PE/VTE

Question 1

What is Virchow’s Triad?

Answer 1

1) Hemodynamic Changes
2) hypercoaguable state
3) vascular injury

Question 2

What is a VTE?

Answer 2

An umbrella term, it is a blood clot in the vein.

Question 3

What is a DVT?

Answer 3

A blood clot in the deep vein, usually the leg.

Question 4

What is a PE?

Answer 4

A blood clot that breaks apart and travels to the lung.

Question 5

Clinical presentation of DVT?

Sxs
Labs
Types

Answer 5

Classic sxs: swelling, pain, erythema.
elevated ESR/WBC and D-Dimer.
Important to identify if proximal or distal (proximal = increased risk of PE).

Question 6

Clinical presentation of PE?

Sxs
Labs

Answer 6

May be asymptomatic, most common sxs - dyspnea, pleuritic pain, cough, syncope, tachypnea.
Elevated ESR/WBC + D-Dimer

Question 7

Persistent Risk Factors for VTE/PE

Answer 7

!!: Strong FHx, prior thrombotic event, age > 64, male, active cancer.
Others: active IBD, active autoimmune disorder, chronic infection, chronic immobility, obesity, nephrotic syndrome, thrombophilias.

Question 8

Transient Risk Factors of VTE/PE

Answer 8

Major sugery with generaliza anasthesia for > 30 mins, recent hospitilization > 3 days, immobilization > 3 days, trauma with fractures, pregnancy, C-section, long haul flight > 8 H, estrogen therapy.

Question 9

Drug causes of VTE/PE

Answer 9

Estrogen, heparin (HIT), chemo agents.

Question 10

Heparin Induced Thrombocytopenia (HIT)

What is it? Types?

Answer 10

low platelet blood counts due to heparin therapy, predisposes patients to thrombosis.
Non-immune mediated (Type 1) and immune mediated (Type 2).

Question 11

Type 1 HIT

Frequency?
Platelet count?
Onset?
Treatment?

Answer 11

Non-immune mediated (10-20%).
Mild decrease, rarely < 100 x 10^9/L
Onset 1-4 days
Tx: observe - platlet count will return to baseline.

Question 12

Type 2 HIT

Platelet Count?
Onset?
Tx?

Answer 12

Immune mediated.
Platlets fall > 30% from baseline.
Onset 5-10 days but may develop w/in 24-48H in those w/ recent (3-6m) heparin exposure.
Tx: cessation of heparin, start alternative non-heparin anticoagulant (not warfarin if platelets <150 x 10^9/L). Treat for at least 4 weeks if no thrombosis and 3m if thrombosis .

Question 13

VTE Complications?

Answer 13

Post thrombotic syndrom (PTS)
Chronic thromboembolic pulmonary hypertension.
Recurrent DVT/PE w/in 10 yrs.

Question 15

Red Flags for anticoagulation

Answer 15

See MD if: persistent bleeding/nose bleeds, blood in urine or stool, or increased swelling or pain in affected extremity.
Go to ER if: SOB, chest pain, black tarry stools, severe sudden h/a or slurred speech, hemoptysis (coughing up blood)

Question 17

Non-pharm tx for VTE

Answer 17

Graduated compression stockings
Ambulation

Question 18

Tx algorithm for VTE?

Answer 18

initial therapy: 3-6m of one of the following - fondaparinux (if risk of HIT), apixaban or rivaroxaban, LMWH (pregnancy), or UFH (pregnancy, CKD).
ongoing therapy: if cancer - LMWH, edoxaban, or dabigatran. if no cancer - DOAC or warfarin.