6: DVT and pulmonary embolism

Question 1

DVT and PE are collectively known as ___ ___ disease.

Answer 1

venous thromboembolic

Question 2

In DVT, thrombi form in venous __ pockets.

Answer 2

valve

Question 3

What is a DVT?

Answer 3

Formation of a thrombus within the lumen of the vessels which make up the deep venous system

Question 4

Where are distal DVTs found?

Answer 4

In the calves (anywhere below the popliteal vein)

Question 5

Where are proximal DVTs found?

Answer 5

At or above the popliteal vein

Question 6

Venous thromboembolic diseases like DV and PE are strongly associated with ___.

Answer 6

cancer

Question 7

The biggest risk factor for thromboembolic disease is __ __.

Answer 7

major surgery

Question 8

Which genetic condition increases your thrombophilia?

Answer 8

Factor V Leiden

Question 9

Thromboembolic disease can be divided into those which are ___ and un___.

Answer 9

provoked , unprovoked

Question 10

If you have had a thrombus, you (are / aren’t) likely to have another one.

Answer 10

are

Question 11

Which GI condition increases the likelihood of developing DVT/PE?

Answer 11

Crohn’s disease

Question 12

What is the clinical presentation of PE?

Answer 12

Breathlessness

Pleuritic chest pain

Haemoptysis

Collapse

Question 13

What is the clinical presentation of DVT?

Answer 13

Red, hot, swollen calf/calves

Question 14

What is post thrombotic syndrome?

Answer 14

A pain/dysfunction syndrome affecting mainly the legs

Question 15

Why do people get post thrombotic syndrome after DVT treatment?

Answer 15

Valve has been removed - pressure in deep venous system increases and damages further valves

Question 16

What is the clinical presentation of post thrombotic syndrome?

Answer 16

Pain

Oedema

Hyperpigmentation

Eczema

Varicose veins

Ulcers

Question 17

What is a chronic complication of PE?

Answer 17

Chronic thromboembolic pulmonary hypertension

Question 18

What is a consequence of chronic thromboembolic pulmonary hypertension (CTEPH)?

Answer 18

Right heart failure

Question 19

What is the initial presentation of CTEPH, a complication of PE?

Answer 19

Progressive breathlessness, hypoxaemia and death

Question 20

What can be used instead of massive tests to estimate someone’s probability of DVT?

Answer 20

Pre-test probability scores

Question 21

What test is used to exclude DVT?

Answer 21

D-dimers (good rule out test, rubbish rule in test)

High = no DVT

Low = maybe DVT

Question 22

What investigation involves compressing veins to rule out DVT?

Answer 22

Ultrasound

If pressure upstream is high (due to blockage) then vein won’t compress very well

Question 23

D-dimers are produced upon breakdown of __.

This gives an indication of the extent of ___.

Answer 23

fibrin

fibrinolysis (clot breakdown)

Question 24

look over d-dimers again

Question 25

Which two scores can be used to estimate the likelihood of PE?

Answer 25

Wells score Geneva score

Question 26

What is the gold standard investigation for diagnosing PE?

Answer 26

**CT pulmonary angiogram**

Question 27

In PE, chest x-rays are usually \_\_\_. What may you see on a chest x-ray indicating PE?

Answer 27

normal **Wedge-shaped infarctions**

Question 28

Which type of scan may you want to do to check for PE in a pregnant woman, where you want to limit radiation dosage to her and the foetus?

Answer 28

**V/Q scan** (usually perfusion only)

Question 29

Which pharmacological interventions are used to treat DVT & PE?

Answer 29

**ANTICOAGULATION** (WARFARIN / *RIVAROXABAN*) ## Footnote **THROMBOLYSIS** **ANALGESIA**

Question 30

Name two mechanical interventions which can be used to treat DVT & PE.

Answer 30

**Compression stockings** **IVC filters**

Question 31

Does an IVC filter block out all clots?

Answer 31

No

Question 32

Which conditions would DVT/PE patients be screened for?

Answer 32

**Cancer** (only if red flag symptoms are met e.g blood in stool, unexplained weight loss) **Thrombophilia**

Question 33

look at nice guidelines for dvt/pe treatment

Question 34

What is an advantage of warfarin over new drugs (e.g rivaroxiban)?

Answer 34

Warfarin anticoagulation can be reversed with Vitamin K

Question 35

What is an advantage of new anticoagulant drugs e.g rivaroxiban?

Answer 35

Act predictably Large therapeutic windows Few interactions

Question 36

What is a disadvantage of new anticoagulant drugs (e.g rivaroxiban)?

Answer 36

Irreversible (i.e no antidote if you overdo it) but not much of a problem

Question 37

What are the two main NOACs used in DVT/PE?

Answer 37

**Apixaban** **Rivaroxaban** (Also dabigatran and edoxaban but these are rarely used.)

Question 38

What do **rivaroxaban** and **apixaban** inhibit?

Answer 38

**Factor Xa** | (forms thrombin from prothrombin)

Question 39

**Rivaroxaban** is (**safer / more dangerous**) than warfarin.

Answer 39

safer

Question 40

In treatment of DVT/PE, the risk of ___ has to be balanced with the risk of death by \_\_\_.

Answer 40

**haemorrhage** **the embolic disease itself**

Question 41

In people with cancer-associated clotting, __ is the first line treatment.

Answer 41

**fragmin**

Question 42

phlegmasia