Ambu Care Anticoag

Question 1

what are the names of the 2 molecular weight heparins?

Answer 1

enoxaparin and dalteparin

Question 2

what does afib predispose someone to?

Answer 2

stroke and systemic arterial thromboembolism

Question 3

T/F CHADSCASc can only be used to determine if we should use anticoags for patients with afib

Answer 3

true

Question 4

T/F female sex by itself does not increase risk, but it is a factor with multiple risk factors

Answer 4

true

Question 5

which DOAC has evidence of use in end-stage renal disease?

Answer 5

eliquis (apixaban)

Question 6

patients with valvular afib can only use which anticoag(s)?

Answer 6

warfarin only

Question 7

patients with nonvalvular afib should use which anticoag(s)?

Answer 7

usually DOAC over warfarin

Question 8

in patients with valvular heart disease and afib with rheumatic mitral stenosis, they should use what anticoag therapy?

Answer 8

long-term warfarin

Question 9

what therapy should be used if a pt has afib with hepatic disease?

Answer 9

warfarin, possibly eliquis

Question 10

what therapy should be used if a pt has afib with renal disease with CrCl less than 25-30?

Answer 10

warfarin or eliquis

Question 11

what therapy should be used if a pt has afib with history of GI bleed?

Answer 11

eliquis as first-line (lowest GI bleed risk), or warfarin

Question 12

what therapy should be used if a pt has afib who is over 90 years old?

Answer 12

eliquis as first-line, or other DOACs

Question 13

what therapy should be used if a pt has afib who wants a once daily med?

Answer 13

rivaroxaban (xarelto), edoxaban (savaysa), or warfarin

Question 14

what therapy should be used if a pt has afib who is non-complaint with taking meds

Answer 14

warfarin

Question 15

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a mechanical valve versus a bioprosthetic valve?

Answer 15

mechanical valves increases clotting more than bioprosthetic valves

Question 16

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a disk/ball valve versus a bileaflet valve?

Answer 16

disk/ball valves increase clotting more than bileaflet valves

Question 17

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between replacing the mitral valve versus the aortic valve?

Answer 17

replacing the mitral valve has a greater impact on clotting than the aortic valve

Question 18

T/F we should consider using DOACs (eliquis as first-line) for mechanical heart valves

Answer 18

false, not recommended for mechanical valves

Question 19

what is the therapy treatment/goal for a mechanical aortic valve replacement?

Answer 19

warfarin with an INR goal of 2.5 (range 2-3)

Question 20

what is the therapy treatment/goal for a mechanical mitral valve replacement?

Answer 20

warfarin with an INR goal of 3 (range 2.5-3.5)

Question 21

what is the therapy treatment/goal for a mechanical aortic and mitral valve replacement?

Answer 21

warfarin with an INR goal of 3 (range 2.5-3.5)

Question 22

CHEST 2012 recommends low-dose aspirin in all mechanical valves when?

Answer 22

patient has a low bleeding risk

Question 23

we can add low-dose aspirin in addition to warfarin for mechanical valve replacements when?

Answer 23

there is an indication and we have assessed patients bleeding risk

Question 24

what is ACC/AHA’s guidelines for treatment/goal of bioprosthetic valve replacement?

Answer 24

Warfarin for 3-6 months with an INR goal of 2.5 (range 2-3), then lifelong aspirin of 81mg daily

Question 25

what is CHESTs guidelines for treatment/goal of bioprosthetic valve replacement?

Answer 25

for MVR: same as ACC/AHA for AVR: aspirin 81mg qd only, no warfarin

Question 26

what is ACC/AHA's guidelines for treatment/goal of transcatheter aortic valve replacement?

Answer 26

lifelong aspirin with 6 months of clopidogrel overlap

Question 27

what is CHESTs guidelines for treatment/goal of transcatheter aortic valve replacement?

Answer 27

lifelong aspirin with 3 months of clopidogrel overlap

Question 28

what are common risk factors for venous thromboembolism?

Answer 28

surgery acute illness immobility (4 or more hours) cancer increased estrogen

Question 29

what is deep vein thrombosis?

Answer 29

when a blood clot forms in deep vein

Question 30

proximal DVTs have the highest risk of?

Answer 30

embolizing

Question 31

what are the signs/symptoms of DVT?

Answer 31

unilateral leg pain, warmth, discoloration, and swelling

Question 32

what is a pulmonary embolism?

Answer 32

when a DVT embolizes and lodges in lungs, most common with proximal DVT

Question 33

what are common symptoms of a pulmonary embolism?

Answer 33

dyspnea, pleuritic chest pain, tachypnea (rapid breathing

Question 34

what is the primary treatment of VTE? when should DOACs be used for VTE?

Answer 34

DOACs, immediately with higher initial dosing

Question 35

which DOACs require initial low molecular weight heparin (lovenox) before starting the DOAC to treat VTE?

Answer 35

dabigatran (pradaxa) and edoxaban (savaysa)

Question 36

if starting warfarin for treatment of VTE, what are the considerations/goals of treatment?

Answer 36

warfarin must be co-administered (bridged) with low molecular weight heparin until INR is 2 or more for 5 or more days

Question 37

what situation can we stop using anticoag after treatment of VTE?

Answer 37

with a provoked VTE by transient risk factor ex. knee replacement

Question 38

what situations should indefinite anticoag therapy be recommended for VTE?

Answer 38

a provoked VTE by a chronic risk factor, or recurrent or unprovoked VTE (if bleeding risk not high)

Question 39

what are the considerations for treating VTE if the patient has cancer?

