Term
| What % of patients with DVT has post-thrombotic syndrome? |
|
Definition
|
|
Term
| What is post-thrombotic syndrome? |
|
Definition
| chronic pain and swelling caused by clot formation in the venous circulation |
|
|
Term
| What % of PE patients have chronic thromboembolic pulmonary hypertension? |
|
Definition
|
|
Term
| Ho many VTE patients are there each year? |
|
Definition
|
|
Term
| What % of VTE patients have clinically silent disease? |
|
Definition
|
|
Term
T/F
The majority of VTE patients are treated in the hospital. |
|
Definition
| False - majority are treated outpatietn |
|
|
Term
| What % of VTE cases result in death within 1 hour? |
|
Definition
|
|
Term
| What is the leading cause of death in women after a live birth? |
|
Definition
|
|
Term
| What is the mortality rate for a hemodynamically stable PE patient? |
|
Definition
|
|
Term
| What 3 factors make up Virchow's triad? |
|
Definition
hemodynamic imbalance (stasis)
hypercoagulability
vessel wall damage |
|
|
Term
| What things may cause stasis? |
|
Definition
| burns, cancer, pregnancy, HF, major surgery, fracture, MI, stroke |
|
|
Term
| What things may cause hypercoagulability? |
|
Definition
| estrogen therapy, thrombophilias, previous VTE, pregnancy, cancer |
|
|
Term
| What things may cause vessel wall damage? |
|
Definition
| trauma, major surgery, fracture |
|
|
Term
| Name 7 risk factors for VTE |
|
Definition
1. multiple trauma
2. major surgery
3. immobility
4. hypercoagulability
5. oral contraceptives
6. obesity
7. smoking |
|
|
Term
T/F
The risk for VTE remains for months after surgery. |
|
Definition
|
|
Term
| What % risk is there for developing VTE after hip, knee, abdominal, or gynecological surgery? |
|
Definition
|
|
Term
| What things may cause a hypercoagulable state? |
|
Definition
| mutations in clotting factors, hyperchromocystinemia, inflammatory bowel disease, pregnancy, postpartum, nephrotic syndrome, CHF |
|
|
Term
T/F
Risk for VTE doubles each decade of life after age 50. |
|
Definition
|
|
Term
| At what altitude is there risk for high altitude induced DVT? |
|
Definition
|
|
Term
T/F
The hypercoagulable state induced by high altitudes exists for several weeks after. |
|
Definition
|
|
Term
| In what 3 situations should you always look for PE? |
|
Definition
1. isolated dyspnea or pleuritic pain
2. hemoptysis
3. circulatory collapse without apparent cause |
|
|
Term
| What may PE be secondary to? |
|
Definition
1. inherited coagulation disorder - 30% of patients with DVT/PE
2. cancer |
|
|
Term
T/F
For 25% of patients with cancer and PE, PE is the sentinel event. |
|
Definition
|
|
Term
| What are the 5 most common sites for cancer in patients diagnosed with idiopathic VTE? |
|
Definition
| lung, pancreas, colon/rectum, kidney, prostate |
|
|
Term
T/F
VTE can precede the diagnosis of malignancy by months or even years. |
|
Definition
|
|
Term
T/F
A thrombus involving the proximal leg veins is more likely to result in PE. |
|
Definition
|
|
Term
| List the clinical features of DVT that are used to determine likelihood of diagnosis. |
|
Definition
1. Tenderness along deep venous system
2. swelling of the leg
3. pitting edema
4. collateral superficial veins
5. active cancer
6. immobility or paralysis
7. recent surgery
These are all given 1 point
8. Other diagnosis likely (cellulitis, phlebitis) -2 pts |
|
|
Term
| Using the point system for the features of DVT, what is a high, moderate and low score? |
|
Definition
high >/= 3 pts
moderate 1-2 pts
low |
|
|
Term
| What tests do you run to diagnose DVT? |
|
Definition
ultrasound of leg
CBC
platelet count
PT/INR
aPTT - activated partial prothrombin time
CMP
Set samples aside for testing for thrombophilias before starting heparin and warfarin |
|
|
Term
| What are 3 common abnormalities found when trying to make the diagnosis of DVT? |
|
Definition
|
|
Term
| What tests do you run to diagnose PE? |
|
