VTE

Question 1

Types of VTE

Answer 1

DVT
PE
- due to blood clot which forms in the veins - restricts blood flow

Question 2

RF

Answer 2

Surgery
Trauma
Significant immobility
Malignancy
Obesity
Pregnancy
Hormonal Therapy (COC or HRT)

Question 3

DVT

Answer 3

• Blood clot occurs in a deep vein leg or pelvis
• Typically in the calf of one leg.

Question 4

Symptoms of DVT

Answer 4

• unilateral, localised pain
• swelling/ tenderness

Question 5

Wells score for DVT

Answer 5

• 2 + = DVT likely
• less than 2 = unlikely

Question 6

2 + wells score for DVT

Answer 6

• Offer a proximal leg vein ultrasound scan
• If the scan is negative for
  DVT, then offer a D-Dimer test

Question 7

Less than 2 wells score for DVT

Answer 7

• Offer first a D-Dimer test
• If the D-Dimer test confirms that DVT is likely, then offer a proximal leg ultrasound scan

Question 8

PE

Answer 8

Blood clot detaches and travels to the lungs and blocks the pulmonary artery.

Question 9

Symptoms of PE

Answer 9

• Chest pain
• Shortness of breath
• Cough
• Coughing blood (Haemoptysis)

Question 10

Wells score for PE

Answer 10

• 4 + = PE likely
• less than 4 = unlikely

Question 11

4 + wells score for PE

Answer 11

• computed tomography pulmonary angiogram (CTPA)
• if PE is negative, consider proximal leg ultrasound if DVT is suspected/likely

Question 12

Less than 4 wells score for PE

Answer 12

• D-dimer test
• if positive = CTPA

Question 13

Methods of thromboprophylaxis (2)

Answer 13

1. Mechanical - graduated compression stockings
2. Pharmacological - anticoagulants

Question 14

How would you reduce risk of VTE in surgical patients?

Answer 14

• LA over GA

Question 15

In surgical pt - how long is mechanical prophylaxis for VTE sufficient

Answer 15

• until sufficiently mobile
• discharged from hospital, some surgeries require them to be worn for certain amount of days

Question 16

Surgery - how long do we continue VTE prophylaxis for?

Answer 16

• Continue for at least 7 days post-surgery, or until sufficient mobility has been re-established
• 28 days after major cancer surgery in the abdomen
• 30 days in spinal surgery

Question 17

Elective hip replacement either

Answer 17

LMWH for 10 days and then 75mg aspirin for 28 days
LMWH for 28 days in + stockings until discharge
Rivaroxaban

Question 18

Elective knee replacement either:

Answer 18

75mg aspirin for 14 days
LMWH for 14 days in + stockings until discharge
Rivaroxaban

Question 19

VTE prophylaxis - Pregnancy high risk of VTE

Answer 19

• If risk of VTE that outweighs the risk of bleeding
• LMWH during hospital admission
• Pregnant women: prophylaxis until no risk of VTE or till patient discharged

Question 20

Women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks →

Answer 20

start LMWH 4-8 hours after the event → continue for a minimum of 7 days

unfractionated if patient is at high risk of haemorrhage

Question 21

Pregnancy - Additional mechanical prophylaxis if immobilised →

Answer 21

until sufficiently mobile or discharged from hospital

Question 22

Why are Heparins used in pregnancy compared to other pharmacological prophylaxis?

Answer 22

• Heparins do NOT cross the placenta
• They are also cleared rapidly in pregnancy

Question 23

If a patient has confirmed DVT or PE, What should you offer for treatment?

Answer 23

• Apixaban
  OR
• Rivaroxaban

Question 24

What if Apixaban or
Rivaroxaban are unsuitable for a patient with VTE, what should you then offer as an alternative?

Answer 24

1. LMWH for at least 5 days followed by Dabigatran or Edoxaban
2. LMWH + warfarin for at least 5 days or until the INR is at least 2.0 or above
3. Stop heparin and continue on warfarin on its own

Question 25

When would Heparin (unfractionated) be recommended in the treatment of VTE?

Answer 25

- Not routinely recommended - only considered in patients with renal impairment

Question 26

How long should patients be on drug treatment for VTE?

Answer 26

* Distal DVT (calf): 6 Weeks * Proximal DVT / PE: At least 3 months (3 to 6 months for those with active cancer) * Provoked DVT / PE: Stop at 3 months if the provoking factor resolved * Unprovoked DVT / PE: 3 Months + * Recurrent DVT / PE: Longterm

Question 27

Review

Answer 27

anually