Lecture 9: DVT and PE's COPY Flashcards
Which 3 factors of the anticoagulant pathway regulate clot formation by preventing excess thrombin production?
Protein C and S and antithrombin
What are the components of Virchow’s triad?
- Venous stasis
- Endothelial damage
- Hypercoagulability
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What is the most common thrombophilic disorder; leads to what?
- Factor V Leiden mutation –> activated protein C resistance
- Results in protein C being unable to inactivate factor V and VIII, which leads to unregulated prothrombin activation
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What is a pro and con of using D-dimer in the assessment of DVT/PE?
- Pro = negative test makes DVT unlikely; simple to perform
- Con = positive test is not diagnostic of DVT; other conditions can elevate D-dimer
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What is considered the gold standard screening modality for DVT/PE in intermediate cases; what are some pros and cons of using it?
- CT pulmonary angiography (CT angiography)
- Pros: high sensitivity and specificity; accurate anatomy assessment
- Cons: requires contrast (allergies, AKI), expensive, radiation exposure, and may miss small peripheral clots
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What are the pros and cons of using ventilation/perfusion scans in the evaluation of DVT/PE?
- Pros: high sensitivity + inexpensive
- Cons: low specificity + may not demonstrate small sub-segmental defects
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What is the tx for factor V leiden mutation in pt with no prior episodes vs. prior episodes of thrombosis?
- No prior episodes: just observation; DVT prophylaxis and risk reduction
- Prior episodes: consider lifelong anticoagulation
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A mutation in the prothrombin gene at position G20210A causes what?
↑ levels of prothrombin that leads to excess thrombin formation
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In a patient whose clot does not respond to heparin therapy, which inherited thrombotic disorder should be suspected; why?
Antithrombin III deficiency; since heparin requires the presence of antithrombin because it enhances the activity of antithrombin
Why is the incidence of DVT of the upper extremities rising in incidence?
Secondary to ↑ use of indwelling venous catheters
The syndrome of DVT includes thrombosis in which 2 areas?
- Proximal leg veins
- Large veins of the upper extremities
If the D-dimer is positive or if the clinical likelihood of DVT is high which imaging modality should be used?
Duplex ultrasonography = excellent sensitivity and specificity
What is the most effective treatment for prevention of VTE in hospitalized pt’s with risk factors?
Pharmacologic prophylaxis
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Which agent is used most often for longer-term anticoagulation in pt with established DVT; describe how it’s administered and the guidelines that need to be followed?
- Warfarin
- Typically initiated w/ heparin and both used for minimum 5 days until INR = 2-3 for 2 measurements taken 24 hrs apart
What are some pros and cons of the newer anticoagulant agents, dabigatran, rivaroxaban, apixaban, and edoxaban?
- Oral, rapid onset, do not require monitoring or overlap w/ heparin; minimal interactions with foods and other meds
- Most cannot be used in pt’s w/ significant kidney failure