Cardiology Test 4-Montepara Venous Thromboembolism

___: clot formation in venous circulation

VTE

VTE manifests as __ __ __ or __ __

deep vein thrombosis, pulmonary embolism

VTE Risk Factors

-increasing __

-___ of VTE

-Virchow's triad

age, history

Virchow's triad

1) __ ___ (blood is stagnant from immobility, paralysis, obesity)

2) ___ ___ (from surgery, trauma, venous catheters)

3) ____ (from cancer, coagulation factor abnormalities, antiphospholipid antibodies, pregnancy, certain drugs)

blood stasis, vascular injury, hypercoagulability

Clinical presentation of DVT

-____ leg swelling

-pain

-tenderness

-erythema

-warmth

unilateral

Clinical presentation of PE

-cough

-chest pain/tightness

-SOB

-palpitations

-____ (cough up blood)

-dizziness

-tachypnea (rapid breathing)

-tachycardia

-diaphoresis (sweating)

-_______ (blueish skin)

-hypotension

-shock

hemoptysis, cyanosis

To diagnose VTE, we can use a __ ___ (indicates recent clot formation and breakdown)

D-dimer

To diagnose DVT:

-compression ___ (non-invasive)

-______ (invasive, more accurate)

ultrasound, venography

To diagnose PE:

-ventilation/perfusion (__/__) scan (non-invasive)

-computed tomography (__) pulmonary angiography (invasive, more accurate)

V/Q, CT

Nonpharm prevention of VTE

-_____ (movement)

-_____ stockings

-intermittent pneumatic compression (____) devices

-inferior vena cava (___) filters

ambulation, compression, IPC, IVC

inferior vena cava (IVC) filters should be used __-term only for a specific subset of patients

short

inferior vena cava (IVC) filters are only for patients with:

1) Contraindication to ____

2) High risk of ____

3) ____-extremity DVT

anticoagulation, PE, lower

The pharmacologic treatment of ___ is the mainstay of VTE treatment. It does not remove clot, but prevents its further growth.

anticoagulation

While anticoagulation is the mainstay of VTE treatment, ___ therapy (clot busters) can also be used in select cases

thrombolytic

Can you use UFH for VTE prophylaxis, VTE treatment, or both?

both

Can you use Enoxaparin (LMWH) for VTE prophylaxis, VTE treatment, or both?

both

Can you use Dalteparin (LMWH) for VTE prophylaxis, VTE treatment, or both?

VTE prophylaxis

Can you use Apixaban (Factor Xa Inhibitor) for VTE prophylaxis, VTE treatment, or both?

both

Can you use Rivaroxaban (Factor Xa Inhibitor) for VTE prophylaxis, VTE treatment, or both?

both

Can you use Edoxaban (Factor Xa Inhibitor) for VTE prophylaxis, VTE treatment, or both?

VTE treatment

Can you use Fondaparinux (Factor Xa Inhibitor) for VTE prophylaxis, VTE treatment, or both?

both

Can you use Dabigatran (Direct thrombin inhibitor) for VTE prophylaxis, VTE treatment, or both?

both

Can you use Warfarin (Vitamin K antagonist) for VTE prophylaxis, VTE treatment, or both?

VTE treatment

UFH Dosing

_____: 5,000 units SC q8-12h

_____: 80 units/kg IV bolus followed by 18 units/kg/hour IV infusion

prophylaxis, treatment

UFH Contraindications

-uncontrolled active ___

-severe ____

-history of ___

-hypersensitivity to ___

bleeding, thrombocytopenia, HIT, pork

UFH Side Effects

-bleeding

-____ (low platelets)

-HIT

-____kalemia

thrombocytopenia, hyper

UFH Monitoring

-_____ or anti-Xa

-platelets

-Hgb (hemoglobin)

-Hct (hematocrit)

aPTT

What is the brand name of Enoxaparin (LMWH)?

Lovenox

What is dosing of Enoxaparin for prophylaxis with preserved renal function?

