VTE Flashcards
What are the components of the modified Well’s Score for pulmonary embolism?
History: Active Cancer (1) Hemoptysis (1) Prior VTE (1.5) Recently Bedridden Surgery (1.5)
Physical Exam:
Symptoms of DVT (3)
Tachycardia (1.5)
No alternative diagnosis (3)
A score of > 4 indicates high probability of PE.
What are the components of the Well’s score for DVT?
History:
Active Cancer (< 6 months)
Recent Lower Limb Immobilization
Recently Bedridden > 3d or surgery (w/in 4 weeks)
Physical Exam: Tenderness along deep veins Evident collateral veins Calf swelling > 3 cm (10cm below tibial tuber.) Pitting Edema Non varicose superficial veins
Minus 2 for alternative diagnosis
High probability > or = 3 points
Moderate probability 1-2 points
Low probability = 0
How long do you treat a provoked VTE?
At least 3 months (up to 6 months)
Which DOACs require pre-treatment with LMWH for 5-10 days?
Dabigatran
Edoxaban
Which cancer patients should receive DVTp?
Per ASCO 2020 clinical practice guidelines, consider DVTp with a DOAC in patients who are at high risk (Khorana score > or = 2)
What are the DOACs (and doses) that may be considered for DVTp in high risk cancer patients?
Apixaban 2.5 mg PO BID
Rivaroxaban 10 mg PO OD
What are the components of the Khorana score?
(1) Cancer Site
(2) Blood Work
(3) BMI
In which types of malignancies should you avoid using DOACs for management of VTE (3)?
GU
GI
Intracranial Malignancy
What is the weight/BMI at which you should consider using LMWH over a DOAC for treatment of VTE?
Weight > 120 kg OR
BMI > 40
In which comorbidities would you avoid the use of DOACs for treatment of VTE?
(1) APLA
(2) Liver Failure (Child Pugh B or C)
(3) Renal Failure CrCl < 30
What are the therapeutic doses of dalteparin, enoxaparin and tinzaparin?
Dalteparin - 200U/kg daily
Enoxaparin 1 mg/kg SC BID
Tinzaparin 175U/kh SC daily
In a patient with unprovoked VTE on full dose DOAC, when can you consider step down therapy?
You can consider step down to low dose DOAC after 6-12 months with:
Apixaban 2.5 mg PO BID
Rivaroxaban 10 mg PO Daily
When would you consider thrombolysis in the setting of a pulmonary embolism?
If hemodynamic instability is present (defined as SBP < 90 mmHg for > 15 minutes) with no high risk of bleeding.
What is the “men continue and HERDOO2” rule?
(1) Men continue indefinite anticoagulation for unprovoked VTE.
(2) Women with > or = 2 HERDOO score continue anticoagulation indefinitely.
H - Hyperpigmentation OR E - Edema OR R - Redness in either leg D - Dimer > or = 250 ug/L O - Obesity (BMI > or = 30) O - Older age (> or = 65)
How do you manage a superficial venous thrombosis?
(1) ≤ 3 cm from saphenofemoral junction —> full dose anticoagulation x 3 months
(2) > 3 cm from SFJ AND ≥5 cm long —> prophylactic anticoagulation x 45d (rivaroxaban 10 mg daily or Fonda 2.5 mg SC daily)
(3) > 3 cm from SFJ + < 5 cm long —> NSAIDS and monitor with serial U/S (except in pregnancy, cancer, surgery, trauma or previous hx of DVT/SVT)
What is the reversal agent for dabigatran?
Idarucizumab
How would you reverse apixaban/rivaroxaban/edoxaban?
4 Factor PCC (Octaplex)
If a patient on warfarin comes in supratherapeutic, with INR 10, and they are not bleeding, how would you manage?
If INR > 9, hold warfarin and given vitamin K 2.5-5 mg PO. Otherwise if they are not bleeding and INR < 9 you can just hold warfarin and monitor INR.
If a patient is on warfarin and is experiencing a life threatening bleed, or is in need of an imminent procedure, how would you manage their anticoagulation?
IV vitamin K
PCC
How would you reverse LMWH in the setting of a life threatening bleed?
Protamine
If a patient has a recurrent VTE while on a DOAC or VKA, how would you manage their anticoagulation if they were compliant/therapeutic?
Switch to LMWH for at least 1 month
How would you manage a patient’s anticoagulation if they had a recurrent VTE while on LMWH?
Increase the dose by 25-30%
How would you change the patient’s LMWH dosing based on their platelet count?
Full dose if platelets > 50
Half dose if platelets 20-50
Hold if platelets < 20
