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Pharm - VTE
Exam 3
84
Pharmacology
Graduate
04/12/2010

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Cards

Term
What % of patients with DVT has post-thrombotic syndrome?
Definition
30%
Term
What is post-thrombotic syndrome?
Definition
chronic pain and swelling caused by clot formation in the venous circulation
Term
What % of PE patients have chronic thromboembolic pulmonary hypertension?
Definition
4%
Term
Ho many VTE patients are there each year?
Definition
2 million
Term
What % of VTE patients have clinically silent disease?
Definition
50%
Term
T/F
The majority of VTE patients are treated in the hospital.
Definition
False - majority are treated outpatietn
Term
What % of VTE cases result in death within 1 hour?
Definition
20%
Term
What is the leading cause of death in women after a live birth?
Definition
VTE
Term
What is the mortality rate for a hemodynamically stable PE patient?
Definition
4.1%
Term
What 3 factors make up Virchow's triad?
Definition
hemodynamic imbalance (stasis)
hypercoagulability
vessel wall damage
Term
What things may cause stasis?
Definition
burns, cancer, pregnancy, HF, major surgery, fracture, MI, stroke
Term
What things may cause hypercoagulability?
Definition
estrogen therapy, thrombophilias, previous VTE, pregnancy, cancer
Term
What things may cause vessel wall damage?
Definition
trauma, major surgery, fracture
Term
Name 7 risk factors for VTE
Definition
1. multiple trauma
2. major surgery
3. immobility
4. hypercoagulability
5. oral contraceptives
6. obesity
7. smoking
Term
T/F
The risk for VTE remains for months after surgery.
Definition
True
Term
What % risk is there for developing VTE after hip, knee, abdominal, or gynecological surgery?
Definition
30%
Term
What things may cause a hypercoagulable state?
Definition
mutations in clotting factors, hyperchromocystinemia, inflammatory bowel disease, pregnancy, postpartum, nephrotic syndrome, CHF
Term
T/F
Risk for VTE doubles each decade of life after age 50.
Definition
True
Term
At what altitude is there risk for high altitude induced DVT?
Definition
above 9,000 feet
Term
T/F
The hypercoagulable state induced by high altitudes exists for several weeks after.
Definition
True
Term
In what 3 situations should you always look for PE?
Definition
1. isolated dyspnea or pleuritic pain
2. hemoptysis
3. circulatory collapse without apparent cause
Term
What may PE be secondary to?
Definition
1. inherited coagulation disorder - 30% of patients with DVT/PE
2. cancer
Term
T/F
For 25% of patients with cancer and PE, PE is the sentinel event.
Definition
True
Term
What are the 5 most common sites for cancer in patients diagnosed with idiopathic VTE?
Definition
lung, pancreas, colon/rectum, kidney, prostate
Term
T/F
VTE can precede the diagnosis of malignancy by months or even years.
Definition
True
Term
T/F
A thrombus involving the proximal leg veins is more likely to result in PE.
Definition
True
Term
List the clinical features of DVT that are used to determine likelihood of diagnosis.
Definition
1. Tenderness along deep venous system
2. swelling of the leg
3. pitting edema
4. collateral superficial veins
5. active cancer
6. immobility or paralysis
7. recent surgery

