Welcome Applicants!!

Morning ReportFriday, October 28th

DEEP VENOUS THROMBOSIS

What is a DVT?

Etiology• Presence of a CVL*• Genetic risk factors

(thrombophelia)• Underlying medical conditions

• Malignancy• Sepsis• Nephrotic syndrome• Vasculitis• Congenital heart disease

Risk Factors• Aging• Immobilization longer than 3 days• Pregnancy • Major surgery in the past 4 weeks• Trauma• IV drug use• Use of OCPs

Clinical Features• Extremity pain/ tenderness• Swelling• Palpable cord• Discoloration (erythema)• Venous distention• Prominence of superficial veins• Cyanosis

Diagnosis

• Gold standard= venography

• Doppler US• Adequate for Dx of

lower extremity DVT• Not very sensitive for

upper extremity DVT

When to Consider Thrombophelia…

• Positive family history• History of recurrent clots• Thrombi in unusual locations• Thrombosis at an early age

Activated Protein C Resistance

• Most common genetic disorder causing thrombophelia• 3-8% Caucasians• 1% African Americans

• Caused by Factor V Leiden mutation• Loss of the ability of the activated

protein C to neutralize ongoing activation of the factor V molecule

• Heterozygotes: threefold increased risk of DVT

• Homozygotes: 30-fold increased risk

Prothrombin 20210A Mutation

• Second most common genetic risk factor

• Mutation increased concentration of prothrombin in plasma 3-5 fold increase of thrombosis

Hyperhomocysteinemia• Mutations in the genes for

cystathionine and methylenetetrahydrofolate reductase elevated homocystine levels

• Rarely causes arterial or venous thrombotic disease in childhood

Deficiency of ATIII, Protein C or S

• Homozygous AT deficiency is incompatible with life

• Homozygous PC or PS deficiency purpura fulminans within hours of birth

• Heterozygotes: 50% increased risk of developing thromboembolism by middle age

Lipoprotein (a)• Elevated levels associated with

cardiac disease in adults• Also has anti-fibrinolytic properties

which can thrombotic disease• Serum levels >30mg/dL increase

the likelihood of thromboembolism by a factor of seven

Antiphospholipid Syndrome

• Due to circulating antibodies against a protein-lipid complex

• Can occur with or without rheumatologic disease

• Can lead to pregnancy-related complications• Miscarriage

Labs to Order

Treatment• Acute life-threatening occlusions

• Thrombolytic therapy• Acute non-life threatening

occlusions• Initally…

• Unfractionated heparin OR• Low-molecular weight heparin

• Then…• Transition heparin to warfarin OR• Continue LMWH

Treatment• Duration 3-6 months• May consider future prophylactic

anticoagulation in patients with genetic predisposition during high-risk situations

Complications• Pulmonary embolism• Recurrent thrombosis• Postphlebitic syndrome

• Chronic pain, swelling and discoloration of the affected extremity

Thanks for your attention!!Noon Conference: Class Housestaff!

*Dr. Desselle will be coming by each class meeting to explain inservice scores as well as go over journal club presentations with the third years!*