Definition
CBC
platelet count
CMP
PT/INR
aPTT
spiral CT (70% sensitive)
V/Q scanning
D dimer
Angiography |
|
|
Term
| What is the normal D dimer value? |
|
Definition
|
|
Term
| How sensitive is the D dimer for PE? |
|
Definition
| If D dimer is normal and patient is low risk, we are 95% sure that the patient does not have a PE |
|
|
Term
T/F
If the D dimer is elevated, it is almost certainly PE. |
|
Definition
| False - elevated D dimer is a nonspecific result |
|
|
Term
| What is the gold standard diagnostic test for PE? |
|
Definition
|
|
Term
| Why is angiography not always done for PE diagnosis? |
|
Definition
| invasive and unavailable in some settngs |
|
|
Term
| What are the Wells Prediction Rules for Pretest Probability of PE? |
|
Definition
Clinical signs of DVT - 3
Recent surgery or immbolization - 1.5
active cancer - 1
Past history of DVT or PE - 1.5
Hemptysis - 1
Tachycardia - 1.5
Unexplained SOB or chest pain (alt. dx less likely than PE) - 3 |
|
|
Term
| According to the Wells Prediction Rules for PE, what is a high, moderate, and low score? |
|
Definition
high >/= 6
moderate 2-6
low |
|
|
Term
| What is the non-pharmacologic treatment for DVT? |
|
Definition
limb elevation
application of heat to the area of pain
minimal activity
compression stockings |
|
|
Term
T/F
Thrombolytic therapy is used for most VTE patients. |
|
Definition
| False - it is used only in rare instances |
|
|
Term
| What is the pharmacologic treatment for VTE? |
|
Definition
rapid acting anticoagulant - unfractionated heparin, LMW heparin, or fondaparinux
Plus warfarin sodium |
|
|
Term
T/F
UFH, LMWH, and warfarin dissolve clots. |
|
Definition
| False - clots are removed by normal physiologic processes. The drugs are to prevent further clotting |
|
|
Term
| When will thrombolytic therapy improve patient outcomes? |
|
Definition
|
|
Term
| When is the only time thrombolytic therapy is used to treat DVT? |
|
Definition
| only to treat or prevent gangrene |
|
|
Term
| Why is thrombolytic therapy not frequently used to treat VTE? |
|
Definition
| risk of hemorrhage outweighs the benefits of treatment |
|
|
Term
| When is thrombolytic therapy used to treat PE? |
|
Definition
massive PE
patient in shock, severe hypoxemia, right heart failure, hypotension |
|
|
Term
| What is the surgical alternative to thrombolytic therapy? |
|
Definition
|
|
Term
| How do thrombolytics work? |
|
Definition
proteolytic enzymes convert plasminogen to plasmin which degrades the fibrin matrix
they enhance the natural process of clot removal |
|
|
Term
T/F
One week following acute treatment, clot lysis and vessel patency are similar with or without thrombolytic therapy. |
|
Definition
|
|
Term
| Name 2 conventional thrombolytic agents. |
|
Definition
| streptokinase and urokinase - nonselective plasmin production |
|
|
Term
| Name 1 clot (Fibrin)-selective thrombolytic agent. |
|
Definition
|
|
Term
T/F
streptokinase and urokinase work on both the clot and circulation in general. |
|
Definition
|
|
Term
| Name 6 counterindications to anti-thrombotic therapy. |
|
Definition
1. recent thoracic, abdominal, or CNS surgery
2. recent cerebrovascular accident, trauma, or neoplasm
3. bleeding ulcer
4. malignant hypertension
5. anticipated invasive procedures
6. concurrent hemostatic dysfunction |
|
|
Term
| Why do we monitor both the aPTT and the PT? |
|
Definition
aPTT - integrity of the intrinsic clotting pathways
PT - integrity of extrinsic clotting pathways |
|
|
Term
T/F
Weight based dosing of UFH to treat DVT is more effective. |
|
Definition
| True - more patients at goal in 24 hours |
|
|
Term
| What is the therapeutic goal after heparin treatment? |
|
Definition
| 48-71 seconds clotting time |
|
|
Term
| Name the 4 anticoagulant properties of heparin. |
|
Definition
1. inhibits activation of fibrin stabilizing enzyme
2. inhibits the aggregation of platelets by thrombin