These are all given 1 point

8. Other diagnosis likely (cellulitis, phlebitis) -2 pts
Term
Using the point system for the features of DVT, what is a high, moderate and low score?
Definition
high >/= 3 pts
moderate 1-2 pts
low
Term
What tests do you run to diagnose DVT?
Definition
ultrasound of leg
CBC
platelet count
PT/INR
aPTT - activated partial prothrombin time
CMP
Set samples aside for testing for thrombophilias before starting heparin and warfarin
Term
What are 3 common abnormalities found when trying to make the diagnosis of DVT?
Definition
electrolyte
renal
hepatic
Term
What tests do you run to diagnose PE?
Definition
CBC
platelet count
CMP
PT/INR
aPTT
spiral CT (70% sensitive)
V/Q scanning
D dimer
Angiography
Term
What is the normal D dimer value?
Definition
< 0.5 mg/L
Term
How sensitive is the D dimer for PE?
Definition
If D dimer is normal and patient is low risk, we are 95% sure that the patient does not have a PE
Term
T/F
If the D dimer is elevated, it is almost certainly PE.
Definition
False - elevated D dimer is a nonspecific result
Term
What is the gold standard diagnostic test for PE?
Definition
angiography
Term
Why is angiography not always done for PE diagnosis?
Definition
invasive and unavailable in some settngs
Term
What are the Wells Prediction Rules for Pretest Probability of PE?
Definition
Clinical signs of DVT - 3
Recent surgery or immbolization - 1.5
active cancer - 1
Past history of DVT or PE - 1.5
Hemptysis - 1
Tachycardia - 1.5
Unexplained SOB or chest pain (alt. dx less likely than PE) - 3
Term
According to the Wells Prediction Rules for PE, what is a high, moderate, and low score?
Definition
high >/= 6
moderate 2-6
low
Term
What is the non-pharmacologic treatment for DVT?
Definition
limb elevation
application of heat to the area of pain
minimal activity
compression stockings
Term
T/F
Thrombolytic therapy is used for most VTE patients.
Definition
False - it is used only in rare instances
Term
What is the pharmacologic treatment for VTE?
Definition
rapid acting anticoagulant - unfractionated heparin, LMW heparin, or fondaparinux

Plus warfarin sodium
Term
T/F
UFH, LMWH, and warfarin dissolve clots.
Definition
False - clots are removed by normal physiologic processes. The drugs are to prevent further clotting
Term
When will thrombolytic therapy improve patient outcomes?
Definition
only in severe cases
Term
When is the only time thrombolytic therapy is used to treat DVT?
Definition
only to treat or prevent gangrene
Term
Why is thrombolytic therapy not frequently used to treat VTE?
Definition
risk of hemorrhage outweighs the benefits of treatment
Term
When is thrombolytic therapy used to treat PE?
Definition
massive PE
patient in shock, severe hypoxemia, right heart failure, hypotension
Term
What is the surgical alternative to thrombolytic therapy?
Definition
venous thrombectomy
Term
How do thrombolytics work?
Definition
proteolytic enzymes convert plasminogen to plasmin which degrades the fibrin matrix

they enhance the natural process of clot removal
Term
T/F
One week following acute treatment, clot lysis and vessel patency are similar with or without thrombolytic therapy.
Definition
True
Term
Name 2 conventional thrombolytic agents.
Definition
streptokinase and urokinase - nonselective plasmin production
Term
Name 1 clot (Fibrin)-selective thrombolytic agent.
Definition
Activase
Term
T/F
streptokinase and urokinase work on both the clot and circulation in general.
Definition
True
Term
Name 6 counterindications to anti-thrombotic therapy.
Definition
1. recent thoracic, abdominal, or CNS surgery
2. recent cerebrovascular accident, trauma, or neoplasm
3. bleeding ulcer
4. malignant hypertension
5. anticipated invasive procedures
6. concurrent hemostatic dysfunction
Term
Why do we monitor both the aPTT and the PT?
Definition
aPTT - integrity of the intrinsic clotting pathways

PT - integrity of extrinsic clotting pathways
Term
T/F
Weight based dosing of UFH to treat DVT is more effective.
Definition
True - more patients at goal in 24 hours
Term
What is the therapeutic goal after heparin treatment?
Definition
48-71 seconds clotting time
Term
Name the 4 anticoagulant properties of heparin.
Definition
1. inhibits activation of fibrin stabilizing enzyme
2. inhibits the aggregation of platelets by thrombin
3. inhibits the thrombin-mediated conversion of fibrinogen to fibrin
4. inhibits activated factors II, VII, IX, and X
Term
Name 3 LMW Heparins.
Definition
enoxaparin, dalteparin, and tinzaparin

