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1- Foundation year Cardiovascular > Blood clots > Flashcards

Blood clots Flashcards

1
Q

What are the two types of venous thromboembolism?

A

-deep vein thrombosis
-pulmonary embolism

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2
Q

what is a deep vein thrombosis?

A

a blood clot occurs in a deep vein, usually in calf of one leg

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3
Q

what is a pulmonary embolism?

A

detachment of blood clot which travels to the lungs and blocks the pulmonary artery

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4
Q

what is included in a VTE risk assessment?

A

-immobility
-obesity BMI >30
-Malignant disease
-60+ years
-history of VTE
-HRT/combined contraception
-varicose veins with. phlebitis
-pregnancy
-critical care
-significant co-morbidites

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5
Q

what can increase risk of bleeding?

A

-thrombocytopenia
-acute stroke
-bleeding disorders acquired: liver failure inherited: haemophilia, von willebrands disease
-anticoagulants
systolic hypertension

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6
Q

what is a type mechanical VTE prophylaxis?

A

-compression stockings
for patients schedule for surgery continued until sufficiently mobile

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7
Q

When is pharmacological VTE prophylaxis needed?

A

-for high risk patients undergoing surgery or patient’s admitted to hospital as general medical.

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8
Q

what the different types of parenteral anticoagulants?

A

-low molecular weight heparin
-unfractionated heparin in renal failure
-fondaparinux

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9
Q

What VTE prophylaxis can be used after knee/hip replacement surgery?

A

NOACs

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10
Q

what is the treatment length for recurrent VTE?

A

long term

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11
Q

what is the needed duration of VTE prophylaxis for general surgery?

A

5-7 days or until sufficient mobility

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12
Q

what is the needed duration of VTE prophylaxis for major cancer surgery in abdominal or pelvis?

A

28 days

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13
Q

what is the needed duration of VTE prophylaxis for knee/hip surgery?

A

extended duration 35 days

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14
Q

what is the treatment of VTE?

A

-lmwh or unfractionated heparin in renal failure
for at least 5 days and until INR at 2 or ore for at least 24 hours. Monitor APTT if unfractionated heparin given.
-start oral anticoagulant at the same time, usually warfarin

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15
Q

what VTE is used in pregnancy?

A

-LMWH is the preferred choice
-Lower risk of osteoporosis and heparin-induced thrombocytopenia
-stop at labour-onset, seeks specialist advice on continuing after birth

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16
Q

what are some examples of unfractionated heparin, duration of action, when its the preferred choice, when its essential?

A

-standard heparin
-shortest duration of action
preferred choice if: high risk of bleeding and renal impairment
-essential to measure APTT (Activated partial thromboplastin time)

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17
Q

what are some examples of low molecular weight heparin, duration of action, when its the preferred choice, when its essential?

A

-tinzeparin
-enoxaparin
-dalteparin
-longest duration of action
-preferred choice lower risk of= osteoporosis, heparin-induced thrombocytopenia
-used in pregnancy

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18
Q

what are the side effects of heparin?

A

-Haemorrhage= withdraw heparin. If rapid reversal required= antidote protamine
-Hyperkalaemia= heparin in hibit aldosterone secretion. Higher risk in Diabetes and CKD. Monitor before treatment and if >7 days use.
-Osteoporosis
-heparin-induced thrombocytopenia= occurs 5-10 days after. Clinical signs 30% reduction in platelets, skin allergy, thrombosis. monitoring: before treatment and if >4 days use

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19
Q

what are some other parenteral anticoagulants?

A

-heparinoid
-argatroban
-hirudin
-heparin flushes
-epoprostenol
-fondaparinux

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20
Q

how long does it take for warfarin to work?

A

48-72hours

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21
Q

what are the different colors and strengths of the 4 warfarin tablets?

A

white- 0.5mg
brown- 1mg
blue- 3mg
pink- 5mg

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22
Q

what is the usual dose and maintenance for warfarin?

A

-5mg initially and monitor every 1-2 days
-maintenance 3-9mg at same time each day

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23
Q

how often is INR checked once the patient is stable on warfarin?

A

every 3 months

24
Q

what is the duration of treatment for isolated/distal calf DVT?

A

6 WEEKS

25
Q

what is the treatment for CONFIRMED proximal DVT and PE? unsuitable?

A

Apixaban or rivaroxaban
-give LMWH for at least 5 days then dabagatran or edoxaban
or
-LMWH + warfarin for at least 5 days or till INR is at least 2 for 2 consecutive readings, followed by warfarin alone

26
Q

what is the duration of treatment for warfarin in PROVOKED vte (COCs, pregnancy, immobile, leg plaster cast)~?

A

3 months

27
Q

what is the duration of treatment in unprovoked (underlying condition that cant be reversed, AF)?

A

3+ months/long term

28
Q

what is the target INR 2.5 indications for?

A

VTE= AF, MI, cardioversion, bioprosthetic mitral valve, treatment of DVT/PE

29
Q

what is the target INR 3.5 indications for?

A

RECURRENT vte in patients receiving anticoagulant and INR >2

30
Q

what two documents need to be given to patients when they are started on warfarin?

A

-yellow (red) treatment booklet
-anticoagulant alert card

31
Q

what can cause changes in INR? (mhra/chm advice)?