30mg SC q12h or 40mg SC daily

What is dosing of Enoxaparin for prophylaxis with CrCl<30mL/min?

30mg SC daily

What is dosing of Enoxaparin for treatment with preserved renal function?

1mg/kg SC q12h or 1.5mg/kg SC daily

What is dosing of Enoxaparin for treatment with CrCl<30mL/min?

1mg/kg SC daily

What is the brand name of Dalteparin (LMWH)?

Fragmin

Enoxaparin/Dalteparin (both LMWH) Contraindications

-history of ___

-active major ___

-hypersensitivity to ___

HIT, bleed, pork

Enoxaparin/Dalteparin (both LMWH) side effects

-bleeding

-____

-thrombocytopenia (low platelets)

-hyperkalemia

-increased _____

anemia, LFTs

Enoxaparin/Dalteparin (both LMWH) monitoring

-___-___ (only in patients with pregnancy, obesity, renal dysfunction for edoxaban)

-platelets

-Hgb

-Hct

-Scr

anti-xa

Heparin-induced thrombocytopenia (HIT)

-risk factor includes source of heparin

-___ has a much higher HIT risk than LMWH

UFH

Heparin-induced thrombocytopenia (HIT)

-risk factor includes duration of heparin exposure

-HIT risk is higher when exposure is > ___ days

4

Heparin-induced thrombocytopenia (HIT)

-risk factor includes past exposure

-HIT risk is higher when a patient has been exposed within the last __ days as compared to exposure within 100 days

30

Heparin-induced thrombocytopenia (HIT)

-risk factor includes gender

-HIT risk is higher when a patient is a ___

female

HIT complications

-thrombocytopenia

-venous/arterial thrombosis

-limb ____

-skin ___/necrosis

-disseminated intravascular coagulation

-death

gangrene, lesions

First test for HIT Diagnosis is the 4 T score

-a score above __ indicates we need to go on to do further testing

4

if patient gets above a 4 on the 4 T scoring system, we move on to the second test: enzyme-linked immunosorbent assay (____)

ELISA

enzyme-linked immunosorbent assay (ELISA)

-immunoassay detects ___ antibodies in serum sample

-high sensitivity but low ____

PF4, specificity

if a patient tests positive on the ELISA, we move on to the third test, which are ___ ___ (SRA+HIPA)

functional assays

What is the gold-standard functional assay that is a diagnosis for HIT?

Seratonin release assay (SRA)

Seratonin release assay (SRA)

-measures platelet activation by detecting the release of seratonin from test platelets, takes 1-2 days for results

-______ sensitivity and specificity

high

Heparin-induced platelet aggregation (HIPA)

-measures platelet aggregation of healthy and suspected patients in presence and absence of low-dose heparin

-high specificity but low ____

sensitivity

HIT treatment

-____ all forms of heparin and LMWH

stop

HIT treatment

_____ is recommended for anticoagulation

argatroban

HIT treatment

argatroban is recommended for anticoagulation, BUT if urgent cardiac surgery or PCI is required ____ is preferred

bivalirudin

HIT treatment- do not start warfarin until:

-platelets are at least _____/mm3 and overlap with a non-heparin anticoagulant for a minimum of ___ days

-the INR is in target range (2-3) for ___ hours

150,000, 5, 24

Argatroban falsely ____ the INR

elevates

What is the duration of HIT treatment for patients with HIT and thrombosis?

3 months

What is the duration of HIT treatment for patients with HIT and no thrombosis?

1 month

Argatroban

-dosage form is an ___ ____

-decrease dose in ___ impairment

IV infusion, hepatic

Argatroban Contraindications

-active major ___

bleeding

Argatroban Side Effects

-bleeding

-____

-____ (localized bleeding outside of blood vessels)

anemia, hematoma

Argatroban Monitoring

-___

-platelets

-Hct

-____ function

aPTT, liver

What is the brand name for Bivalirudin?