used for treatment of DVT with or without PE
Term
T/F
UFH and LMWH both enhance the activity of antithrombin.
Definition
True
Term
How do you treat bleeding that is a side effect of both UFH and LMWH?
Definition
protamine sulfate

maximum dose 50 mg
discontinue any heparin dose
Term
What is the maximum dose of protamine sulfate?
Definition
50 mg
Term
How is protamine sulfate given in proportion to heparin?
Definition
1 mg/1 mg or 1 mg/100 units
Term
What are the benefits of using LMWH over UFH?
Definition
1. LMWH has a more reliable/predictable anticoagulation response
2. greater subQ bioavailability
3. Lower incidence of thrombocytopenia
4. reduced need for lab monitoring
5. dose independent clearance
6. Lower incidence of Heparin Induced Thrombocytopenia
Term
How do we dose fondaparinux for use with DVT or PE?
Definition
< 50 kg - use 5 mg SC QD for 5-9 days
50-100 kg - use 7.5 mg
> 100 kg - use 10 mg
Term
What precautions do we need to be aware of when using fondaparinux?
Definition
renal excretion - unchanged
elevations in ALT and AST
QT prolongation
Term
T/F
Fondaparinux is a synthetic compound and has a more predictable pharmacokinetic response than LMWH.
Definition
True
Term
What kind of drug is fondaparinux?
Definition
Factor Xa inhibitor
Term
T/F
Fondaparinux has no interaction with thrombin.
Definition
True
Term
T/F
Fondaparinux tends to cross react with HIT antibodies.
Definition
False - it does not
Term
What is the half life of fondaparinux?
Definition
17-21 hours for once daily dosing
Term
When are direct thrombin inhibitors used?
Definition
to treat heparin induced thrombocytopenia
Term
Name 4 direct thrombin inhibitors.
Definition
1. argatroban
2. bivalrudin
3. desirudin
4. lepirudin
Term
How do direct thrombin inhibitors work?
Definition
interact directly with the thrombin molecule - inhibiting both circulating and clotting thrombin
Term
T/F
Direct thrombin inhibitors can induce thrombocytopenia.
Definition
False
Term
Name the contraindications for anti-thrombotic therapy.
Definition
inaccessible ulcerative lesion (GI lesion)
CNS lesion (stroke, surgery, trauma)
Spinal anesthesia or LP
malignant HTN
advanced retinopathy
Term
What is the starting dose of warfarin sodium for DVT/PE patients?
Definition
5/10 mg per day
Term
When do you begin to adjust the warfarin dose daily?
Definition
after day 3
Term
How do you dose warfarin on day 3 for DVT/PE?
Definition
INR < 1.3 - increase dose to 7.5/15
INR 1.3-1.6 - continue dose
INR 1.7-1.9 - decrease dose to 2.5/5
INR 2.0-2.2 - decrease dose to 1/2.5
INR > 2.3 - hold one day then use 1/2.5
Term
How often do you monitor the PT/INR of DVT/PE patients on coumadin?
Definition
weekly until stable for 2 weeks, then monthly
Term
What are some contraindications to anti-thrombotic therapy with coumadin?
Definition
(in ambulatory patients)
early and late pregnancy
poor patient cooperation, understanding, and reliability
unsatisfactory lab or pt follow up
occupational risk to trauma
Term
What is the goal INR for all pts on coumadin except those with mechanical prosthetic valves or recurrent systemic embolism?
Definition
2.0-3.0

For the 2 exceptions listed: 3.0-4.5
Term
How long does the American College of Chest Physicians recommend coumadin therapy for DVT/PE?
Definition
6-12 months

optimal duration is uncertain
Term
What is the DOC for anticoagulation during pregnancy?
Definition
UFH or LMWH

LMWH is "good" alternative according to book, but according to some studies, it is the DOC
Term
What anti-coagulating drug may be used in infants and children?
Definition
UFH
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