lots of clots Dr Tom Mabin Vergelegen Mediclinic Somerset West October 16th 2015 Helderberg Cardiac Support Group Seminar

The players……….. Red blood cells

Kick-off………. what starts it all off? any breach of the artery wall

The scrum…………………….. The sequence of clot formation Red blood cells + = Clot (thrombus )

The perfect try…………..

Foul play….clots however can form in unwanted area within the blood vessels of the body. Coronary artery = myocardial infarction (heart attack) Brain artery = stroke Leg vein lungs = pulmonary embolus Left atrium brain = stroke The penalties………

Blood flow in a normal artery…….good clean play

The endothelium…miles and miles of “silk stocking”……………

This lining of the artery can however become diseased with build up of plaque and becomes abrasive………

Plaque may activate the platelets making them sticky…..

Plaque contents may rupture into the mainstream of the artery and this activates platelets and clot formation in exactly the same way…………….. Yellow card

The sequence of clot formation Red blood cells + = Clot (thrombus)

if the lining of the artery is damaged the platelets become activated and form a CLOT Clot!!

Similar clots can form on the inside of arteries anywhere in the body if the endothelium(silk stocking) is damaged and plaque has formed

Myocardial infarction(heart attack)…… Red card

Stroke….also a red card Red card

Various drugs are used to *prevent the formation of clots *to remove clots *do both

The sequence of clot formation in the arteries and where the drugs work Red blood cells + = Clot (thrombus) Anti-platelets Aspirin clopidogrel Antithrombotics heparin Thrombolytics “clot busters” IV drugs

Once the clot is formed it needs to be broken up by the “clot busters” These are given in a drip and the sooner they are given, the more likely to be effective.Best <2 hours after onset of heart attck (<4 hours for stroke)

Similar clots can form on the inside of arteries anywhere in the body if the endothelium(silk stocking) is damaged and plaque has formed

In the fast flowing arteries the sticky platelets start the clotting process by sticking onto diseased areas of the artery lining……….. Platelet inhibitors are ASPIRIN: CLOPIDOGREL(plavix:clopivasc) etc Once occlusion has occurred damage to the heart muscle(infarction) or brain tissue(stroke) immediately ensues and the “clot busters” are needed “Clot busters” (thrombolytics) are IV drugs given to early MI and strokes

However stents can also attract platelets and they need to be inhibited using aspirin and clopidogrel ifig Stents can play a vital role in busting up the clot and clearing the plaque. Again, time is the factor

Direction of blood flow…. Veins flow back to the heart: slow flow and sluggish Arteries flow away from the heart: rapid flow high pressure

Risk factors are:- Varicose veins After surgery After long air flights

Pulmonary embolus

Another common area of slow flow and clot formation is in the left atrium of the heart after atrial fibrillation has developed

Stroke: atrial fibrillation is the commonest cause Anticoagulation is required

Full ANTICOAGULATION is required when fully formed clots are at risk of detaching and travelling to critical areas eg lungs and brain

WARFARIN: Effective Cheap Safe under instruction Atrial fibrillation DVT Artificial heart valves Reversible Requires regular blood tests INR Interacts with various medications eg antibiotics;pain pills Bleeding risk

New Anticoagulants: NOACs: More effective than warfarin Regular daily dose No blood testing No interactions with medications Expensive No antidotes Bleeding Ineffective with artificial heart valves

NOACs currently available Xarelto Single daily dose Rash bleeding Pradaxa Twice a day Care with kidney function Indigestion bleeding

Left atrial appendage plug for those who cannot/will not take an anticoagulant

Drugs used to manage clots in the body vary according to when and where and what the problems are … To prevent clot formation we make the platelets less “sticky” using:  ASPIRIN  CLOPIDOGREL(Plavix)  HEPARIN(Clexane) Once the clot has formed we need to dissolve it using the clot busters:  THROMBOLYTICS.to avoid dislodge of clot in veins and the heart we need ANTICOAGULATION with  WARFARIN  XARELTO  PRADAXA

Different strokes for different folks…who takes what? Aspirin or clopidogrel Angina Heart attack Stent Bypass Stroke TIA any arterial disease Warfarin or NOAC Atrial fibrillation DVT Pulmonary embolus

Similar clots can form on the inside of arteries anywhere in the body if the endothelium(silk stocking) is damaged and plaque has formed

Different strokes for different folks…who takes what?

Thankyou………