AF and anticoagulation

Question 1

When is an INR target of 3.5 indicated in warfarin therapy?

Answer 1

In recurrent DVT/PE already on warfarin with a target >2

Question 2

What is the INR target for treatment of DVTs/PEs and AF?

Answer 2

2.5

Question 3

When is AF classed as persistent?

Answer 3

> 7 days

Question 4

What are the symptoms of AF?

Answer 4

Syncope, palpitations, breathlessness, chest tightness, dizziness

Question 5

What orbit score is classed as medium bleeding risk?

Answer 5

3

Question 6

What investigation needs to be carried out to confirm diagnosis of AF?

Answer 6

12 lead ECG- characteristic P waves

Question 7

How is acute life threatening haemodynamic instability from AF treated?

Answer 7

Cardioversion

Question 8

How is acute AF treated if the onset is <48 hours?

Answer 8

Rate or rhythm control (Fleicanide and amiodarone options)

Question 9

How is acute AF treated if onset >48 hours? (So as to not throw off a clot)

Answer 9

Rate control preferred (BB or rate-limiting CCB) or electrical cardioversion

Question 10

How should a patient be prepared before cardioversion (non-emergency)?

Answer 10

anti-coagulation 3 weeks prior, and continued 4 weeks after + rate control

Question 11

How should a patient be prepared before cardioversion (emergency)?

Answer 11

Rule out left atrial thrombus and commence on heparin

Question 12

First-line therapy for AF?

Answer 12

BB or rate-limiting CCB

Question 13

Second line therapy if not tolerated or monotherapy failed?

Answer 13

2 of the following- digoxin, diltiazem, BB

Question 14

When is digoxin indicated as monotherapy?

Answer 14

If predominantly sedentary, non-paroxysmal AF, and other rate control drugs unsuitable

Question 14

What CHADSVASC score means anticoagulation is indicated in men?

Answer 14

1

Question 15

What procedure is indicated if anticoagulation is unsuitable for a patient?

Answer 15

left atrial appendage occlusion

Question 16

Reduction criteria apixaban 2.5mg in the treatment of non-valvular AF?

Answer 16

Non-valvular AF and at least 2 of the following:
- 80+
- Cr 113+
- 60kg or less

OR if CrCl 15-29ml/min

Question 17

Reduction criteria edoxaban 30mg in the treatment of non-valvular AF?

Answer 17

• <61kg
• CrCl 15-50ml/min
• On strong P-gp inhibitors e.g., ketoconazole, erythromycin, dronedarone

Question 18

Reduction criteria rivaroxaban 15mg in the treatment of non-valvular AF?

Answer 18

CrCl 15-49ml/min

Question 19

Reduction criteria Dabigatran from 150mg BD in the treatment of non-valvular AF?

Answer 19

If patient qualifies for lower dose- switch to alternative Apixaban

Question 20

How long should warfarin be used in an isolated calf DVT?

Answer 20

6 weeks minimum

Question 21

What is the reversal agents for heparins?

Answer 21

Protamine sulphate

Question 22

What are the reversal agents for vitamin K antagonists?

Answer 22

Phytomenadione or Octaplex

Question 23

What is the reversal agent for Dabigatran?

Answer 23

Idararucizamab

Question 24

Rivaroxaban, Edoxaban, and Apixaban reversal agent?

Answer 24

Andexanet alfa (off-label for Edoxaban)

Question 25

How do you manage a patient with an INR of >8, but with no bleeding?

Answer 25

Stop warfarin, give Phytomenadione IV prep orally. Repeat after 24h if still high. Re-start warfarin when INR <5

Question 26

How do you manage a patient with an INR of 5-8, but with no bleeding?

Answer 26

Withold 1-2 doses of warfarin and adjust subsequent maintenance dose

Question 27

How do you manage a patient with an INR of 5-8, with minor bleeding?

Answer 27

Stop warfarin + give Phytomenadione IV. Restart warfarin when INR <5

Question 28

If a a patient is on warfarin and needs emergency surgery that can't be delayed- What is the course of action?

Answer 28

IV Phytomenadione + Octaplex- check INR before surgery

Question 29

If a a patient is on warfarin and needs emergency surgery that can be delayed 6-12 hours- What is the course of action?

Answer 29

IV Phytomenadione

Question 30

How long before elective surgery should warfarin be stopped?

Answer 30

5 days before

Question 31

If a patient at high risk of thrombus formation needs elective surgery and has stopped warfarin- what is the course of action?

Answer 31

Bridge with a LMWH- stop 24 hours before the surgery

Question 32

How long after a high bleeding risk surgery should a LMWH be re-started?

Answer 32

48 hours minimum

Question 33

What is the course of action if a patient has stopped warfarin 5 days prior to an elective surgery but INR 1.5+ the day before surgery?

Answer 33

Give IV Phytomenadione orally.

Question 34

Which antiplatelet in combination with warfarin has a lower bleeding risk?

Answer 34

Aspirin

Question 35

Toxicity signs of digoxin

Answer 35

Headache N&V Yellow 'halo' or visual disturbances Arrythmias- hypokalaemia Bradycardia Eosinophilia Rash

Question 36

Reversal agent for digoxin

Answer 36

Digoxin immune fab

Question 37

Trough digoxin serum level range

Answer 37

0.5-1 nanograms/ml

Question 38

Digoxin levels suggesting possible toxicity

Answer 38

1.5-3.0

Question 39

Digoxin levels suggesting likely toxicity

Answer 39

>3 nanogram/ml

Question 40

What must digoxin levels be before starting digoxin?

Answer 40

>4.0

Question 41

Electroylte disturbances that enhance the effects of digoxin

Answer 41

Hypokalaemia, Hypomagnesia, Hypocalcaemia sensitise myocardium to digoxin

Question 42

Effect of hypothyroidism on digoxin

Answer 42

Increased liklihood of toxicity

Question 43

Effect of hyperthyroidism on digoxin

Answer 43

Resistance to digoxin

Question 44

Which rate control medicine class should be avoided in HF due to risk of decompensation?

Answer 44

calcium channel blockers

Question 45

Inotropic effect of digoxin

Answer 45

Positively inotropic