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Anticoagulation Flashcards

1
Q

CHADS2-VASC calculation

A

C - congestive heart failure/ LV EF < 40%
H - hypertension
A - age >75 (2)
D - diabetes
S - stroke, TIA (2)
V - vascular disease (MI, PAD, aortic plaque)
A - age >65 - 74
S - sex (female gets a point)

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2
Q

HAS Bled Score

A

H - hypertension >160mmHg
A - abnormal renal/liver (1 pt each) (scr >2.2)
S - stroke
B - bleeding hx (anemia, bleeding disorder, prior bleed)
L - labile INR (time in range <60%)
E - elderly >65 years old
D - drug or alcohol excess (1 pt each)

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3
Q

What disease state do we use CHADS2-VASC and HAS-BLED?

A

Non valvular A fib

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4
Q

CHADS2 Score and treatment options

A

Men 0 / Female 1 - ASA or nothing
Men 1 / Female 2 - ASA or DOAC or nothing
Men >2 / Female 3 - DOAC

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5
Q

HAS BLED Score to worry about bleeding with Afib DOAC treatment

A

> =3
try to reduce risk factors if you can

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6
Q

Warfarin goal time in range

A

> 65%

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7
Q

duration of needed anticoagulation before cardioversion of Afib

A

3 weeks

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8
Q

duration to anticoagulated after cardio version of afib

A

4 weeks

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9
Q

more potent isomer of warfarin

A

S is 5 x more potent

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10
Q

indication to start lower dosing of warfarin initially

A

> age
low body weight
liver / heart / thyroid disorder
low albumin

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11
Q

warfarin drug interactions

A

decreased absorption - cholestyramine and sucralfate

CYP2C9 hits S enantiomor harder than 3A4

fevers eat up clotting factors faster

OTC - garlic and ASA

reduce INR - phenytoin, phenobarbital, carbamazepine, rifampin, St John’s wort

reduced clearance - flagyl, bactrim, fluconazole, isoniazid, fluoxetine, sertraline, amiodarone

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12
Q

Dabigatran Dosing

A

Afib - 150mg BID
Total Hip - dabigatran 110mg BID, then 220 daily
VTE - 5 days injection then 150mg BID

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13
Q

Rivaroxaban Dosing

A

Afib - 20mg PM
Total Hip/Knee - 10mg daily (don’t need food)
VTE: 15mg BID x 21 days, then 20mg PM, cut to 10mg after 6 mo.

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14
Q

Dabigatran renal dosing cutoff

A

Afib: CrCl <30 use 75mg BID, CrCl <15 do not use
VTE: CrCl <30 do not use

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15
Q

Rivaroxaban renal dosing cutoff

A

Afib - CrCl <50 - 15mg PM
VTE: avoid if CrCl <15

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16
Q

Apixaban Dosing

A

Afib - 5mg BID
Total Hip/Knee - apixaban 2.5mg BID (Hip x 35, Knee x 12)
VTE: 10mg BID x 7 days, then 5mg BID, 2.5mg after 6 mo.

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17
Q

Apixaban renal dosing cutoff

A

Afib - 2.5mg BID if >80yo, <60kg, sCr >1.5
VTE: avoid if CrCl <15, sCr >2.5

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18
Q

Edoxaban Dosing

A

Afib - 60mg daily
VTE - 5 days injectable then 60mg daily

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19
Q

Edoxaban renal dosing cutoff

A

Afib - <50 - 30mg daily, avoid if CrCl >95

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20
Q

dialysis effects on DOACs

A

Do Not Use - edoxaban, dabigatran

Reduce Dose - apixaban, rivaroxaban

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21
Q

INR to start DOAC

A

rivaroxaban <3
edoxaban <2.5
apixaban and dabigatran <2

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22
Q

Afib + PCI anticoagulants of choice

A

DOAC and clopidogrel x 1 yr, then DOAC only

if high bleed risk may do 6 months or 3 months of plavix

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23
Q

bioprosthetic valve replacement - anticoagulant choice and duration

A

ASA - could do warfarin for 3 - 6 months - but should do ASA for life

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24
Q

transcatheter aortic valve replacement (TAVR) Less invasive

A

ASA only but could do aspirin/plavix x 6 mo. or warfarin x 3 mo.

