Thromboembolism ,DVT Flashcards by Mavis Mawuena

What does hypercoagulable state mean

A person in this state has a higher than normal tendency to clot due to increased procoagulants or decreased antocoagulants

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In what cases will you suspect hypercoagulable state

Spontaneous thrombosis without obvious risk factors
A family history of recurrent venous thrombosis at early age
Thrombosis with concomitant risk factor at an early age
Thrombosis at unusual site, i.e vessels in arm or organ
recurrent thrombosis

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Balance of coagulation in hypercoagulable state

tipped towards thrombosis

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Diseases involved in hypercoagulable state

Myocardial infarction
Cardiovascular disease
Deep vein thrombosis
Peripheral arterial disease

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General areas thrombosis occurs

Arterial and venous system

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Risk factors for arterial thrombosis

Family history of arterial thrombosis
Male sex
Hypertension
Cigarette smoking
Hyperlipedimea

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Risk factors for venous thrombosis

Virchow’s triad

Stasis
Hyper coagulopathy
Vessel wall damage

age
sex
obesity

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Causes of hypercoagulability disorders

Hereditary hemostatic disorders i,e factor 5 leiden

Hereditary and acquired hemostatic disorders i.e raised levels of factor 7,8

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How is stasis a risk factor/ what causes stasis

Cardiac failure- sluggish flow of blood

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Hereditary prothrombotic factors

Elevated levels of

Fibrinogen- factor 1
Prothrombin - factor 2

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What is factor 5 leiden

A mutated form of factor 5, given the name factor 5 leiden which is resistant to cleavage by activated protein c complex

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Normal action of factor 5

Factor 5 is supposed to be cleaved by protein C ( anticoagulant) in order to stop its procoagulant activity to ensure it doesn’t overwork

A mutation–. resistance…..> Persistent procoagulant activity

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Most significant genetic risk factor for thrombosis

Factor 5 leiden

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Prevalence in caucasians

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Thrombotic risk for heterozygotes

6-8 fold

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Thrombotic risk for homozygotes with factor 5 mutation

80 times risk

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This contributes to risk of thromboembolism

Elevated factor 8

Elevated von Willebrand factor - also an independent risk factor for MI or stroke

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Inhibitors of hemostasis

Protein c, protein s
Tissue factor pathway inhibitor
Antithrombin

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Acquired prothrombotic risk factors

Central venous catheter used as supportive management by being placed in the vein to keep it patent is an important risk factor for thrombosis
Malignancies. Thromboembolism is a complication of cancer. Chemotherapy as well as complex interaction of factors play a role. Malignancies also cause immunosuppression;–>infection, dehydration(stasis)
Sepsis
Congenital heart dx
hypovoleamia
Trauma/surgery
7 immobilization
Estrogen containing contraceptives
9.Steroids
Nephrotic syndrome

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Prevalence of CVC related DVT

1-70%

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Screening test for hypercoagulability

FBC, expected to be high and will cause stasis
Myeloproliferative disorders
Shortened PT/APTT
High factor assay
Deficiency in anticoagulants i.e assay for protein C and S

Protein C resistance test

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Deep vein thrombosis

Formation of blood clot in the deep leg vein which may lead to post thrombotic syndrome

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Prevalence im US

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600.000 cases

Prognosis of DVT

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1 out of 100 people die

Risk factors for DVT

``` Previous DVT Family History Recent surgery greater than 40 Hormone therapy/ oral contraceptives pregnancy / post partum Previous or current cancer limb trauma/ orthopedic procedure coagulation abnormality Obesity ```

Symptoms of DVT

``` Discoloration of legs Swelling of leg Calf or leg pain Warm skin Visibility of surface veins Leg fatigue ```

Diagnosis of DVT

Serial compression ultrasonography which may be combined with doppler contrast venography Plasma D-dimer conc MRI

Anticoagulant drugs for DVT

Unfractionated heparin LMW heparin Anticoagulant prevents further formation of the clot whiles the body compensates for thrombus already formed. it doesnt lyse thrombus

Precautions when using unfractionated heparin

Monitor with APTT because you dont want to over/under anticoagulate your patient. APTT should be 1.5-2.5 times the normal APTT

Dosage of unfractionated heparin

Continous IV or intermittent subcutaneous, i.e every 12 hrs

Advantage of LMW heparin

No need to monitor with APTT | Given once a day

When bleeding occurs with heparin what do you do

Reverse effect with protamine 1mg/100 units

Common oral anticoagulant

Warfarin

How to monitor warfarin

With INR

Target INR for warfarin in DVT, atrial fibrillation, Pulmonary embolism, cardioversion

Ideally 2.5 but between 2-3

Target INR for warfarin therapy in recurrent DVT on warfarin, mechanical heart valves, Antiphospholipid syndrome

Ideally 3.5 but 3.0-4.0 okay

How many hours does it take for warfarin to work

72 hrs. it is first procoagulant before becoming anticoagulant. Starting therapy with just warfarin is not wise due to delay in onset and initial procoagulant activity

When starting warfarin therapy do this

Give warfarin plus LMW/Unfractionated heparin whose anticoagulant effect starts immediately before warfarins anticoagulant activity can set in after 72 hrs

Warfarin preferred to heparin because

it is administered orally

When someone is on warfarin avid these foods

Green leafy vegetables rich in vitamin k. Warfarin is a vitamin K antagonist. Their work ends up cancellimg out

What foods can cause INR to shoot up/ potentiate warfarin

Citrus fruits

Warfarin overdose manifests as

High INR

If INR is between 3-6 what do you do

Ideal is supposed to be 2.5 . I will reduce dose or stop and restart at another time

If Ideal INR is 3.5 and INR of patient is 4-6

Reduce/stop | Restart when INR less than 5

If INR is 6-8 with no bleed

Stop and start when INR is less than 5

If INR is greater than 8 with no or minor bleed

You stop and restart when INR is less than 5 | You may give vitamin K

If INR is greater than 8 with major bleed

Stop warfarin and give fresh frozen plasma, vitamin k, prothrombin complex

Under heparin clot resolves in

5-14 days

Thrombolytic drugs

Rarely used except i emergency Dissolves the clot eg. streptokinase, urokinase

Therapy for thrombosis

Surgical embolectomy Anticoagulant Antithrombolytic drugs

Newer drugs for DVT

Heparinoids Oral Direct FX inhibitor Oral direct FII inhibitor

Post thrombotic syndrome

Common complication of DVT treated with anticoagulant alone

Pathophysiology of PTS

Anticoagulant therapy--> Body tries to dissolve clot--> Destruction in valves of veins--> pooling of blood---> thrombosis can recur

DVT can cause

Pulmonary embolism

Risk of getting pulmonary embolism from DVT is reduced with

Early treatment. Chances reduced to 1 percent

Thromboembolism ,DVT Flashcards

(55 cards)