Answer 39

DOAC>LMWH>warfarin

Question 40

what are the considerations for treating VTE if the patient has hepatic disease?

Answer 40

LMWH, maybe DOACs

Question 41

what are the considerations for treating VTE if the patient has renal disease with CrCl less than 25-30?

Answer 41

warfarin

Question 42

what are the considerations for treating VTE if the patient has history of GI bleed?

Answer 42

eliquis (lowest GI bleed risk), or warfarin

Question 43

what are the considerations for treating VTE if the patient wants a once daily med?

Answer 43

warfarin, rivaroxaban (xarelto), or edoxaban (savaysa)

Question 44

what are the considerations for treating VTE if the patient is non-compliant with taking meds?

Answer 44

warfarin

Question 45

what does the INR tell us?

Answer 45

the time it takes for blood to clot on warfarin

Question 46

as a INR goal overview, every indication has an INR target range of 2.5 (2-3) except for?

Answer 46

mechanical mitral valve or mechanical aortic valve (optional if other risk factors) target INR of 3 (2.5-3.5)

Question 47

why do we use low molecular weight heparin combined with warfarin?

Answer 47

decreases risk of an embolism

Question 48

why do we need an INR over 2 for at least 5 days when starting treatment?

Answer 48

Factor II is still highly active until around the 5 day mark

Question 49

how long does it take for warfarin weekly dose adjustments to reach steady state?

Answer 49

2-4 weeks

Question 50

counseling points with warfarin

Answer 50

-take around the same time once daily -can take any time of the day (usually evening) -with or without food is okay -tablets can be split or crushed

Question 51

what variables can increase INR and what is their interaction with warfarin?

Answer 51

-acute use of alcohol (inhibits warfarin metabolism) -diarrhea (decreases secretion of vitK by gut flora) -infection, inflammation, or fever (increase sensitivity) -stress or pain (metabolic changes) -liver disease (decreases clearance) -heart failure -renal disease -hyperthyroidism

Question 52

what variables can decrease INR and what is their interaction with warfarin?

Answer 52

chronic use of alcohol (induces warfarin metabolism) smoking (induces warfarin metabolism via cyp1A2) -hypothyroidism

Question 53

what variable increases sensitivity to warfarin?

Answer 53

older age

Question 54

what are the FAB-Four drug-warfarin interactions, what should we do if we know a patient is starting one of these drugs?

Answer 54

Fluconazole, amiodarone, bactrim, and flagyl 25-50% preemptive reduction in warfarin dose

Question 55

which drugs increase INR but don't req dose adjustment?

Answer 55

fluoroquinolones allopurinol thyroid hormones corticosteroids

Question 56

which drugs decrease INR but don't req dose adjustment?

Answer 56

rifampin primidone phenytoin carbamazepine cholestyramine sucralfate

Question 57

why is acetaminophen first line for pain control if pt is using warfarin?

Answer 57

it may increase INR, but it is predictable/adjustable

Question 58

what are other pain controllers besides acetaminophen while taking warfarin?

Answer 58

lidocaine patch/cream and gabapentin for nerve pain

Question 59

what pain drug class should we avoid with warfarin?

Answer 59

NSAIDs and aspirin

Question 60

what is the recommended daily intake of vitamin K?

Answer 60

90-120mcg

Question 61

what vitamin K therapy is used to stabilize INR?

Answer 61

low-dose VitK1

Question 62

what are the recommendations for vitamin K use when: INR is less than 10 and patient is not bleeding INR is more than 10 and patient is not bleeding

Answer 62

less than 10: no vitK more than 10: 2.5-5mg vitK

Question 63

what supplements increase INR which increases bleeding risk? *which one decreases INR?

Answer 63

turmeric ginkgo garlic ginger CoQ10 cannabis *st. john's wort

Question 64

what should patients do if they miss their dose of warfarin?

Answer 64

can take within 12 hours of missing dose to stay on schedule

Question 65

what are rare adverse effects of warfarin?

Answer 65

necrosis (purple toe syndrome) rare hair loss (alopecia)

Question 66

what is dosing for eliquis for acute VTE (DVT/PE)?

Answer 66

10mg bid for 7 days then 5mg bid

Question 67

what is dosing for eliquis for nonvalvular afib?

Answer 67

5mg bid, but do 2.5mg bid if patient has 2 of the following: age 80 or over, less than 60kg, or SCr 1.5 or higher

Question 68

what is dosing for eliquis for renal disease who have afib?

Answer 68

2.5mg bid if patient has 2 of the following: age 80 or over, less than 60kg, or SCr 1.5 or higher

Question 69

what is dosing for xarelto for acute VTE (DVT/PE)?

Answer 69

15mg bid w/f for 21 days, then 20mg qd w/f

Question 70

what is dosing for xarelto for nonvalvular afib? what if CrCl = 15-20?

Answer 70

20mg qd w/f 15mg qd w/f

Question 71

what is dosing for xarelto for renal disease who have afib?

Answer 71

15mg qd if CrCl 15-50

Question 72

what does a patient need to do to prepare for a procedure if they are taking warfarin?

Answer 72

-stop warfarin 5 days prior -start LMWH when INR <2 -stop LMWH at least 24 hours before procedure time

Question 73

what is the warfarin management for after a procedure?

Answer 73

if low bleed risk: restart warfarin and LMWH if high bleed risk: restart warfarin within 24 hours, then LMWH within 48-72 hours -stop LMWH when INR at goal

Question 74

if patients risk of clotting is high, what should we consider and why?

Answer 74

bridging with anticoag. we'd rather have increased bleeding risk than increased clotting risk