PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
VTE
• Statistics
o 600,000 – 900,000 cases of VTE per year
▪ 100k to 300k deaths 25%
sudden, 10-30% die within a
month
o Long term post thrombotic
syndrome
▪ Pain, swelling, scaling,
and discoloration
• VTE can be deep vein thrombosis or a
pulmonary embolism
• Virchows Triad is super important
o Alterations in blood flow,
endothelial injury, and
hypercoagulability can cause clotting
• Thrombosis
o Thrombus is a clot that develops but remains stationary (DVT)
o Embolus is a clot that travels from site where it was formed (PE)
• Artery vs. Vein
o VTE happens mostly in veins because there is low pressure and
high volume compared to arteries.
o Artery Clot: White, made up of platelets, at sites of injury
o Venous Clot: Red, made of fibrin and RBCs, usually from stasis and injury.
• Clinical Presentations
o DVT:
▪ Leg pain, swelling, tenderness, warmth, redness
o PE:
▪ Dyspnea, chest and back pain, cough, fever, hemoptysis, fatigue,
syncope, fast and irregular HR, low BP.
• Risk Factors (see table)
• Prevention
o Identify risk factors and
determine level of risk at
admission or at change
in clinical status
o Select regiments that best
protect that level while
keeping in mind bleeding
risk (mechanical, Pharm)
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
,PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
• CHEST guidelines: VTE risk
• When to use
mechanical
prophylaxis?
o Low risk, high bleed,
contraindications, or in
addition to
pharmacologic
methods.
o Displace blood from
superficial to the
deep veins by
increasing velocity
and volume
▪ Graduated
compression
stocking, intermittent pneumatic compression devices, and venous foot
pumps.
o Inferior vena cava filter (IVC filter) prevents
embolization of thrombus formed in lower
extremeties
▪ Minimally invasive, but not as common,
offers short term protection, and limited
efficacy data.
• Lifestyle changes
o Exercise, monitor weight, stop smoking,
hydration, avoid prolonged immobility.
• Who gets Pharmacological treatment?
o Mostly surgical hip, knee surgeries.
▪ Start night prior or post op and extend up to
2 months
o Acutely ill MEDICAL
patients with
PADUA score
>/= 4
o Given while in hospital
• PADUA Score:
o high risk if >/= 4 points
o Malignant conditions
(lung, pancreas, colon,
rectum, kidney,
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
,PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
prostate)
o CKD
o IBS
o Pregnancy and hormones
o Oral contraceptives with estrogen
• VTE prophylaxis pharmacological options?
o UFH (SQ), LMWH, fondaparinux, warfarin, dabigatran, rivaroxaban, apixiban.
o NO Aps
VTE Therapeutics
• Diagnosis -- Objective
o Done alone via clinical assessment – risk factors and probability scores
o D-Dimer tests
▪ Blood test that tests for fibrin degradation products. Sensitive, but
not specific.
o Imaging:
▪ DVT:
• Ultrasound and Invasive contrast venography
▪ PE:
• CT scan, V/Q scan (measure blood and airflow through lungs)
• Goals of Therapy
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
, PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
o Decrease progression/incidence/complications from DVT to PE
▪ Prevent long-term complications such as Post-thrombotic syndrome
o Avoid bleeding complications
o Prevent and treat symptoms of DVT and PE
• Treatment of VTE
o Initial – 0-7 days
▪ UFH, LMWH, Fondaparinux, IV DTIs, Rivaroxaban, Apixiban, Fibrinolytics
• IV Heparin = 80 units/kg bolus then 18 units/kg/hr continuous
infusion
o Monitor Platelets and HIT
o Long term – 7 days to 3 months
o Extended therapy – 3 months to infinity
• MOA of parenteral ACs
o UFH
▪ Binds to AT inactivates thrombin and factor 10a (factor 5 and 8) can be
reversed with protamine
o LMWH
▪ Bind to AT inactivates factor 10a (9a, 12a, thrombin)
o Factor 10a inhibitors
▪ Fondaparinux Binds to AT inhibits 10a
o Direct thrombin inhibitors
▪ Bivalirudin do not binds to AT, but binds to circulating clot-bound
thrombin reversible
• UFH monitoring
o aPTT (activated partial thromboplastin time)
▪ Monitors AC effect to determine
anticoagulation and should be
measured prior to start to
obtain baseline.
o Heparin reversal
▪ Protamine is cationic, binds
to anionic heparin to form a
salt
▪ Neutralizes in 5 mins, lasts for 2 hours.