A

-direct acting antivirals to treat chronic hepatitis C: AFFECTS EFFICACY OF WARFARN SHOULD CLOSELY MONITOR
-over the counter oral miconazole gel (Dakarin) contraindicated in patients taking warfarin. Closely monitor if miconazole prescribed. It is a potent enzyme inhibitor; increases anticoagulant effect of warfarin- risk of bleeding

32
Q

what are some side effects of warfarin?

A

-bleeding: nose bleeds <10mins, bleeding gums, bruising
-calciphylaxis; patient should report painful skin rashes. Risk factor is end stage renal disease

33
Q

what is the antidote for warfarin?

A

vitamin K; phytomenadione

34
Q

what should a patient do if they start bleeding when they are on warfarin?

A

major bleeding:
-stop warfarin
-IV phytomenadione (vitamin K)
-dried prothrombin complex or fresh frozen plasma

35
Q

what should be done if a patient’s INR is between 5-8 with no bleeding?

A

-withhold 1-2 doses
-reduce maintenance dose
-measure INR after 2-3 days

36
Q

what should be done if a patient’s INR is > 8 with no bleeding?

A

-omit warfarin
-oral phytomenadione
-repeat if INR still high after 24hrs
-restart warfarin when INR < 5

37
Q

what should be done if a patient’s INR is between 5-8 with minor bleeding?

A

-omit warfarin
-IV phytomenadione
-repeat if INR still high after 24hrs
-restart warfarin when INR <5

38
Q

what should be done if a patient’s INR is >8 with minor bleeding?

A

-omit warfarin
-IV phytonadione
-repeat if INR still high after 24hrs
-restart warfarin when INR <5

39
Q

what should be done if a patient is on warfarin and has a surgery and is minor risk, high risk patients and risk of thromboembolism ?

A

-Minor risk: surgery goes ahead if INR <2.5, restart warfarin 24hr after surgery.

-increased risk of bleed: stop warfarin 3-5 days before elective surgery
-give oral phytomenadione if INR >1.5 on day before surgery
-patient high risk of thromboembolism bridge with LMWH, STOP LMWH 24hrs before then restart 48 hrs after surgery

40
Q

what should be done if a patient is on warfarin and has an emergency surgery?

A

-delay 6-12 hours
-no delay: give IV phytomenadione and dried prothrombin complex

41
Q

what should be done if a patient is on warfarin and is high risk of VTE?

A

vte IN LAST 3 MONTHS, af WITH PREVIOUS STROKE/TIA, mechanical valve= bridge with LMWH (treatment dose) and stop 24hrs before surgery

42
Q

what should be done if a patient is on warfarin and is high risk of bleeding?

A

-start LMWH 48 hours after surgery

43
Q

what are the difference between dabigatran and the other NOACs?

A

dabigatran is a direct thrombin inhibitor and the others are direct factor Xa inhibitors

44
Q

what are some examples of direct Xa inhibitors?

A

-apixaban
-edoxaban
-rivaroxaban

45
Q

why are NOACs used instead of warfarin?

A

rarely causes bleeding and no monitoring required

46
Q

what does ischaemic mean and what are the different types of stroke?

A

-blood clots obstruct blood supply
-ischaemic stroke
-Transient ischaemic attack ‘mini stroke’
-haemorrhagic

47
Q

what does haemorrhagic mean and what should be avoided in them when managing?

A

-intracerebral haemorrhage
-manage blood pressure and avoid statins

48
Q

what is the initial management for a TIA or ischaemic stroke?

A

300mg aspirin
TIA- continue till diagnosis is established
Ischaemic stroke- aspirin for 14 days

49
Q

what is the long term management for stroke?

A

TIA- first line: clopidogrel 75mg, second line: MR dipyridamole and aspirin
Ischaemic- clopidogrel and in AF related stroke review for anticoagulant
-Both TIA/ischaemic strokes- statin irrespective of serum cholestrol 48 hours after stroke , treat hypertension, not with beta-blocker unless indicated for another condition

50
Q

what is the target BP for patients after a stroke?

A

<130/80
no beta blockers

51
Q

what should be avoided with patients that have intracerebral haemorrhage?

A

-avoid aspirin, statin and anticoagulants as it increases the risk of bleeding; only give if essential
-treat hypertension and take care to avoid hypoperfusion

52
Q

what are antiplatelet drugs?

A

decrease platelet aggregation and Inuit thrombus formation in the arterial circulation

53
Q

when is a low-dose aspirin used? dose?

A

75mg daily for secondary prevention of cvd/event

54
Q

when is clopidogrel used?

A

following acute coronary syndromes or PCI

55
Q

when is dipyridamole used and how? special features

A

used for secondary prevention of stroked. Take tablets 30-60mins before food. Persantin retard capsules special container- 6 weeks expiry

56
Q

what are some examples of antiplatelets?

A

-cangrelor
-prasugrel
-ticagrelor
-abciximab (monoclonal antibody)=glycoprotein IIa/IIb inhibitor
-eptifibatide=glycoprotein IIa/IIb inhibitor
-tirofiban=glycoprotein IIa/IIb inhibitor

57
Q

what should the inn BE IF SWAPPING FROM WARFARIN DIRECTLY TO APIXABAN?

A

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1- Foundation year Cardiovascular (7 decks)

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