Thread by @helthy_dose

مره تجلط / يجلط "😤
بالعاميه معناه من كثر ما قهرني سبب لي جلطه
طيب لو تكلمنا من ناحيه علميه وطبيه واخذنا نوع من انواع الجلطات وتعرفنا عليه ايش راح يصير ؟؟
اكيد راح تزيد معلوماتنا الطبيه👻

اليوم نستكمل سلسله #cardiology وراح نتكلم عن
#venousThromboembolism

راح نتناول عده نقاط :🗒

🤔- ما هو الـ #venousThromboembolism

- ما الفرق بين التخثر الشرياني والتخثر الوريدي- 🤔

- الفسيولوجيا المرضيه للـ- 📖
#venousThromboembolism

كيف تتشكل الجلطه المرضيه ؟ 📈
ماهي عوامل الخطر واسباب الاصابه بـ 🚨#venousThromboembolism

ماهي الاعراض والعلامات الخطيره للـ🚑 #venousThromboembolism
كيف يتم التشخيص ؟👨🏻‍⚕
وماهو العلاج ؟💊
كيف نمنع الاصابه بـ💉 #venousThromboembolism
كيف يتم اداره الـ #venousThromboembolism اثناء الحمل ؟🤰🏻
كيف نقيم النتائج العلاجيه ؟📉📑

🤔- ما هو الـ #VenousThromboembolism
(VTE): blood clot that starts in a vein. It is the third leading
vascular diagnosis , after heart attack and stroke , potentially deadly medical condition .
الجلطات الدموية الوريدية : هي اضطراب شايع ومميت وممكن يعمل مضاعفات خطيرة

🔶There are two types:
1-(DVT = Deep Vein Thrombosis )
تخثر الوريد العميق
is a clot in a deep vein, usually in
the leg, but sometimes in the arm or other veins.

2-PE = Pulmonary Embolism
occurs when a DVT clot breaks free
from a vein wall, travels to the lungs and blocks some or all of the blood supply.
clots in the thigh are more likely to break off and travel to the lungs than blood clots in the lower leg or other parts of the body

🔹 ما الفرق بين التجلط الشرياني والتجلط الوريدي- 🤔؟
Arterial vs. Venous thrombosis:

الفسيولوجيا المرضيه للـ- 📖 📍
#venousThromboembolism

Pathologic VTE occurs in the absence of gross vessel wall damage and may be triggered by tissue factor (TF) brought to the clot formation site by circulating microparticles.

causing VTE impair B.F and often cause complete vessel occlusion.
Disruption of the endothelial cell lining with injury results in platelet activation and tissue mediated initiation of the clotting factor cascade, culminating in formation of thrombin and ultimately a fibrin clot.

🔶Pathologic thrombus formation
(تشكل الجلطة المرضية)
.
(A)
Activated platelets adhere to vascular endothelium.
(B)
Activated platelets express P-selectin.

(C)
Pathologic micro particles express active tissue factor and are present at a high concentration in the circulation—these micro particles accumulate, perhaps by binding to activated platelets expressing P-selectin.
.

.
(D)
Tissue factor can lead to thrombin generation, and thrombin generation leads to platelet thrombus formation and fibrin.

🚨📈 Risk factors and Causes for VTE include
عوامل الخطورة والأسباب لVTE تشمل :
Acquired : مكتسبة
1. Cancer السرطان
2. Obesity السمنه
3. Pregnancy الحمل
..
Inherited: وراثية
1. Activated P C
2. Factor V
3. AT deficiencies PS

Risk factors for VTE include📈🚨
عوامل الخطورة تشمل:
1-age كبار السن
2-History of VTE من يحمل تاريخ مرضي
3-Aspects related to Virchow’s triad
A-blood stasis ركود الدم
:e.g
immobility عدم الحركه,obesity السمنة
B-vascular injury إصابة الأوعية الدموية
:e.g
surgery الجراحة,trauma

Cont..
C-Hypercoagulability ارتفاع تخثر الدم
e.g:
malignancy سرطان,coagulation factor abnormalities,certain drugsبعض الادوية.
4-Activated protein C (aPC) resistance
- Results from a factor V gene mutation طفره في جين fV
5-Prothrombin G20210A mutation طفرة في البروثرومبين

📋💡Signs and symptoms:
الأعراض والعلامات
VTE can occur without any warning signs or symptoms. ممكن ان تحدث بدون اي اعراض او علامات
Symptoms that do appear may be associated with either DVT or PE. الاعراض الي تظهر قد تكون بسبب DVT او PE

Diagnosis
-Assessment should focus on identifying Risk factors
تقييم حالة المريض يجب ان تركز على عوامل الخطورة لدى المريض
Compression ultrasound (CUS) and computed tomography pulmonary angiography (CTPA)
يعتبر اكثر جهازان مستخدمان للفحص الأولي عند الاشتباه بوجود الجلطات الوريديه

Cont..📌
Radiographic contrast studies (venography, pulmonary angiography)
1. MostAccurate
2. reliable diagnostic methods
But
1. expensive
2. invasive
3. difficult to perform and evaluate.
تتعبر أكثر دقة في التشخيص ولكن من عيوبها إنها غالية الثمن وصعبة التطبيق

🔹- (V/Q) scan is an alternative PE diagnostic test.
- Serum concentration of d-dimer is nearly always elevated; values less than 500 ng/mL (mcg/L) combined with clinical decision rules are useful in ruling out VTE.
- Clinical assessment checklists (eg, Wells score) can be used.