3. inhibits the thrombin-mediated conversion of fibrinogen to fibrin
4. inhibits activated factors II, VII, IX, and X |
|
|
Term
|
Definition
enoxaparin, dalteparin, and tinzaparin
used for treatment of DVT with or without PE |
|
|
Term
T/F
UFH and LMWH both enhance the activity of antithrombin. |
|
Definition
|
|
Term
| How do you treat bleeding that is a side effect of both UFH and LMWH? |
|
Definition
protamine sulfate
maximum dose 50 mg
discontinue any heparin dose |
|
|
Term
| What is the maximum dose of protamine sulfate? |
|
Definition
|
|
Term
| How is protamine sulfate given in proportion to heparin? |
|
Definition
| 1 mg/1 mg or 1 mg/100 units |
|
|
Term
| What are the benefits of using LMWH over UFH? |
|
Definition
1. LMWH has a more reliable/predictable anticoagulation response
2. greater subQ bioavailability
3. Lower incidence of thrombocytopenia
4. reduced need for lab monitoring
5. dose independent clearance
6. Lower incidence of Heparin Induced Thrombocytopenia |
|
|
Term
| How do we dose fondaparinux for use with DVT or PE? |
|
Definition
< 50 kg - use 5 mg SC QD for 5-9 days
50-100 kg - use 7.5 mg
> 100 kg - use 10 mg |
|
|
Term
| What precautions do we need to be aware of when using fondaparinux? |
|
Definition
renal excretion - unchanged
elevations in ALT and AST
QT prolongation |
|
|
Term
T/F
Fondaparinux is a synthetic compound and has a more predictable pharmacokinetic response than LMWH. |
|
Definition
|
|
Term
| What kind of drug is fondaparinux? |
|
Definition
|
|
Term
T/F
Fondaparinux has no interaction with thrombin. |
|
Definition
|
|
Term
T/F
Fondaparinux tends to cross react with HIT antibodies. |
|
Definition
|
|
Term
| What is the half life of fondaparinux? |
|
Definition
| 17-21 hours for once daily dosing |
|
|
Term
| When are direct thrombin inhibitors used? |
|
Definition
| to treat heparin induced thrombocytopenia |
|
|
Term
| Name 4 direct thrombin inhibitors. |
|
Definition
1. argatroban
2. bivalrudin
3. desirudin
4. lepirudin |
|
|
Term
| How do direct thrombin inhibitors work? |
|
Definition
| interact directly with the thrombin molecule - inhibiting both circulating and clotting thrombin |
|
|
Term
T/F
Direct thrombin inhibitors can induce thrombocytopenia. |
|
Definition
|
|
Term
| Name the contraindications for anti-thrombotic therapy. |
|
Definition
inaccessible ulcerative lesion (GI lesion)
CNS lesion (stroke, surgery, trauma)
Spinal anesthesia or LP
malignant HTN
advanced retinopathy |
|
|
Term
| What is the starting dose of warfarin sodium for DVT/PE patients? |
|
Definition
|
|
Term
| When do you begin to adjust the warfarin dose daily? |
|
Definition
|
|
Term
| How do you dose warfarin on day 3 for DVT/PE? |
|
Definition
INR < 1.3 - increase dose to 7.5/15
INR 1.3-1.6 - continue dose
INR 1.7-1.9 - decrease dose to 2.5/5
INR 2.0-2.2 - decrease dose to 1/2.5
INR > 2.3 - hold one day then use 1/2.5 |
|
|
Term
| How often do you monitor the PT/INR of DVT/PE patients on coumadin? |
|
Definition
| weekly until stable for 2 weeks, then monthly |
|
|
Term
| What are some contraindications to anti-thrombotic therapy with coumadin? |
|
Definition
(in ambulatory patients)
early and late pregnancy
poor patient cooperation, understanding, and reliability
unsatisfactory lab or pt follow up
occupational risk to trauma |
|
|
Term
| What is the goal INR for all pts on coumadin except those with mechanical prosthetic valves or recurrent systemic embolism? |
|
Definition
2.0-3.0
For the 2 exceptions listed: 3.0-4.5 |
|
|
Term
| How long does the American College of Chest Physicians recommend coumadin therapy for DVT/PE? |
|
Definition
6-12 months
optimal duration is uncertain |
|
|
Term
| What is the DOC for anticoagulation during pregnancy? |
|
Definition
UFH or LMWH
LMWH is "good" alternative according to book, but according to some studies, it is the DOC |
|
|
Term
| What anti-coagulating drug may be used in infants and children? |
|
Definition
|
|
