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VTE
Cardiology
| Question | Answer |
|---|---|
| Wells Criteria components | Clinical evidence for DVT; PE=most likely dx; HR > 100; Immobilization/Surgery in past 4 wk; prior DVT/PE; cancer; hemoptysis |
| Wells Criteria: Score of <2: | makes dx highly unlikely |
| Wells Criteria: Score of > 6: | highly likely |
| Venous Thromboembolism: DVT common in patients with fractures of: | spine, pelvic, hip, femur |
| Venous Thromboembolism: Risk factors | Trauma, surgery, CVP line, smoking, prolonged immobility, PG/OCP/hormone tx, age, cancer, prior VTE, obesity, HF, coagulopathy/P vera/CTD nephrotic syndrome, prior DVT; NOT GENDER |
| Venous Thromboembolism: Calf pain: next step: | Calf pain in post-op hip or knee patient deserves US |
| The first sign of DVT may be: | PE |
| Antithrombotics include: | Fibrinolytics, anticoagulants, antiplatelet drugs |
| Use of fibrinolytics in CAD is restricted to: | STEMI only |
| Anticoagulants: acute & chronic | Acute: UFH, LMWH, DTIs; chronic: warfarin |
| UFH vs LMWH re: inactivating thrombin | UFH > LMWH |
| Irreversibly binds to ADP receptor on platelets; Full reversal requires removal of plts | Clopidogrel |
| UFH: main risk = | bleeding |
| UFH: used for: | Both STEMI and NSTEMI |
| ATPIII/heparin has greatest effect on: | Factor II (thrombin) |
| Can use to monitor LMWH: | Factor Xa |
| UFH/LMWH AEs | Bleeding, HIT, osteoporosis |
| UFH vs LMWH: which is inhibited by PF4 (thus limited effect vs ACS)? | UFH |
| UFH vs LMWH: requires dose adjustment for renal: | LMWH |
| Catheter thrombosis during PCI | Fondiparinux |
| Bivalirudin used in STEMI in place of: | UFH / LMWH |
| Add warfarin for: | pts w/ USA or NSTEMI w/anticoag indication (to maintain INR 2.0-3.0) |
| Clopidogrel dosing | usu loading & maint doses |
| Clopidogrel AEs | Bleeding; Thrombocytopenia; Leukopenia; TTP |
| Clopidogrel: who gets: | All STEMI/NSTEMI (2-4 wks to 1 yr) |
| GP IIb/IIIa inhibs: who gets: | STEMI pts going for PCI |
| GP IIb/IIIa inhibs: not recommended if: | PCI is not planned |
| What percentage of pts with PE present with clinical findings of LE VTE? | 50% |
| Massive PE may presents as: | RV failure and systemic hypotension |
| Factor V Leiden accounts for what percent of new VTE incidents? | 20% |
| 90% of patients with PE have a PaO2 of: | <80 mmHg |
| Effusions in patients with PE: | Small, seen in 30% of PEs, usually exudative & often hemorrhagic |
| Gold standard for diagnosing PE: | pulmonary angiography |
| DVT Tx: start UFH, with warfarin started when? | at the same time |
| Which lab test is used to monitor warfarin? | PT (INR) |
| What is considered a latent finding in a PE? | R wave pattern with strain on ECG |
| Most common site of origin of a PE: | vein of a lower extremity |
| Patients on warfarin for PE should have INR checked every: | 4 weeks |
| What med may interact with dabigatran? | Carbamazepine |
| ECG findings in PE: | S1 Q3 T3: S waves in lead I, Q waves and inverted T waves in lead III |
| DVT increases 12-month MI risk by: | up to 60% |
| A proximal DVT is located: | above the knee |
| For a patient with DVT, treat with ____ for about 5 days | UFH or LMWH |
| For a patient with DVT treat with ____ for at least 3 months | warfarin |
| Emboli from heart: destinations | 50%-60% to LEs, 20% to cerebrovascular; 10-20% to UEs/ renal/ mesenteric circulation |
| DVT: sites | 80% deep v. of the calf; 20% femoral or iliac vein |
| Wells Criteria: Clinical evidence for DVT = | 3 points |
| Virchow’s triad = | Venous stasis, vessel wall injury, hypercoagulability |
| Thromboembolus of deep veins of LEs (deep saphenous) or pelvis = | DVT |
| Wells Criteria: Immobilization/Surgery in past 4 wk = | 1.5 points |
| Wells Criteria: Previous DVT/PE = | 1.5 points |
| Wells Criteria: Cancer = | 1 point |
| Wells Criteria: Hemoptysis = | 1 point |
| DVT Evaluation | D-dimer; LE Doppler/ US; if PE suspected, VQ scan versus spiral CT; hypercoaguable w/u if no identifiable predisposing event |
| D-dimer results: | negative result is helpful; pos results non-specific |
| DVT Tx | Hep (vs LMWH) & concomitant warfarin loading; warfarin; Thrombolytic tx; embolectomy; IVC filter |
| warfarin tx for DVT | (INR 2.0 – 2.5); idiopathic 6 mos 1st event; non-idiopathic or recurrent event: consider indefinite tx |
| DVT complications | PE; ischemic limb; varicose v.; chronic venous insufficiency |
| DVT Prevention in Surg pts: Low risk: | Minor surg in pt < 40 yrs w/ no additional risk factors |
| DVT Prevention in Surg pts: mod risk: | Minor surg in pt < 40yrs w/ an additional risk factor or surg in pt 40-60 years of age |
| DVT Prevention in Surg pts: High risk: | Surgery in pt > 60 years or in pt 40-60 with risk factors |
| DVT Prevention in Surg pts: Highest Risk: | Surg in pt > 40 yrs w/ multiple risk factors or hip/knee arthroplasty or major trauma spinal cord injury |
| DVT Prophylaxis in Surg pts: Low risk: | Early ambulation, pneumatic stockings |
| DVT Prophylaxis in Surg pts: Mod risk: | SubQ unfract hep or LMWH +/- pneumatic compression |
| DVT Prophylaxis in Surg pts: High risk: | SubQ LMWH |
| DVT Prevention in medical pts | No formal risk assessment; pneumatic compression stockings for low risk pts; unfract hep or LMWH for other pts w/ systemic illness limiting mobility esp w/ other risk factors |
| Venous thrombosis Epi | 1 in 1000?; M>F, AA>W |
| Venous thrombosis RF | inherited (Factor V Leiden, Pro S or C def), surgery, bedrest/immobility, PG, OCP; malig |
| Venous thrombosis Sx/Sx | DVT & PE; palpable cord (= thrombosed vein), calf or thigh pain, unilateral edema / difference in calf diameters, warmth, tenderness, erythema, superficial venous dilation; Homan sign |
| Venous thrombosis DDx | Mx strain/injury; lymphangitis / lymph obstruction; venous insuff; Baker cyst; Cellulitis |
| Venous thrombosis Dx studies | Contrast venography (gold standard); venous U/S (noncompressible veins); impedance plethysmography |
| Venous thrombosis Tx | Anticoag (not tx but secondary prevention); heparin (monitor aPTT) followed by warfarin x6 mos (PT 2-3); possibly thrombolytics (streptokinase, urokinase, tPA) |
| VTE etiology: | venous stasis, coagulopathies, genetic |
| Coagulopathies associated with VTE: | Antiphospholipid Abs, protein C&S, Factor V Leiden & activated protein C resistance, antithrombin III deficiency |
| Venus Thromboembolism: Screen with: | duplex Doppler venous ultrasound |
Created by:
Abarnard
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