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Thromboembolism Risk and "Bleeding Patients"


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Thromboembolism Risk and "Bleeding Patients"

  1. 1. Thromboembolism risk. COCP/ HRT, long haul travel, referral of suspected DVT Dr Gary Benson Haemophilia Centre Director N Ireland Haemophilia Comprehensive Care Centre BHSCT
  2. 2. Aim <ul><li>Family history </li></ul><ul><li>Thrombophilia screen </li></ul><ul><li>COCP/ HRT </li></ul><ul><li>Long haul flight </li></ul><ul><li>Wells score </li></ul>
  3. 5. Family history <ul><li>First degree family member with history of unprovoked VTE prior to the age of 40 years. </li></ul>
  4. 6. Thrombophilia screen <ul><li>Acquired </li></ul><ul><ul><li>Lupus anticoagulant </li></ul></ul><ul><li>Congenital </li></ul><ul><ul><li>Antithrombin deficiency </li></ul></ul><ul><ul><li>Protein C/ S deficiency </li></ul></ul><ul><ul><li>Factor V Leiden </li></ul></ul><ul><ul><li>Prothrombin G20210A </li></ul></ul>
  5. 7. 1 st VTE related to OCP, pregnancy, HRT. 1 st VTE not related to altered hormonal status Hormonal status Peak <400nm Peak >400nm Thrombin generation Within reference range Shortened APTT Within reference range Raised D-dimer Good Poor (especially INR <1.5) Quality of anticoagulant control Absent Present Residual thrombosis Femoral/ popliteal Iliofemoral Site of thrombosis Hispanic/ African American Caucasian Race Female Male Gender Absent Present Malignancy Absent Present Thrombophilia Transient (e.g. surgery) Idiopathic Cause of 1 st VTE Lower risk of recurrence Higher risk of recurrence Factor
  6. 8. COCP/ HRT <ul><li>COCP </li></ul><ul><ul><li>3 rd generation greater risk </li></ul></ul><ul><ul><li>Dianette as high even if for skin! </li></ul></ul><ul><li>POP </li></ul><ul><ul><li>Risk less that combined but not zero </li></ul></ul><ul><li>HRT </li></ul><ul><ul><li>Contraindicated if history of hormonally mediated clot </li></ul></ul><ul><ul><li>Remember older patient </li></ul></ul><ul><ul><li>Anticoagulate to allow HRT </li></ul></ul>
  7. 9. DVT risk assessment, Wells score
  8. 10. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Wells PS; Anderson DR; Bormanis J; Guy F; Mitchell M; Gray L; Clement C; Robinson KS; Lewandowski B Lancet 1997 Dec 20-27;350(9094):1795-8. +1 Previously documented DVT -2 Alternative diagnosis more likely than DVT +1 Active cancer or cancer treated within six months +1 Collateral non-varicose superficial veins +1 Pitting edema greater in the symptomatic leg +1 Calf swelling 3 cm greater that the other leg, measured 10 cm below the tibial tuberosity +1 Swelling of an entire leg +1 Localized tenderness in the deep vein system +1 Recently bedridden for longer than three days or major surgery within the past four weeks +1 Paralysis, paresis, or recent orthopaedic casting of a lower extremity
  9. 11. LOW MODERATE HIGH Probability <1 1-2 >3 Score
  10. 13. Ruling out the diagnosis of venous thromboembolism in the elderly: is it time to revise the role of D-dimer? 19 777 1 168 >85 14 287 75-84 25 159 65-74 35 85 55-64 47 78 <54 % negative D-dimer No. of patients Age
  11. 14. Normal pregnancy Venous malformations Chronic renal failure and underlying cardiovascular disease Acute renal failure Nephrotic syndrome (eg, renal vein thrombosis) Renal disease Malignancy Severe liver disease (decreased clearance) Vasoocclusive episode of sickle cell disease Systemic inflammatory response syndrome Surgery/trauma (eg, tissue ischemia, necrosis) Severe infection/sepsis/inflammation Cardiovascular disease, congestive failure Abnormal fibrinolysis; use of thrombolytic agents Preeclampsia and eclampsia Disseminated intravascular coagulation Pulmonary embolism Deep vein thrombosis Venous thromboembolic disease Intracardiac thrombus Atrial fibrillation Acute limb ischemia Stroke Myocardial infarction Arterial thromboembolic disease
