Anticoagulants Flashcards
(51 cards)
What do you need to consider prior to giving patients anticoagulants? (1)
Benefits vs. Risk (bleeding)
When would you consider monitoring the patient if not taking anticoagulants? (2)
Review at 65 yrs.
Or if develop diabetes, HF, PAD, CHD, stroke, TIA or systemic thromboembolism.
Explain the use of antocoagulants in haemodynamically unstable AF. (1)
Heparin at initial presentation and continue until appropriate anticoagulant is started.
When would you consider offering anticoagulants in patients with confirmed AF < 48 hrs (haemodynamically stable)? (4)
- Stable sinus rhythm isn’t successfully restored within the same 48-hr period after onset.
- High risk of AF recurrence (Hx of failed cardioversion, structural heart disease, prolonged AF > 12 months) or previous recurrences.
- Based on CHAD2VASc.
When would you consider offering anticoagulation in AF? (6)
Offer if CHADsVASc = 2+
Consider in male biological sex = 1
Apixaban, Dabigatran, Edoxaban + Rivaroxaban = recommended options.
DOAC c/i, not tolerated or unsuitable in people with AF, offer Vitamin K antagonist:
- If already on warfarin, discuss option switching treatment at their next routine appointment, accounting person’s time in TTR.
Don’t offer anticoagulation to people aged < 65 yrs with AF and no risk factors other than their sex.
Don’t withhold anticoagulation solely because of age or risk of falls.
When would you consider assessing bleeding risk? (2)
Starting anticoagulants
Reviewing patients taking anticoagulants.
What does personalised AF care consist of? (4)
Stroke awareness and prevention
Rate/rhythm control + management
Who to contact for advice/psychological support.
Information on cause, effects and possible complications AF.
State the particulars for CHA2DS2VASc. (8)
CHD/LV dysfunction = 1
HPT = 1
Age >= 75 yrs = 2
Diabetes = 1
Stroke/TIA/TE = 2
Vascular disease (prior MI,PAD,Aortic plaque) = 1
Age (65-74 yrs) =1
Sex (female) = 1
Explain the use of ORBIT tool. (3)
Bleeding risk tool for AF.
Score of 2 for:
- Males with haemoglobin < 130g/L or haematocrit < 40%
- Females with haemoglobin <120g/L or haematocrit < 36%.
- People with Hx of bleeding (e.g. GI/intracranial bleeding or haemorrhagic stroke)
Score of 1 for people:
- Aged > 74 yrs.
- eGFR = < 60ml/min
- Tx with antiplatelets
(3
What are the severity ranges for ORBIT tool? (3)
0-2 - Low
3 - Medium
4-7 - High
What are the limitations of ORBIT tool? (3)
Doesn’t account choice of anticoagulation.
Not including all modifiable risk factors including HAS-BLED.
Not recommended as a bleeding risk tool for other conditions e.g. VTE.
What particulars makes up the HAS-BLED score? (8)
All with a score of 1:
- HPT (systolic >= 160mmHg)
- Abnormal renal/liver function
- Age >=65 yrs
- Past stroke
- Bleeding
- Labile INRs
- Taking other drugs
- Alcohol intake at same time.
What does a HAS-BLED score of 3 or more indicate? (1)
Increased 1 year bleed risk on anticoagulation. Risk is for IC bleed, bleed requiring hospitalisation or haemoglobin drip > 2g/L or needs transfusion.
What are the risk factors for bleeding? (5)
Uncontrolled HPT
Poor INR control in patients on vitamin K antagonists.
Medication (Antiplatelet, SSRI, NSAIDs)
Harmful alcohol consumption
Reversible causes of anaemia.
What should be discussed with the patient regarding to starting anticoagulation? (3)
Benefits vs risks.
Reduces risk of stroke
Don’t withhold solely due to patient’s risk of falls.
What factors would you need to consider to determine choice of anticoagulants? (4)
+/- of anticoagulants.
Patient factors: weight, renal function
Reversal agents
Monitoring
What are the main differences of warfarin vs. DOACs? (2)
DOACs have predictable pharmacokinetics, coagulation control doesn’t need to be monitored vs. Warfarin needs regular blood tests for INR monitoring.
Major bleeds
What is the reversal agent for Warfarin? (1)
Phytomenadione (Vitamin K)
What is the reversal agent for Dabigatran? (1)
Idarucizumab (available but expensive)
What is the reversal agent for Apixaban and Rivaroxaban? (1)
Andexanet Alfa (available but expensive)
What is the reversal agent for Edoxaban? (1)
No specific reversal agent.
What does MHRA state about the use of DOACs? (4)
High risk of recurrent thrombotic events in patients with anti phospholipid syndrome.
Bleeding risk and reversal agents.
Dose adjustments in people with renal impairment.
Rivaroxaban (Xarelto) = 15mg and 20mg tablets taken with food.
What are the main features of Apixaban? (5)
Direct inhibitor of activated factor X (factor Xa).
Reversal agents = andexanet alfa
BD daily.
When used for stroke prophylaxis and systemic embolism in non-valvular AF, reduce dose to 2.5mg BD if:
- Serum creatinine 133mcmol/L and over AND is associated with one of the following:
- 80 yrs and over OR
- Body weight <=60kg
- Creatinine clearance 15-29ml/minute.
What are the main features of Rivaroxaban? (6)
Direct inhibit of activated factor X (factor Xa)
Reversal agent = Andaxanet Alfa
15-20mg licensed for stroke prophylaxis in AF (taken with food.)
Renal impairment:
- Reduce dose to 15mg CrCl 15-49ml/min
- Caution if CrCl 15-29ml/min, avoid if CrCl < 15ml/min.
New licensing:
- DVT prophylaxis following total knee replacement and hip replacement. (10mg OD dose)
- Atherothrombotic event prevention following an ACS with elevated cardiac bio markers (low dose Rivaroxaban 2.5mg + aspirin alone or aspirin + clopidogrel)