Treatments :💊
 
A. Goal of therapy :
ممكن نعبر عنه بالاختصار (PPPR)
1- Prevent VTE at risk populations -
)من اهمهم)  critically care patient in the ICU
2- Prevent thrombus extension & embolization

3- Prevent complications as ( post thrombotic syndrome & chronic thrombotic pulmonary hypertention ).
4- Reduce recurrence risk.

B. Nonpharmacologic therapy:
1. Encourage patients ambulate as much as symptoms permit
تشجيع المرضى على الإسعاف على حسب الاعراض 🏩

2. Ambulation in conjunction with graduated compression stockings results in faster reduction in pain and swelling than strict bedrest with no increase in embolization rate.
استعمال الجوارب يؤدي الى تقليل الألم 🧦والانتفاخ اكثر من strict bedrest))

3. . Inferior vena cava filters should only be used when anticoagulants are contraindicated
due to active bleeding.
يجب استخدام الفينا كافا عندما لا تنفع مضادات التخثر 💊 🚫

4. Elimination of the obstructing thrombus via thrombolysis or thrombectomy may be warranted in life- or limb-threatening DVT
لازالة الجلطه احيانا نحتاج نستخدم Thrombolysis Or Thrombectomey

C. Pharmacological treatment:💊
Enoxaparin dose for Venous thromboembolism prophylaxis:
(الجرعة الوقائية)
- If the patient’s weight is less than 100kg 30mg subQ every 12 hours 
- If the patient’s weight is 100k or more then 40mg subQ every 12 hours.

- The dose can be adjusted after 3 to 4 doses of the initial dosage, change as needed to achieve an anti-Xa activity range of 0.2 to 0.5 international units/mL (if less than 0.2 international units/mL increase the dose by 20% and if greater than 0.5 international units/mL )

For patients with Cancer: -
(جرعات مرضى السرطان )
1. Prophylaxis dose: 40mg subQ once daily
2. Treatment dose: 1 mg/kg subQ every 12 hours or 1.5 mg/kg subQ every 24 hours
Enoxaparin dose for Deep vein thrombosis:-

-

1. Inpatient, with or without pulmonary embolism 1 mg/kg subQ every 12 hours or 1.5 mg/kg subQ every 24 hours
2. Outpatient, with or without pulmonary embolism 1 mg/kg subQ every 12 hours

Transitioning from Enoxaparin to Warfarin (inpatient or outpatient)-
Initiate warfarin sodium when appropriate, usually within 72 hours of enoxaparin then continue enoxaparin for at least 5 days anticoagulant effect is achieved (INR 2 or 3)

Prevention :
البقاء نشط وتجنب قلة الحركة والخمول🏃🏻‍♂.
🏋🏻‍♀- تجنب الجلوس لفترات طويلة )مثل: بعد إجراء عملية جراحية
-استخدام أجهزة ضغط هوائي عند عدم القدرة على التحرك من السرير🛏 
- استخدام جوارب ضاغطة للساقين
-ممارسة النشاط البدني بانتظام🏃🏻‍♂
-تحريك القدمين ورفعهما🔽

أو القيام بالتجول عند السفر لمسافات طويلة، سواء عن طريق الجو أو البر✈️.
🥛-شرب الكثير من الماء لتجنب الجفاف.
- المحافظة على وزن صحي وتجنب زيادة الوزن
.- تجنب تقاطع الساقين )وضع الساق على الساق( لفترة طويلة؛ حيث يمكن أن يعرقل تدفق الدم.
-تناول الدواء
-الاقلاع عن التدخين 🚭

🔹طرق الحماية غير الدوائيه-Nonpharmacologic methods –
improve venous blood flow by mechanical means and include early ambulation, graduated compression stockings, intermittent pneumatic compression (IPC) devices, and inferior vena cava filters.

· Hospitalized and acutely ill medical patients at high VTE risk and low bleeding risk shouldreceive pharmacologic prophylaxis with low-dose unfractionated heparin (LDUH), low-molecular-weight heparin (LMWH), or fondaparinux during hospitalization or until fully ambulatory.

· In general, nonorthopedic surgery patients at high VTE riskbut low bleeding risk shouldreceive
بشكل عام المرضى الذين لم يخضعون لعمليات جراحية و عندهم إحتمالية الاصابه ب تجلط الدم و لكن بنسبة ضئيلة من ) (إحتمالية التعرض لنزيف يتم إعطاءهم عدة ادوية منها)

LDUH or LMWH prophylaxisplus graduated compression stockings or IPC.
· Recommended VTE prophylaxis following joint replacement surgery may include aspirin, adjusteddose warfarin, unfractionated heparin (UFH), LMWH, fondaparinux,..يتبع🔽

dabigatran, apixaban, or rivaroxaban for at least 10 days postsurgery. Clinical trials support prophylaxis for 21 to 35 days after total hip replacement and hip fracture repair surgeries.

