Warfarin

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12
Q

What anticoag use in severe renalimpairment

A

Warfarin

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13
Q

What drug more likely cause ICH and is reversible

A

Warfarin

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14
Q

What are clots like in heparin induced thrombocytopenia?

A

Platelet rich white clot (more common arterial disease)

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15
Q

Do you treat sub segmental PE

A

If symptomatic yes #If not detabatable

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16
Q

What is budd chiari syndrome

A

Thrombosis of hepatic veins which drain liver -> culminant hepatitis liver failure

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17
Q

What is portal vein thrombosis

A

Clot in portal veins, bring blood from GI tract into liver - 1/3 of hepatic nutrients/O2

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18
Q

What causes upper limb clots

A

In the upper extremity, 40-80% of clots are related to central venous catheters, and 4% are related to anatomic thoracic outlet obstruction/tight space between subclavian and 1st rib.

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19
Q

Massive eg illiofemoral DVT presentation

A

phlegmasia cerulea dolens (venous gangrene, cyanosis, arterial compromise).

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20
Q

What is pleuritic chest pain

A

i.e. sharp, localized, worse when taking a deep breath, persistent;

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21
Q

Why repeat US in one week for DVT

A

Check for signs of extension/embolisation as often within one week

22
Q

Wells categories DVT

A

1 bedridden > 3day or major surgery past 4 weeks
1 cast/immobilization lower extremity
1 active cancer or cancer treatment past 6 months
1 swelling of entire leg
1 collateral veins
1 tenderness along deep veins
1 pitting oedema greater in symptomatic leg
1 calf swelling >3 cm diameter at 10 cm below tibial tuberosity
-2 alternative diagnosis more likely than DVT

23
Q

Management dependent on Wells

A

-2-0 = low probability
1-2 = moderate probability
>2 = high probability
low or moderate probability: if D-dimer negative, DVT excluded; if D-dimer +, proceed to
compression U/S
high probability: Proceed to U/S. If U/S negative or inconclusive, repeat in 1 week or
consider MRV/venography.

24
Q

Wells categories for PE

A

3.0 – signs/symptoms of DVT
3.0 – alternative diagnosis less likely (to me, practically this often means hypoxaemia
with a clear CXR)
1.5 – previous DVT/PE
1.5 – tachycardia
1.5 – immobilization/plaster cast/surgery past four weeks
1.0 – haemoptysis
1.0 – active malignancy

25
Q

Managemnt depending on Wells score PE

A

> 4 = PE likely need CTPA or V/Q
≤ 4 = PE unlikely
- if D-dimer positive, CTPA or V/Q
- if D-dimer negative, PE excluded

26
Q

Investigations lower DVT

A

Compression US +/-doppler
Venography gold standard but rarely done

27
Q

What investigation for isolated iliac vein thrombosis in pregnancy

A

MR venogram

28
Q

Options for treating VTE

A

1) DOACs: rivaroxaban, dabigatran, apixaban
2) LMWH
3) Warfarin
4) IV UFH
5) Others- fondaparinux

29
Q

Minimum duration for heparin therapy

A

5 days AND therapeutic INR x 48 hours

30
Q

Thrombolysis indications in VTE

A

Massive PE (with hypotension)
DVT w plegmasia cerulea dolens
Clinical evidence of RHF eg raised JP, unable to ambulate

31
Q

MOA of unfractionated heparin

A

IIa and Xa binds, 30-60 min onoset of action, immediate if IV

32
Q

Dosage TE treatment UFH in hosptial

A

80 U/kg IV bolus followed by a rate of 18 U/kg/hour (follow UFH levels)

33
Q

What Creatinine clearance is dangerous for LMWH use?

A

<20/30ml/min

34
Q

VTE prophylaxis with LMWH

A
  • VTE prophylaxis
     Dalteparin: 5,000 U SC OD
     Enoxaparin: 40 mg SC OD or 30 mg SC BID. If >100kg, 60 mg SC OD
     Tinzaparin: 35-55 kg: 3500 U SC OD, 56-100 kg: 4500 U SC OD
35
Q

VTE treatment with LMWH

A
  • VTE treatment
     Dalteparin: 200 U/kg SC OD or 100 U/kg SC BID
     Enoxaparin: 1.5 mg/kg SC OD or 1 mg/kg SC BID
     Tinzaparin - 175 U/kg SC OD
36
Q

Monitoring on LMWH

A

CBC and CrC
Not routinely required unless obese, renal dysfunction, unexplained bleeding, breakthrough thrombosis, regnancy

37
Q

Common indications for warfarin

A

Stroke prevention AF
Long term secondary prevention of VTE
Prevention of thrombosis or systemic embolisation in patients with mechanical heart valves

38
Q

Metabolism of warfarin

A

CYP450

39
Q

Renal concerns with warfarin

A

No need to cahnge dose
CKD can increase bleeding risk

40
Q

What INR goal for patients with mechanica heart vlave

A

INR 2.5-3.5

41
Q

Complications of warfarin treatment

A

Warfarin skin necrosis
Purple toe syndrome
Tetraogenic in first trimester - crosses placenta

42
Q

What is apixaban

A

Xa inhibitor

43
Q

Half life and onset of apixaban

A

12 hour half life (longer in elderly)
Rapid onset of action 30 mins with peak effect at 3-4 hours

44
Q

Metabolism of apixabam

A

CYP3A4 and P-gp substrate

45
Q

Whaat drugs avoid with apixaban

A

CYP3A4 inhibitors - increase serum concentration of apixaban
CYP3A4 inducers - decrease

46
Q

Dosing of apixaban

A
  • VTE treatment: 10mg PO BID for 7 days, then 5mg PO BID (does not require initial heparin or LMWH)
  • Reduction in risk of VTE recurrence: 2.5mg PO BID after at least 6 months of treatment
  • VTE prophylaxis: 2.5mg PO BID, start 12-24 hours post-op if hemostasis achieved
  • Atrial fibrillation: 5mg PO BID or 2.5mg PO BID if 2 out of 3 of the following – Age ≥ 80 years, weight ≤ 60kg or serum creatinine ≥ approximately 133 μmol/L
47
Q

Renal adjusments with apixaban

A

Dose adjust in mild to mod renal impairment
Not recommended if severe eg CrCl <25ml/min

48
Q

Liver CIs with apixaban

A

ALT/AST 2-3x upper limit
Bilirubin >1.5 x ULN

49
Q

Dabigatran MOA

A

Direct thrombin inhibitor

50
Q

Onset of dabigatran

A

T½ approximately 8-12 hours (prolonged in elderly); Rapid onset ofaction 30 minutes with peak effect at 2 hours;

51
Q

Can you use other CYP enzyme metabolised drugs with dabigatran

A

Yes - not metabolised by them

52
Q
A

Haemotology (19 decks)

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