Angiomax

Bivalirudin

-dosage form for HIT (off label) is an __ ___

-decrease dose when CrCl<__mL/min

IV infusion, 30

Bivalirudin Contraindications

-active major ___

bleeding

Bivalirudin Side Effects

-bleeding

-___

-____ (localized bleeding outside of blood vessels)

anemia, hematoma

Bivalirudin Monitoring

-____ (activated clotting time)

-platelets

-Hgb

-Hct

-___ function

ACT, renal

What is the brand name for the Factor Xa inhibitor Apixaban?

Eliquis

What is dosing of Apixaban for VTE treatment?

10mg po bidx7 days, then 5mg po bid

Apixaban contraindications

-active pathological bleeding (avoid use with strong dual inducers/inhibitors of __ and ___-__

CYP3A4, P-gp

Apixaban side effects

-bleeding

-___

anemia

Apixaban monitoring

-Hgb

-Hct

-Scr

-___

LFTs

What is the brand name for the Factor Xa inhibitor Rivaroxaban?

Xarelto

Rivaroxaban can be used for VTE prophylaxis in ___ ___ patients

acutely ill

What is dosing of Rivaroxaban for VTE treatment?

15mg PO bid x 21 days, then 20mg po daily

avoid using Rivaroxaban if CrCl<___mL/min

30

Rivaroxaban 15mg and 20mg need to be taken with ___

food

Rivaroxaban contraindications

-active pathological bleeding (avoid use with strong dual inducers/inhibitors of __ and ___-__)

CYP3A4, P-gp

Rivaroxaban side effects

-bleeding

-___

anemia

Rivaroxaban monitoring

-Hbg

-Hct

-SCr

-___

LFTs

What is the brand name for the Factor Xa inhibitor Edoxaban?

Savaysa

What is dosing of Edoxaban for VTE treatment?

60mg po daily

What is dosing of Edoxaban for VTE treatment if CrCl is 15-50 mL/min or if patient is <60kg or on certain P-gp inhibitors?

30 mg po daily

using Edoxaban is not recommended if CrCl< ___mL/min

15

Edoxaban must be started after 5-10 days of ___ anticoagulation

parenteral

Edoxaban contraindications

-active pathological __

bleeding

Edoxaban side effects

-bleeding

-anemia

-____

-increased ___

rash, LFTs

Edoxaban monitoring

-Hgb

-Hct

-SCr

-___

LFTs

What is the brand name of Fondaparinux?

Arixtra

Fondaparinux VTE treatment dosing:

-for <50kg patients?

5mg SC daily

Fondaparinux VTE treatment dosing:

-for 50-100kg patients?

7.5mg SC daily

Fondaparinux VTE treatment dosing:

-for >100kg patients?

10 mg SC daily

Fondaparinux Contraindications

-active major bleed

-CrCl< ___ mL/min

-patients <___kg when being used for VTE prophylaxis

30, 50

Fondaparinux Contraindications

-_______ (low platelets)

-bacterial ____ (infection in heart)

thrombocytopenia, endocarditis

Fondaparinux Side Effects

-bleeding

-anemia

-thrombocytopenia

-___kalemia

-____tension

hypo, hypo

Fondaparinux Monitoring

-___-__

-platelets

-Hgb

-Hct

-Scr

anti-xa

What is the brand name of Dabigatran?

Pradaxa

when using Dabigatran for VTE treatment, it must be started 5-10 days after a ___ ___

parenteral anticoagulant

-avoid using Dabigatran if CrCl<___mL/min AND patient is on a __-__ inhibitor

30, P-gp

Dabigatran Contraindications

-active pathological bleeding

-mechanical ___ ___ valve(s)

prosthetic heart

Dabigatran Side Effects

-Bleeding (especially ____ bleeding)

-dyspepsia

-____-like symptoms

GI, gastritis

Dabigatran Monitoring

-___ (hemoglobin)

-___ (hematocrit)

-Scr

Hgb, Hct

Dabigatran capsules contain drug-coated pellets (“beads”) surrounded by ____ acid. This acidic core is what causes dyspepsia and gastritis-like symptoms

tartaric