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Venous thromboembolism Flashcards

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1
Q

Define thrombosis

A

Pathological clot formation within blood vessel

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2
Q

Describe the difference between venous thrombi and arterial thrombi

A

Venous- red cells in fibrin mesh (red clot)

Arterial- platelets and fibrin (white clot)

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3
Q

Define embolism

A

Clot breaks off and travels through circulation until obstructed by vessels of smaller diameter

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4
Q

What is difference between distal and proximal DVT

A 
Distal= confined to calf vein
Proximal= involved popliteal vein and above
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5
Q

Where do majority of pulmonary embolisms arise from

A

DVT

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6
Q

Where do majority of DVTs arise from

A

Calf venous sinuses

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7
Q

What % of DVTs extend proximally to popliteal vein or above

A

25

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8
Q

Of the DVTs that extend proximally to popliteal vein, what % embolise

A

40

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9
Q

Of the DVTs that embolise, how many are fatal

A

20

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10
Q

What is the third most common cause of cardiovascular death

A

Pulmonary embolism

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11
Q

What is the mortality of untreated and treated pulmonary embolism

A

30% untreated

<5% when treated

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12
Q

What are the causes of venous thromboembolism (Virchows triad)

A

Static blood
Vessel wall disorder
Hypercoagulability

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13
Q

Name the strong risk factors for VTE (5)

A
  • Hip/ pelvis fracture
  • Hip/ knee replacement
  • Major general surgery
  • Major trauma
  • Spinal cord injury
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14
Q

Name the moderate risk factors for VTE (7)

A
  • Previous VTE
  • Cancer outpatient
  • Resp failure
  • Pregnancy
  • Combined OC pill/ HRT
  • Central venous line
  • Thrombophilia
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15
Q

Name the weak risk factors for VTE (5)

A
  • Bed rest > 8 days
  • Travel
  • Obesity
  • Day case srugery
  • Varicose veins
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16
Q

Signs and symptoms of DVT (8)

A 
Tenderness
Erythema
Pain
Palpable cord
Superficial venous dilation
Ipsilateral oedema
Warmth
Swelling
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17
Q

Why is it important to get objective diagnosis of DVT

A
  • 75% of suspected patients negative on investigation

- Drugs used to treat VTE cause serious side effects

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18
Q

3 steps of diagnosing DVT?

A

1) Clinical pre-test probability (Wells score)
2) D-dimer test
3) Radiological assessment

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19
Q

What is D-dimer

A

Blood test for non specific marker of fibrin formation

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20
Q

What radio-logical assessment is usually used to diagnose DVT and why?

A

Compression ultrasound as non invasive

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21
Q

Gold standard for radiological assessment

A

Venography

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22
Q

Name some components of a Wells score test

A 
Active cancer
Paralysis
Recently bedridden
Localised tenderness
Entire leg swollen
Calf swelling
Pitting oedema
Collateral superficial veins
Previous documentated DVT`
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23
Q

What is post-thrombotic syndrome

A

Recurrent pain and swelling in leg that may progress to local skin pigmentation and ulceration

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24
Q

Is post-thrombotic syndrome more or less common in distal or proximal DVT

A

Proximal (30-50% of proximal cases)

