Stroke Prevention

Question 1

Non-modifiable Risk Factors

Answer 1

age, male sex, african american or hispanic, and family history

Question 2

Modifiable Risk Factors

Answer 2

HTN, Afib, HLD, tobacco smoking, TIA, alcohol/drug use

Question 3

Blood Pressure Goal

Answer 3

<130/80 mm Hg

Question 4

CHADS2VASC Score
Afib Stroke Risk

Answer 4

C: CHF
H: HTN
A2: age =/>75 years
D: diabetes
S2: prior stroke/TIA
V: vascular disease
A: age 65-74 years
Sc: sex category (female)

Question 5

At whats CHADSVASC score do we anticoagulate?

Answer 5

2

Question 6

After Afib, when do primary prevent with Aspirin

Answer 6

patients greater than 75 years old with no other risk factors

Question 7

After Afib, when do primary prevent with Warfarin

Answer 7

patients with chadvasc score 2 or greater

Question 8

Secondary Prevention

Answer 8

have ALREADY had a stroke

Question 9

If stroke is atherothrombotic, lacunar, or cryptogenic use:

Answer 9

antiplatelet therapy

Question 10

If stroke is high-risk cardioembolic related (afib) use:

Answer 10

Anticoagulant

Question 11

If afib is valvular anticoagulate with:

Answer 11

warfarin

Question 12

If afib is non-valvular anticoagulate with:

Answer 12

DOAC

Question 13

Aspirin drug interactions

Answer 13

P-450 inhibitors and inducers

Question 14

Plavix adverse effect

Answer 14

thrombotic thrombocytopenic purpura
- will appear within one month and if it does D/C

Question 15

Clopidogrel and preferred PPI

Answer 15

pantoprazole (least likely to interact)
lansoprazole and rabeprazole

Question 16

Is Plavix approved for primary prevention of stroke?

Answer 16

NO

Question 17

When is plavix first line for secondary prevention of stroke?

Answer 17

patients with peripheral arterial disease or are allergic to ASA

Question 18

Dipryridamole (aggrenox)

Answer 18

third line antiplatelet
A/E: headache bc of vasodilation

Question 19

When is double antiplatelet therapy indicated?

Answer 19

as secondary prevention for patients with minor stroke (NIHSS 3 or less) or TIA initiated within 24 hours
**for 21 days

Question 20

What blood pressure meds are recommended?

Answer 20

Diuretic either alone or in combo with ACEi

Question 21

Cons of warfarin

Answer 21

close monitoring, several drug interactions, and main cause for emergencies in elderly

Question 22

Dabigatran

Answer 22

longest half life and is dialyzable

Question 23

how many doses of a DOAC does it take for full anticoagulation?

Answer 23

1-2 doses

Question 24

Which DOAC is least likely to cause major bleeding?

Answer 24

Apixaban

Question 25

Which DOAC is least likely to cause ICH?

Answer 25

all 3 DOACs are less likely to than warfarin

Question 26

Which DOACs cause the most major GI bleeds?

Answer 26

Dabigatran and Rivaroxaban Apixaban and warfarin have lower chance

Question 27

who is high for thromboembolic events if anticoag is interrupted?

Answer 27

AFib with CHADS >4, mechanical heart valve, and thromboembolic event within 3 months - keep the anticoagulation more aggressive

Question 28

High risk of major bleeding surgeries

Answer 28

major cardiac, neurosurgical, orthopedic, urologic, vascular surgery any major operation lasting > 45 minutes kidney biopsy, polypectomy, variceal treatment, spincterectomy, pneumatic dilatation

Question 29

What to do is high risk patients undergoing high risk surgery?

Answer 29

use short half-life anticoagulant for rapid offset and onset (LMWH or target-specific oral anticoagulant)

Question 30

When to stop Dabigatran for minor surgery

Answer 30

- >50 GFR: 1 day - 31-50 GFR: 2 days - <31 GFR 4 days

Question 31

When to stop Dabigatran for major surgery

Answer 31

- >50 GFR: 2 days - 31-50 GFR: 4 days - <31 GFR 6 days

Question 32

When to stop Rivaroxaban/Apixaban for minor surgery

Answer 32

- >50 GFR: 1 days - 31-50 GFR: 1-2 days - <31 GFR 2 days

Question 33

When to stop Rivaroxaban/Apixaban for major surgery

Answer 33

- >50 GFR: 2 days - 31-50 GFR: 3-4 days - <31 GFR 4 days

Question 34

How many hours after last Rivaroxaban dose can you remove epidural catheter?

Answer 34

18 hours

Question 35

After epidural removal, when can you give next rivaroxaban dose?

Answer 35

6 hours

Question 36

Switch from Warfarin to DOAC

Answer 36

wait for INR to drop below 2.0 (apixaban/dabigatran) or 3.0 (rivaroxaban) and anticoagulate immediately

Question 37

how to switch from DOAC to warfarin

Answer 37

wait for INR to be near therapeutic range and stop DOAC (1-3 day overlap) OR Stop DOAC and bridge with LMWH and intiate warfarin

Question 38

how to switch from heparin to DOAC

Answer 38

initiate DOAC when heparin infusion stopped

Question 39

how to switch from DOAC to LMWH

Answer 39

wait until next dose is due

Question 40

Dabigatran interacts with

Answer 40

Rifampin, ketoconazole, and dronedarone

Question 41

Rivaroxaban interacts with

Answer 41

ketoconazole, itraconazole, lopinavir/ritonavir, conivaptan carbamazepine, phenytoin, rifampin, st. johns wort

Question 42

Apizaban interacts with

Answer 42

rifampin, ketoconazole, clarithromycin, ritonavir

Question 43

Missed dose of Dabigatran

Answer 43

take missing dose if >6 hours ## Footnote do not give via NG tube, no chew

Question 44

Missed dose of Xarelto

Answer 44

take missing dose ASAP ## Footnote take with food and ok to crush and put in NG tube

Question 45

Missed dose of Apixaban

Answer 45

do not double dose is missed

Question 46

Dabigatran reversal

Answer 46

Idarucizumab

Question 47

Apixaban/Xarelto reversal

Answer 47

Andexanet alfa