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25
bioprosthetic valve replacement in Afib
guidelines say to use warfarin within the first 3 months of replacement, but clinically we use DOACs
26
mechanical heart valve replacement
warfarin only increase target INR to 2.5 - 3.5 if in the mitral position can add ASA low dose if indication for anti-platelet therapy
27
VTE Risk Factors (13)
THE DICE SHOES elderly (>40) surgery cancer trauma immobile Central Line Estrogen ESA Obese Hx Smoker hypercoagulable disease states (pregnancy, infection, CHF)
28
Hip Fracture Anticoagulants
Warfarin Enoxaparin 30mg SC BID Fondaparinux 2.5mg SC daily
29
Total Hip Surgery Anticoagulation Options
enoxaparin 40mg SC daily Dalteparin 5000 SC daily Fondaparinux 2.5mg daily apixaban 2.5 BID rivaroxaban 10mg dabigatran 110mg, then 220mg daily warfarin
30
Total Knee Surgery Anticoagulation Options
Lovenox 30mg SC BID Fondaparinux 2.5mg daily dalteparin 2500, then 5000 daily warfarin apixaban 2.5mg BID rivaroxaban 10mg daily
31
difference in Ortho surgery anticoagulations
40mg SC daily in total Hips dabigatran in Total Hip Only Hip Fracture is only Warfarin for Oral options fondaparinux is the same across the board dabigatran is only for total hip edoxaban has no place in therapy
32
inpatient DVT prophylaxis
dalteparin 5000 units daily enoxaparin 40mg SC daily rivaroxaban 10mg daily - extended treatment heparin 5000 SC q8h or q12h fondaparinux 2.5mg daily
33
contraindications to Xarelto as inpatient DVT prophylaxis
active cancer causing stay GI ulcer in last 3 months bleed in last 3 months pulomonary cavity, bleeds, etc dual antiplatelet therapy
34
VTE prophylaxis as an inpatient and renal dysfunction
dialysis - heparin CrCl < 15 - avoid rivaroxaban and apixaban CrCl <30 - avoid fondaparinux and dabigatran
35
LMWH dosing in obese and weight cutoffs
>120kg or BMI >40 enoxaparin 40mg SC BID heparin 7500 units SC q8hH fondaparinux 5mg
36
Heparin dosing VTE
80units/kg bolus, then 18u/kg/hr infusion
37
Enoxaparin dosing VTE
1mg/kg SC q12h or 1.5mg/kg q24h CrCl <30 1mg/kg q24h
38
dalteparin dosing VTE
100units/kg SC q12h 200units/kg SC q24h
39
fondaparinux dosing VTE
weight <50kg: 5mg weight 51-100kg: 7.5mg weight >100kg: 10mg
40
treatment of VTE with dabigatran or edoxaban
start injectable x 5 days then start dabigatran 150mg BID or edoxaban 60mg daily
41
what dose does rivaroxaban not need food?
10mg daily or less
42
duration of anticoagulation with provoked and unprovoked DVT
provoked - 3 months idiopathic - lifetime
43
INR Risk Levels
INR < 1.8 increases clot risk by 60% INR > 4.0 starts to increase bleed risk
44
dabigatran expiration date and most common ADR
dyspepsia and 4 months after opening
45
when to give edoxaban after a heparin infusion
4 hours after stopping
46
which DOACs safer for bleeding than warfarin
apixaban and edoxaban
47
who to avoid DOACs in
pregnant hepatic dysfunction antiphospholipid syndrome low body weight bariatric surgery
48
which DOAC has best data with obesity
rivaroxaban or apixaban
49
duration of time SCDs have to be on to be effective
18 hours/day
50
DOC for burns in medically ill
heparin is best
51
duration of hip replacement and knee replacement VTE prophylaxis
Knee x 10 days Hip x 35 days
52
DOC for hemodialysis
Heparin
53
pregnancy DOC
LMWH or heparin
54
duration of VTE treatment
1st - 3 mo. if known reason cancer - 3-6mo. or longer 2nd - indefinite 1st w/o cause - 3 mo. +
55
1 unit PRBCs raises Hgb _____ g/dl
1 - 2
56
FFP
fresh frozen plasma spun out all the protein - mostly clotting factors similar risks as blood and has to thaw out must type and cross
57
Warfarin Reversal
prothrombin complex concentrate 25x more clotting factors than plasma Factors II, IX, X, VIIa, C and S does not require type and crossing Balfaxar and KCentra 25 units/kg INR 2 - 3.9, max 2500 units 35 units/kg INR 4 - 6, max 3500 units 50 units/kg INR >6, max 5000 units
58
Factor Xa Reversal Agent
Andexanet alfa (Andexxa) 400mg bolus then 4mg/min x 2 hours for apixaban 5 or rivaroxaban 10 or if dose was > 8 hours ago of any strength 800mg bolus then 8mg/min x 2 hours for > apixaban 5mg or rivaroxaban >10mg or if unknown dose/timing of anticoagulant max dose 1750mg/event, no repeat dosing safety/efficacy data
59
risk of activated vs inactivated factors
clotting
60
risks of massive blood transfusions
acidosis hyperkalemia citrate-induced hypocalcemia dilution-induced thrombocytopenia
61
UFH Reversal
protamine 1mg for every 100 units of heparin if continuous drip: last 1 hour = full dose, 2nd hour 1/2 of dose, 3rd hour 1/4 of dose never administer more than 50mg in a single dose
62
protamine ADR
hypotension, bradycardia NPH insulin use, vasectomy, sensitivity to fish
63
LMWH Reversal
protamine will reverse 50-60% of LMWH Within 8 hours of last dose: 1mg = 1mg enoxaparin = 100 anti-Xa units >8 hours from last dose: 0.5mg = 1mg enoxaparin = 100 anti-Xa units
64
dabigatran reversal
KCentra 25-50 units/kg idarucizumab 5g IV x 1 reverses in 15 minutes and remains 12 - 24 hours
65
DOAC Reversal
can use Andexanet alfa or aPCC 25 - 50 units/kg
66
time to hold DOACs prior to surgery
dabigatran - 1-2 days unless CrCl <50 then 3 - 5 days apixaban, rivaroxaban, edoxaban minor or vascular procedures: 1 - 2 days vascular surgery CrCl <30: 3 - 4 days

Notes (14 decks)

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