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25
What causes post-thrombotic syndrome
Occurs due to venous hypertension (obstruction and valve damage) as well as abnormal microcirculation with reversal of blood flow from deep to superficial veins
26
Signs of pulmonary embolism
Tachypnoea and tachycardia Crepitations Pleural rub
27
What % of PE patients have isolated breathlessness
25
28
What % of PE patients have collapse/ hypotension/ shock
10
29
What does an ECG of somebody with PE show
Sinus tachycardia Right heart strain T wave inversion S1Q3T3
30
What would chest x-ray show
Focal oligaemia Peripheral wedge shaped density above diaphragm Arterial blood gases show hypoxia, low CO2
31
What are the components of wells score for PE
- Clinical signs and symptoms DVT - Alternative diagnosis less likely - Pulse >100 - Immobilisation or surgery - Previous DVT/ PE - Cancer
32
What is the % mortality of pulmonary embolism within 1 hour of symptoms onset
10
33
What is the % mortality of pulmonary embolism within 2 weeks if untreated
30
34
What is the % mortality of treated pulmonary embolism
<5%
35
What is 1 year mortality of pulmonary embolism
25
36
What blood tests are used to manage vte
FBC Clottting screen D dimer U&E
37
Describe treatment outline for VTE
- Blood tests - Start low molecular weight heparin unless contraindication - Confirm diagnosis - Continue heparin and start warfarin - Stop heparin, continue warfarin - Review after 3 months
38
When can heparin be stopped?
After minimum of 5 days and when INR is in therapeutic range (2-3) for 2 consecutive days
39
What do anti-coagulants do (brief)
Prevent extension and recurrence (not clot busters)
40
Why is low molecular weight heparin used?
- As effective as and safer than unfractioned heparin - More predictable response - No monitoring required - Easier to use
41
How is low molecular weight heparin adminster
Subcutaneously
42
What is half life of low molecular weight heparin
4 hours
43
Brief mechanism of low molecular weight heparin
anti Xa
44
What is the half life of unfractionated heparin
60-90 mins
45
When is unfractionated heparin usually used
When rapid reversibility is important
46
How is unfractionated heparin monitored
ATPP
47
What is fondaparinux
Synthetic pentasacchairde
48
Half life of fondaparinux
18 hours
49
When is fondaparinus unsuitable
Renal impairment (GFR<30mL/min)
50
Site of action of vitamin K antagonists
Factor IX Factor VII Factor X Factor II
51
Site of action of heparin
Factor Xa | Thrombin
52
Site of action of apixaban, edoxaban, rivaroxaban
Factor Xa
53
Site of action of dabigatran
Thrombin
54
Name 3 side effects of heparin
- Major bleeding - Heparin induced thrombocytopenia - Osteroporosis
55
What % of patients have major bleeding due to heparin within first week of treatment
1-5%
56
How can heparin related bleeding be treated
Specific heparin antagonist (protamine sulphate)
57
What are the features of heparin induced thrombocytopenia
Onset of moderate thrombocytopenia and high risk of thrombosis Develops 5-14 days after treatment
58
Does osteoporosis occur after exposure to low molecular weight heparin, unfractionated heparin or both
UFH
59
Briefly state mechanism of action of warfarin
Vitamin K antagonist
60
Half life of warfarin?
36 hours
61
What measurement does warfarin primarily affect
Prothrombin time (INR)
62
By how much does warfarin decrease recurrence of VTE
90
63
How should you manage bleeding that occurs when on warfarin
- Stop warfarin - Consider vitamin K 0.5-5mg orally or IV - Prothrombin complex concentrate if patient needs rapid reversal
64
How long does the vitamin K used to treat warfarin related bleeding take to work
4 hours via IV | Maximum of 12-24 hours
65
When in the treating of VTE can the following drugs be used: a) Rivaroxaban b) Apixaban c) Dabigatran d) Edoxaban
a) Start day 1- no need for heparin lead in b) Start day 1- no need for heparin lead in c) Heparin lead in required: 5-10 days d) Heparin lead in required 5-10 days
66
3 options for treating VTE
- LMWH bridged to warfarin - LMWH followed after 5 days by dabigatran or edoxaban - Rivaroxaban or apixaban without LMWH
67
What is DOAC stand for
direct oral anticoagulant
68
How should VTEs be treated in pregnant women
- Warfarin and DOACS closs placenta- warfarin causes bleeding and DOACs may - Use LMWH
69
Which drugs are safe and which drugs are unsafe for women while they breastfeed
LMWH and warfarin safe | Not DOACs
70
What drug is most effective in patients with cancer-associated thrombosis
LMWH is more effective than warfarin
71
When is thrombolysis (clot busting) treatment used? | What is main risk factor
Massive PE or limb threatening DVT | 1-3% intracranial bleeding risk
72
When is inferior vena cava filter used
If major contraindication to anticoagulation | If PE recurrss despite adequate anticoagulation
73
What is thrombophilia
Laboratory detected predisposition to thrombosis
74
Name some heritable causes of thrombophilia
``` Factor V Leiden Prothrombin gene mutation Protein C deficiency Protein S deficiency Antithrombin deficiency ```
75
Clinical manifestation of antiphospholipid syndrome
``` Migraines, strokes PE CAD Renal vein thrombosis, renal infarction, Recurrent miscarriage, pre-eclampsia DVT ```
76
Describe how antiphospholipid syndrome affects pregnancies/ fertility
- Unexplained fetal deaths after 10 weeks - Premature deliveries - Miscarriages
77
How many preventable PE deaths are there a year in England
25000

CR 2 (33 decks)

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