Management in pregnancy:
علاج الجلطات الدموية الوريدية في المرأة الحامل🤰🏻
Anticoagulation therapy is commonly used for the prevention and treatment of VTE during pregnancy. UFH and LMWH do not cross the placenta and are preferred during pregnancy.

📌
ليش ما نستخدم Warfarin في النساء الحوامل ؟
--Warfarin crosses the placenta and can result in:
· fetal bleeding
· central nervous system abnormalities 
· embryopathy 
🔽

so, it should not be used for VTE treatment during pregnancy
Fondaparinux has not been extensively studied in pregnancy and may cross the placenta
However, fondaparinux may be a viable option in pregnant patients intolerant to LMWH or those with a history of heparin-induced (HIT)

💊Unfractionated and Low-Molecular-Weight Heparin Use During Pregnancy:
Acute treatment à (Anticoagulation for acute VTE during pregnancy should continue for at least 6 weeks postpartum and a minimum total duration of 3 months)
- LMWH

· Enoxaparin 1 mg/kg SC q 12 h or 1.5 mg/kg q 24 h 
Or
· Dalteparin 100 units/kg SC q 12 h 
Or UFH
· Initiate using weight-based IV therapy and adjust dose to achieve therapeutic anti-Xa level for at least 5 days 
🔽

· Transition to SC adjusted-dose UFH administered q 8-12 h with mid-interval anti-Xa activity in the therapeutic range.

Issues at time of delivery :
🤰🏻مشاكل وقت الولادة
· Elective induction of labor:
(قبل الحث على الولاده )
§ Discontinue UFH or LMWH 24 hours prior to induction. 
§ Initiate therapeutic doses of UFH by IV infusion and discontinue 4-6 hours ..🔽

prior to expected time of delivery if risk of recurrent VTE is deemed high. 
· Spontaneous labor  
(في حالة الولادة المفاجئة)
§ For LMWH, if there is a reasonable expectation that significant anticoagulant effect will be present at time of delivery: 🔽

(a) epidural should be avoided and (b) reversal with protamine sulfate may be considered.  
§ For UFH, monitor the aPTT and reverse with protamine sulfate if aPTT is prolonged near the time of delivery

· Postpartum
)بعد الولادة)
§ Commence UFH or LMWH as soon as safely possible (usually 12 hours following delivery 
§ Concurrently initiate warfarin therapy and discontinue UFH or LMWH when the INR is 2 or greater.
§ Continue anticoagulants for at least 6 weeks following delivery

§ Warfarin can be safely used by women who are breast-feeding
- Pregnant women with a history of VTE should receive VTE prophylaxis for 6 to 12 weeks after delivery.

Antenatal prophylaxis may also be indicated depending on other risk factors, such as
1. history of multiple VTE
2. VTE associated with pregnancy
3. estrogen therapy
🔽

4. known thrombophilia.
Abbreviations: aPTTà activated partial thromboplastin time. INRà international normalized ratio. LMWHà low-molecular-weight heparin. SCà subcutaneously. UFHà unfractionated heparin. VTE à venous thromboembolism

Evaluation of therapeutic outcome :
تقييم المخرجات العلاجيه✅
-Monitor patients for resolution of symptoms, development of recurrent thrombosis, symptoms of complications , and adverse effects from anticoagulants. (as hematoma , bleeding and HIT ) .

- Monitor hemoglobin, hematocrit, and blood pressure carefully to detect bleeding from anticoagulant therapy.
 
-Perform coagulation tests (aPTT, PT and 4TS score
للهيبارين and INR للوارفرين (  
(prior to initiating therapy with anticoagulation and within treatment.

نسوي مونيتورنق على حسب نوع مضاد التخثر
💊Enoxaparin : CBC, platelet and serum creatinine ,every 5-10 days during first 2 weeks then every 2-4 weeks on selected patient Uncomplicated patient unnecessary to monitor .
💊 Fondaparinx : kidney function crcl < 30 contraindication

Alteplase : aPTT pretreatment and post treatment .
 
Monitor medication adherence, other medication use, changes in health status and and dietary intake of vitamin K-rich foods should be assessed.

💡هل المريض على الجرعة الصحيحة وهل أستخدامه لادويه أخرى ممكن تسبب تفاعل أو حتى لازم ماتتعدى حد معين Supplement as vit K and vit E
-نتابع حالة المريض من ناحية وظائف الكلى ممكن يحتاج
adjustment dose  according to  crcl
-هل مضاد التخثر مناسب لحاله المريض ؟
Cancer patient

من لايشكر الناس لايشكر الله حابين نقدم شكر من فريق جرعة ترياق لـ:
الليدر :
د.هيفاء@AntiHifaz
والاعضاء :
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د.رانيا خالد @rania1997301
د.شروق المطيري@Shrooug___
د.سلطان مطلق @smu6laq
د.ساره حكمي@PharmDsarah123
د.اسراء شهاب

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