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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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