▪ Dosing based on heparin IN the patient
• If heparin given within 30-60 minutes, give 1mg
protamine for every 100 units of heparin (max 50mg)
• If given over an hour ago, decrease protamine dose. May not
be beneficial if dose was given more than 5-6 hours prior.
o MONITORING
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
Module 4 2022 Pharmacy and Health Sciences Study Guide
VTE
• Statistics
o 600,000 – 900,000 cases of VTE per year
▪ 100k to 300k deaths 25%
sudden, 10-30% die within a
month
o Long term post thrombotic
syndrome
▪ Pain, swelling, scaling,
and discoloration
• VTE can be deep vein thrombosis or a
pulmonary embolism
• Virchows Triad is super important
o Alterations in blood flow,
endothelial injury, and
hypercoagulability can cause clotting
• Thrombosis
o Thrombus is a clot that develops but remains stationary (DVT)
o Embolus is a clot that travels from site where it was formed (PE)
• Artery vs. Vein
o VTE happens mostly in veins because there is low pressure and
high volume compared to arteries.
o Artery Clot: White, made up of platelets, at sites of injury
o Venous Clot: Red, made of fibrin and RBCs, usually from stasis and injury.
• Clinical Presentations
o DVT:
▪ Leg pain, swelling, tenderness, warmth, redness
o PE:
▪ Dyspnea, chest and back pain, cough, fever, hemoptysis, fatigue,
syncope, fast and irregular HR, low BP.
• Risk Factors (see table)
• Prevention
o Identify risk factors and
determine level of risk at
admission or at change
in clinical status
o Select regiments that best
protect that level while
keeping in mind bleeding
risk (mechanical, Pharm)
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
,PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
• CHEST guidelines: VTE risk
• When to use
mechanical
prophylaxis?
o Low risk, high bleed,
contraindications, or in
addition to
pharmacologic
methods.
o Displace blood from
superficial to the
deep veins by
increasing velocity
and volume
▪ Graduated
compression
stocking, intermittent pneumatic compression devices, and venous foot
pumps.
o Inferior vena cava filter (IVC filter) prevents
embolization of thrombus formed in lower
extremeties
▪ Minimally invasive, but not as common,
offers short term protection, and limited
efficacy data.
• Lifestyle changes
o Exercise, monitor weight, stop smoking,
hydration, avoid prolonged immobility.
• Who gets Pharmacological treatment?
o Mostly surgical hip, knee surgeries.
▪ Start night prior or post op and extend up to
2 months
o Acutely ill MEDICAL
patients with
PADUA score
>/= 4
o Given while in hospital
• PADUA Score:
o high risk if >/= 4 points
o Malignant conditions
(lung, pancreas, colon,
rectum, kidney,
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
,PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
prostate)
o CKD
o IBS
o Pregnancy and hormones
o Oral contraceptives with estrogen
• VTE prophylaxis pharmacological options?
o UFH (SQ), LMWH, fondaparinux, warfarin, dabigatran, rivaroxaban, apixiban.
o NO Aps
VTE Therapeutics
• Diagnosis -- Objective
o Done alone via clinical assessment – risk factors and probability scores
o D-Dimer tests
▪ Blood test that tests for fibrin degradation products. Sensitive, but
not specific.
o Imaging:
▪ DVT:
• Ultrasound and Invasive contrast venography
▪ PE:
• CT scan, V/Q scan (measure blood and airflow through lungs)
• Goals of Therapy
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
, PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
o Decrease progression/incidence/complications from DVT to PE
▪ Prevent long-term complications such as Post-thrombotic syndrome
o Avoid bleeding complications
o Prevent and treat symptoms of DVT and PE
• Treatment of VTE
o Initial – 0-7 days
▪ UFH, LMWH, Fondaparinux, IV DTIs, Rivaroxaban, Apixiban, Fibrinolytics
• IV Heparin = 80 units/kg bolus then 18 units/kg/hr continuous
infusion
o Monitor Platelets and HIT
o Long term – 7 days to 3 months
o Extended therapy – 3 months to infinity
• MOA of parenteral ACs
o UFH
▪ Binds to AT inactivates thrombin and factor 10a (factor 5 and 8) can be
reversed with protamine
o LMWH
▪ Bind to AT inactivates factor 10a (9a, 12a, thrombin)
o Factor 10a inhibitors
▪ Fondaparinux Binds to AT inhibits 10a
o Direct thrombin inhibitors
▪ Bivalirudin do not binds to AT, but binds to circulating clot-bound
thrombin reversible
• UFH monitoring
o aPTT (activated partial thromboplastin time)
▪ Monitors AC effect to determine
anticoagulation and should be
measured prior to start to
obtain baseline.
o Heparin reversal
▪ Protamine is cationic, binds
to anionic heparin to form a
salt
▪ Neutralizes in 5 mins, lasts for 2 hours.
▪ Dosing based on heparin IN the patient
• If heparin given within 30-60 minutes, give 1mg
protamine for every 100 units of heparin (max 50mg)
• If given over an hour ago, decrease protamine dose. May not
be beneficial if dose was given more than 5-6 hours prior.
o MONITORING
PHARMACY 112CARDIO VTE DYSLIPIDEMIA Albany College
Module 4 2022 Pharmacy and Health Sciences Study Guide
