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VTE, 💡antithrombotics include antiplatelets, anticoagulants,…
VTE
4. Treatment Options
(antithrombotic agents)
warfarin
(stabilizes clot)
INR
initiation/maintenance
mechanism
indirectly impacts clotting factors; delayed
thrombolytics
role in
massive
PE
injectable anticoagulants
(stabilize clot)
UFH
Fondaparinux
LMWH
antidotes
Andexanet Alfa
Vitamin K
idarucizumab
Direct Oral Anticoagulants (DOACs)
(stabilize clot)
rivaroxaban
edoxaban
apixaban
dabigatran
act directly on clotting factors quickly
antiplatelets
(stabilize clot)
ASA, ticlopidine, clopidogrel, dipyridamole, prasugrel, ticagrelor
fibrinolytics
(break down the clot)
streptokinase, alteplase, tenecteplase, reteplase
1. VTE Basics
Virchow's Triad (3)
hyper coagulable state, endothelial injury, circulatory stasis
risk factors to getting a clot
abnormal blood vessels: disruption of a plaque, injury, change in tissue
abnormal blood flow: blood flows through veins at a low pressure, so there can be risk of it stopping completely (stasis) and forming a clot; caused by not moving around, HF, AF
abnormal blood: overactive clotting factors, high estrogen, cancer
Definition of VTE
DVT
clot in deep veins (legs, arms, cerebral)
PE
blockage of a lung artery by a clot that has traveled from somewhere else in the body like legs or pelvis
VTE: blood clot in the vein that may or may not embolize
Red vs White Clot (arterial vs venous)
white clot happens in arteries and is called "atherosclerotic", it is caused by platelets so it needs antiplatelet tx
presents as: ACS or atherosclerotic stroke
red clot happens in veins and is called "thrombus", it is caused by RBC being trapped within the walls due to fibrin; it needs anticoagulant for tx
presents as: VTE, or cardioembolic stroke
arteries vs veins
arteries have high flow and pressure and have thick walls; carry oxygenated blood
veins have low flow and pressure and have thinner walls; carry Deoxygenated blood
complications of VTE
DVT ➡️ PE, recurrence, post-clot syndrome, pain in limbs
PE ➡️ death, recurrence, pulmonary HTN, right ventricle failure
7. Monitoring and Management
Anti-Xa levels for LMWH
HIT (Type I vs II)
monitoring DOACs (when needed)
managing critical INRs
INR for warfarin
duration and follow-up strategies
5. Choosing + Dosing Therapy
dose adjustments
weight
age
renal
duration of therapy
provoked VTE
unprovoked VTE
parenteral bridging
dabigatran
edoxaban
summary table: DOAC dosing in VTE
DOACs: drug-specific regimens
6. Special Populations and Contraindications
pregnancy and breastfeeding
drug interactions (CYP 3A4, P-gp)
renal/hepatic dysfunction
COVID + VTE risk
cancer-associated thrombosis
2. Clinical Presentation and Diagnosis
Signs and Sx of PE
SOB, hypoxemia, tachycardia, sudden cough, chest pain that worsens with breathing, tiredness, more vascular resistance in the lungs, fainting, confusion, unstable body
Severity Classifications of PE
sub-massive
no hypotension; right ventricle of the heart is starting to fail, high troponin and BNP
non-massive
stable, no need for hospital admission
massive
unstable, in shock; admitted to hospital
Signs and Symptoms of DVT
Distal DVT (legs)
anything below the knee, smaller veins, smaller clots; likely to get bigger and travel up the leg
superficial vein thrombosis (SVT)
can happen in the legs, but in the superficial veins, not deep ones, so risk of PE is low, and urgency is not that high
presents as red, warm, inflamed tender area
proximal DVT (legs)
majority of DVTs; anything above knee, larger veins, larger clots; more likely to travel up to lungs
pain, tenderness in area, swelling far from the clot, discolouration, joint pain, warm,
nonspecific sx/signs = we NEED testing to confirm DVT
diagnostic tools
D-dimer blood test
used for low-intermediate likelihood of the diagnosis being VTE
above threshold ➡️ do a compression US to confirm VTE
below threshold ➡️ not VTE ❌
Compression Ultrasonography
done right away if high likelihood of VTE, or if D-dimer was high; useful for PROXIMAL DVT
Wells Criteria (DVT and PE)
DVT
low = 0 ✅
intermediate = 1-2 ⚠️
high = 3+ 🚩
active cancer (1), paralysis (1), bedridden or has had surgery (1), local tenderness (1), entire leg swollen (1), calf swelling 3+cm (1), superficial veins (1)
PE
low = 1-2
intermediate = 2-6
high = 7+
hx of PE or DVT (1.5), HR >100 (1.5), recent surgery (1.5), clinical signs of DVT (3), cancer (1)
if intermediate or high, an OAC should be initiated while waiting for tests
V/Q, CT angiography
for PE diagnosis
CT angiography has risk of cancer bc of radiation so be careful when using
3. Goals + Phases of Treatment
Goals:
reduce sx of clot
recurrence
prevent PE death
prevent long term complications of DVT/PE
treatment phases
long term (7-21 days to 3-6 months)
goal
: let the clot heal
warfarin (INR of 2-3) OR DOACs
extended (secondary prevention, can be lifelong)
goal
: prevent future clots
warfarin (less common now) OR DOACs (low doses sometimes)
initial (0-7 days)
injection anticoagulant + warfarin/
dabigatran/edoxaban OR riva high dose OR apix high dose
goal
: stabilize the clot from growing or moving
💡antithrombotics include antiplatelets, anticoagulants, fibrinolytics