DVT/PE

Question 1

Post thrombotic syndrome

Answer 1

C/F

- Chronic swelling
- Chronic pain
- Chronic discomfort when walking
- Chronic skin discoloration
- Pron for infection/ulceration

Treatment:
18 months of high pressure compression stocking

Question 2

overview of anticoagulant management in DVT/PE

Answer 2

1. CKD with CrCl < 25
   warfarin with need of bridging clexane for 1st 5 days
2. CKD CrCl > 25 /Cancer / pregnancy
   clexane 1mg/kg BD or 1.5mg/Kg daily
3. CKD CrCl > 25/others others –> NOAC

Question 3

NOAC and doses

Answer 3

1. Apixaban (Eliquis) best (CrCl should be > 25)
   Treatment dose: 10mg PO BD for 7 days
   Maintainance dose: 5mg PO BD
2. Rivaroxiban (Xarelto) (CrCl should be > 30)
   Treatment dose: 15mg PO BD for 7 days
   Maintainance dose: 20mg PO daily
3. Dabigatran (Pradaxa)
   a. clexane D1-5 therapeutic dose then
   b. Dabigatran on D6 forward
   - < 75 years and CrCl > 50 –> 150mg PO BD
   - > 75 years OR CrCl 30-50 –> 110mg PO BD

the only has antidot is Dabigatran (Pradaxa)

Question 4

distal DVT

Answer 4

C/F

- swelling : increase circumference of calf area
- Redness
- Tenderness
- Homan’s sign +ve : increase pain on dorsiflexion
- Dilated superficial veins

Investigation
- Doppler ultrasound of deep veins of the affected leg

Treatment: anticoagulation

Other management

- Monitor for signs of Pulmonary embolism
- Early mobilisation
- Monitor for signs of Pulmonary embolism
- Prevent post thrombotic syndrome

Question 5

Duration of treatment

Answer 5

1. unprovoked (no cause identified) –> 3/12
2. provoked and cause removed
   a. distal DVT –> 6/52
   b. Proximal DVT/PE –> 3/12

OR (same as above)

1. proximal DVT/PE –> 3/12
2. Distal DVT
   a. provoked but cause removed –> 6/52
   b. unprovoked –> 3/12

Question 6

risk of recurrent DVTs (7)

Answer 6

1. previous DVT
2. pregnancy
3. Cancer
4. unprovoked DVT
5. provoked proximal DVT/PE
6. thrombophilias
7. antiphospholipid syndrome

Question 7

Thrombophilia screen (7)

Answer 7

Causes

- Factor V leiden deficiency
- Prothrombin gene mutation
- Anti-thrombin III deficiency
- Protein C deficiency
- Protein S deficiency
- Antiphospholipid syndrome esp in SLE
- Homocysteine level (high)

Investigation

- Factor V Leiden
- Prothrombin
- Anti-thrombin III level
- Protein C
- Protein S
- Antiphospholipid Ab
- Homocystin level

Question 8

Superficial thrombophlebitis

Answer 8

1. due to IV cannula –> NSAIDs

2. in veins of thigh: clexane (prevention) 40mg SC for 6/12

Question 9

assessment of Pulmonary embolism

Answer 9

1. Wells score > 4 –> CTPA
2. wells score < 4 –> PERC score
   a. PERC score –> all no–> no PE
   b. PERC score –> x1 yes
   - D-dimer -ve –> no PE
   - D-dimer +ve –> CTPA

Question 10

risk of intracranial bleeding while on anticoagulant

Answer 10

HAS-BLED

1. HTN > 160 (1)
2. abnormal liver/kidney function (1)
3. history of stroke (1)
4. bleeding tendency (1)
5. labile INR (1)
6. Elderly > 65 (1)
7. Drug (antiplatelet, NSAIDs) (1)

total score of 3 or more –> increase risk of bleeding