  12. 15. <ul><li>The pretest probability of DVT is determined from the Wells score and a D-dimer test is performed </li></ul><ul><li>For those with a &quot;low probability&quot; score and a negative D-dimer, DVT is effectively ruled out. If the D-dimer test is positive, ultrasound is performed to rule out DVT </li></ul><ul><li>For those in whom DVT is likely (ie, Wells score ≥1) ultrasound is performed in all patients to rule out DVT. For the separate group in which the D-dimer test was positive and the initial ultrasound negative, a repeat ultrasound is performed one week later to rule out DVT. </li></ul>
  13. 16. “ Bleeding patients” Assessment of patients presenting with bruising/ nose bleeds and suspected bleeding disorder
  14. 17. Aim <ul><li>Family history </li></ul><ul><li>Significant bleeds </li></ul><ul><li>Acquired vs congenital bleeding disorders </li></ul>
  15. 19. Classification of bleeding disorders <ul><li>Disorders of primary haemostasis </li></ul><ul><li>Disorders of coagulation factors </li></ul><ul><li>Disorders of fibrinolysis </li></ul><ul><li>Disorders of vessel walls/ skin </li></ul>
  16. 20. Evaluation of the Bleeding Patient <ul><li>Type and extent of bleeding (eg, mucous membrane bleeding, petechiae, haemarthrosis, severity, etc.) </li></ul><ul><li>Past history of bleeding, surgery, dental extractions </li></ul><ul><li>Family history of bleeding disorder, autoimmune disease </li></ul><ul><li>Underlying diseases (eg, liver disease, renal failure, malabsorption syndrome, sepsis, SLE) </li></ul>
  17. 21. Mucocutaneous haemorrhage <ul><li>Nose bleeds (epistaxis) </li></ul><ul><li>Gum bleeds (gingival bleeding) </li></ul><ul><li>Excessive bruising </li></ul><ul><li>Gastrointestinal bleeding </li></ul><ul><li>Bleeding following tooth extraction </li></ul><ul><li>Post-operative bleeding </li></ul><ul><li>Heavy periods (menorrhagia) </li></ul><ul><li>Postpartum hemorrhage </li></ul><ul><li>Heavy bleeding following cuts </li></ul>
  18. 22. Menorrhagia can be defined objectively or subjectively <ul><li>Objectively , menorrhagia is taken to be a total menstrual blood loss –80 ml per menstruation </li></ul><ul><li>Subjectively , menorrhagia is defined as a complaint of excessive menstrual blood loss occurring over several consecutive cycles in a woman of reproductive years </li></ul>
  19. 23. What do you mean by heavy? <ul><li>Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours </li></ul><ul><li>The need to use double sanitary protection to control your menstrual flow </li></ul><ul><li>The need to change sanitary protection during the night </li></ul><ul><li>Menstrual period that lasts longer than 7 days </li></ul><ul><li>Menstrual flow that includes large blood clots </li></ul><ul><li>Heavy menstrual flow that interferes with your regular lifestyle </li></ul><ul><li>Constant pain in the lower abdomen during menstrual period </li></ul><ul><li>Irregular menstrual periods </li></ul><ul><li>Tiredness, fatigue or shortness of breath (symptoms of anaemia) </li></ul>
  20. 24. Von Willebrands disease <ul><li>Type 1 </li></ul><ul><li>Type 2 </li></ul><ul><li>Type 3 </li></ul>
  21. 25. Acute menorrhagia in adolescents <ul><li>9-year case review January 1971-80 </li></ul><ul><li>Admissions to hospital excluding genital tract pathology </li></ul><ul><li>Primary coagulation disorder </li></ul><ul><li>20% of total 59 patients </li></ul><ul><li>25% of those with HB < 10g/dl </li></ul><ul><li>33% of those requiring transfusion </li></ul><ul><li>50% of those presenting at the menarche </li></ul>Claessons and Cowell Am J Obstet Gynecol 1981; 139: 277-80
  22. 26. The frequency of bleeding symptoms in the normal population compared with 264 Scandinavian patients with VWD (Silwer, 1973; Mauser Bunschoten et al, 1988; Nosek-Cenkowska et al, 1991; Sramek et al, 1995)
  23. 27. Predictive value of bleeding symptoms in diagnosis of type 1 VWD (Tosetto et al JTH 2006)
  24. 28. Platelet disorders <ul><li>Congenital </li></ul><ul><ul><li>Storage pool disorders </li></ul></ul><ul><ul><li>Release defects </li></ul></ul><ul><ul><li>Surface glycoprotein deficiency </li></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Aspirin/ clopidogrel </li></ul></ul><ul><ul><li>NSAID </li></ul></ul><ul><ul><li>Cumin </li></ul></ul>
  25. 29. Disorders of clotting factors
  26. 31. Haemophilia <ul><li>Haemophilia A </li></ul><ul><li>Haemophilia B </li></ul><ul><li>Haemophilia C </li></ul>