Blood Clots

Question 1

What is a Venus Thromboembolism

Answer 1

Deep-vein thrombosis and pulmonary embolism which occurs as a result of thromboembolism in a vein.

Question 2

Name two methods of thromboprophylaxis

Answer 2

Mechanical- anti-embolism stockings that provide graduated compression. These should be worn day and night until he patient is sufficiently mobile.
Pharmacological- should start within 14 hours of admission to hospital or as soon as possible. This is only when VTE>Bleed risk

Question 3

VTE treatment

Answer 3

When offering anti-coagulation treatment take into account co-morbities and contra-indications.
First line for proximal DVT or PE is apixaban or rivaroxaban.
If these are unsuitable offer a low molecular weight heparin for at least 5 days then dabigatran etexilate or edoxaban.
If CrCl between 15-30ml/min follow locally agreed protocols.

Question 4

Name some key counselling points for anti-coagulants.

Answer 4

-Provide written advice on how to take the medication and for how long
-Possible side-effects, Interactions and monitoring requirements
-Advice on travel and on sports/managing bleed risk
-Patient alert card
-Advice on dental treatments
-When to seek medical advice

Question 5

Duration of anti-coagulant treatment for:
1) Confirmed unprovoked DVT or PE
2) After a provoked DVT or PE

Answer 5

1) Consider stopping after 3 months after discussion with the patient.
2) Consider stopping after 3 months if provoking factor is no longer present (3-6 months in those with active cancer).
These are reliant on the clinical course being uncomplicated. Patients should be given advice on the likelihood of recurrence and signs and symptoms to look out for.

Question 6

How often should we review long-term anti-coagulation use?

Answer 6

Yearly to assess general health, bleeding risk, risk of VTE recurrence and treatment preferences.

Question 7

What is a transient ischemic attack

Answer 7

Often described as a ‘mini stroke’.

Question 8

What is an Ischaemic stroke

Answer 8

Blood-clot formation preventing oxygen from reaching the brain

Question 9

What is an intracerebral haemorrhage

Answer 9

Where a blood vessel ruptures within the brain and causes bleeding within.

Question 10

Initial management of transient ischemic attack

Answer 10

Patients should immediately receive aspirin, those in which aspirin is contra-indicated despite use of a PPI should recieve another suitable anti-platelet. They should then receive treatment for secondary prevention.

Question 11

Initial management of Ischaemic stroke

Answer 11

Alteplase is reccomended in the acute treatment if administered within 4.5 hours of symptom onset and if intracranial haemorrhage has been ruled out. Treatment with apirin should commence within 24 hours of symptom onset (may add PPI).Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks.

Question 12

Why do we not treat hypertension in an ischemic stroke (except in a hypertensive crisis)

Answer 12

Can result in reduced cerebral perfusion.

Question 13

Long term management of Ischaemic stroke and transient ischemic attack

Answer 13

Anti-platlet- Long-term treatment with clopidogrel monotherapy is recommended in patients who presented with transient ischaemic attack or ischaemic stroke. If contra-indicated, aspirin should be used.
Lipid-lowering- A high-intensity statin (such as atorvastatin) should be initiated in patients not already taking a statin as soon as they can swallow medication safely, irrespective of the patient’s serum-cholesterol concentration.

Question 14

Intra-cerebral haemorrhage inniital management

Answer 14

Surgical intervention may be required to remove the haematoma and relieve intercranial pressure. Patients receiving anti-coagulation should have this treatment stopped and reversed. Patients with a blood pressure 150-220mmHg who don’t fit into any exclusion criteria should receive rapid BP lowering therapy.

Question 15

Long term management of Intra-cerebral haemorrhage

Answer 15

Specialist advice should be sought for patients with atrial fibrillation and those at a high risk of ischaemic stroke or cardiac ischaemic events, as aspirin and anticoagulant therapy are not normally recommended following an intracerebral haemorrhage.

Blood pressure should be measured and treatment initiated where appropriate, taking care to avoid hypoperfusion.

Statins should be avoided following intracerebral haemorrhage.

Question 16

Reversal agents of warfarin in haemorrhage/bleed event

Answer 16

Phytomenadione (vitamin K1)
see bnf for INR based doses

Question 17

What happens if you miss the dose of a DOAC

Answer 17

The anticoagulant effects of DOACs diminish 12 to 24 hours after the last dose is taken, therefore omitted or delayed doses could lead to a reduction in anticoagulant effect.

Question 18

Reversal agents of DOAC’s
1) Apixaban and Rivaroxaban
2) Dabigatran Etexilate

Answer 18

1) Andexanet alfa
2) Praxbind (idarucizumab)

Question 19

What are the four types of antiplatelet drug and how do they work?

Answer 19

1) Aspirin (irreverisble inhibitor of cyclo-oxygenase and blocks production of thromoxane)
2) Clopidogrel, prasugarel and ticagrelor (block platelet P2Y12 Receptor, preventing aggregation by preventing ATP binding)
3) Dipyridamole (this has both antiplatelet and vasodilatory properties. It is a phosphodiesterase III inhibitor, and suppresses cyclic AMP (cAMP) degradation, leading to increased cAMP in platelets and blood vessels, inhibiting aggregation)
4) Glycoprotein IIb/IIIa inhibitors (for example abciximab, eptifibatide, and tirofiban) block the binding of fibrinogen to glycoprotein IIb/IIIa receptors on the platelet.

Question 20

Main indications for antiplatelet treatment include?

Answer 20

The secondary prevention of atherothrombotic events in people with acute coronary syndrome (ACS), angina, peripheral arterial disease (PAD), and atrial fibrillation (AF) (although anticoagulants are usually used).
The secondary prevention of atherothrombotic events in people after myocardial infarction (MI), percutaneous coronary intervention (PCI), stroke, or transient ischaemic attack (TIA).

Question 21

Name the anti-platelet of choice in the following stable conditions.
1) Coronary heart disease
2) Cerebrovascular disease
3) Peripheral arterial disease

Answer 21

1) Aspirin 75mg OD
2) Clopidogrel 75mg OD
3) Clopidogrel 75mg OD

Question 22

Dual antiplatelet treatment is usually initiated in acute conditions.
1) Acute coronary syndrome
2) Elective PCI
3) Acute cerebrovascular disease

Answer 22

1) Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor
2) DAPT — aspirin with clopidogrel for 6 months
3) in some circumstances DAPT may be used, for example, for 3 - 4 weeks following TIAs or minor ischaemic strokes.

Question 23

What is the maximum dose of methotrexate when used with aspirin?

Answer 23

15mg Weekly

Question 25

Treating VTE in pregnancy

Answer 25

Carry out baseline blood tests (including full blood count, coagulation screen, urea and electrolytes, and liver function tests). Τhen, A low molecular weight heparin (LMWH) should be started immediately for suspected VTE (until VTE has been excluded) and be continued as maintenance treatment in patients with confirmed DVT or PE.

Question 26

How would you manage pain and swelling in a pregnant woman with VTE

Answer 26

In the initial management of a DVT, an elastic graduated compression stocking should be applied on the affected leg as an additional treatment to manage symptoms such as pain and swelling.