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54 > 5. SPAF > Flashcards

5. SPAF Flashcards

1
Q

Cause of stroke in AF

A

Turbulent flow caused by uncoordinated contraction of fibrillation of left atrium → concentration of clotting factors in left atrial appendage (LAA) → clot formation → embolism of clot → emboli travels to brain → ischemic stroke

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2
Q

What is CHA2D2VASc for?

A

estimate stroke risk

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3
Q

List all the risk factors in CHA2DS2VASc

A

Congestive HF
HTN >140/90 or need antiHTN drugs
Age >=75 yo (x2 score)
DM
Stroke hx/TIA (x2 score)
Vascular disease - hx MI, PAD, aortic plaque
Age 65-74

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4
Q

When to start tx with anticoagulation in SPAF

A

Score 0: no anticoagulants
Score = 1: CONSIDER anticoagulant
Score ≥ 2: START anticoagulant (DOAC > warfarin)

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5
Q

when is warfarin preferred over VKA?

A

mechanical heart valve
moderate to severe mitral stenosis
left ventricular thrombus
antiphospholipid syndrome

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6
Q

can antiplatelet be used in SPAF?

A

NO ANTIPLATELETS

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7
Q

List all the bleeding RF in HASBLED

A

HTN uncontrolled >160mmHg
Abnormal renal/hepatic function
Stroke (hx)
Bleeding hx
Labile INR (unstable or high INRs)
Elderly age >65yo
Drugs (antiplatelet/NSAIDs)/alcohol use (men 14u, female 7u/ week)

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8
Q

What is considered high bleeding risk and what is the management?

A

HASBLED ≥3 = high bleeding risk
Identify and modify risk factors (does not limit/ withhold use of OAC)

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9
Q

Tx of SPAF

A

anticoagulants (DRAWE)

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10
Q

Dabigatran dose in SPAF
renally impaired?

A

150mg BD
110mg BD (≥80yo, concomitant PGP inhibitors, high risk of bleeding)

  • CrCL 30-50ml/min: no dose adjustments unless DDI
  • CrCL <30: CI
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11
Q

Rivaroxaban SPAF dose

A

20mg OD

CrCL 30-50ml/min: 15mg OD
CrCL 15-30: caution
CrCL <15: CI

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12
Q

Apixaban SPAF dose

A

5mg BD
2.5mg BD (any 2 of following: ≥80yo, weight ≤60kg, SCr ≥133mmol/L)

CrCl 30-50ml/min: 5mg BD
CrCL <30: 2.5mg BD

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13
Q

Edoxaban SPAF dose

A

60mg OD
30mg OD (CrCL 30-50ml/min, weight ≤60kg, concomitant verapamil/quinidine/dronedarone)

CrCL 30-50ml/min: 30mg OD
CrCL 15-30: 30mg OD
CrCl <15: not recommended

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14
Q

warfarin for SPAF

A

INR 2.0-3.0, TTR ≥70% (time in therapeutic range)
if TTR <70% switch to DOAC

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15
Q

Renally impaired pt on SPAF what is the tx

A

DOAC preferred over warfarin (in SPAF)

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16
Q

which DOAC is a substrate of CYP450?

A

Rivaroxaban, Apixaban (both 3A4)

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17
Q

which DOAC is a substrate for Pgp?

A

all DOAC (not warfarin)

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18
Q

CI for DOAC use (DDI and illness)

A
  • rifampicin, valproate, St John’s wort, azole
  • sever hepatic impairment, ESRD (CrCl <30), mechanical heart valve, moderate-severe mitral stenosis, LV thrombus
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19
Q

Renal failure pt SPAF tx

A

DOAC preferred over warfarin (better safety and efficacy profile)

20
Q

Elderly SPAF tx

A

DOAC preferred over warfarin (less intracranial haemorrhage, less major bleeding, less stroke)
Elderly: Apixaban preferred

21
Q

underweight and overweight SPAF tx

A
  • Low body weight: dosing adjustments for apixaban and edoxaban (further decrease if renally impaired)
  • High body weight (limited data): rivaroxaban, apixaban
22
Q

Warfarin pgx

A

2C9 and VKORC1

23
Q

what factors does warfarin decrease?

A

Decrease factors II, VII, IX, X, protein C and S (endogenous anticoagulants)

24
Q

how to prevent hypercoagulable state with warfarin initiation

A

Add clexane (LMWH/ enoxaparin) together with warfarin when initiating to prevent hypercoagulable state (~4-5 days)

25
Q

factors affecting warfarin dose

A
  • BSA, age, target INR, race, current thrombosis, current amiodarone use, smokers
  • PGx: VKORC1, CYP2C9
  • indians require higher dose of warfarin
26
Q

warfarin DDI (2C9 inhibitors)

A

amiodarone, fluconazole, metronidazole

27
Q

warfarin DDI (2C9 inducers)

A

carbamazepine, enzalutamide, phenobarbital, rifampicin, st. john’s wort

28
Q

which drugs when used with warfarin requires preemptive dose adjustment of warfarin

A

Bactrim (sulfamethxazole, trimethoprim)
Ciprofloxacin
Metronidazole??
Amiodarone (decr dose by 30-50%)
Fluconazole (decr dose by 10-20%)
Rifampicin (incr dose by 1.5-2x)

29
Q

Alcohol binge effect on INR

A

increase CYP450 inhibition → increase INR (INR “blip”)

30
Q

Chronic alcoholism effect on INR

A

CYP450 induction → increase warfarin metabolism → decrease INR

31
Q

Increase physical activity effect on INR

A

increase warfarin metabolism → decrease INR

32
Q

smoking effect on INR

A

CYP450 induction → increase warfarin metabolism → decrease INR

33
Q

liver impairment effect on warfarin

A

decrease clotting factor synthesis & warfarin metabolism → increase INR

34
Q

fluid retention effect on INR

A
  • Liver congestion: decrease metabolism of warfarin → increase INR (more impactful)
  • Gut edema: malabsorption of warfarin → decrease INR
35
Q

fever effect on INR

A

increase INR (increase turnover/metabolism of clotting factor = less clotting factors)

36
Q

thyroid disease effect on INR

A
  • Hyperthyroidism: increase clotting factor turnover → increase INR
  • Hypothyroidism: decrease clotting factor turnover → decrease INR
37
Q

warfarin target INR

A
  • INR 2.5 (2-3)
    • DVT/PE: usually 3mths tx if no CI/ chronic RF
    • SPAF, severe mitral stenosis: lifelong
    • Bioprosthetic: 3-6mths after surgery
    • LV thrombus: 3mths tx
  • INR 3 (2.5-3,5)
    • Mechanical heart valve
38
Q

switching warfarin to DOAC

A

Stop warfarin for 3 days → when INR below 2, start DOAC

39
Q

switching DOAC to warfarin

A
  • no need hold DOAC (use for 3-5 days)
  • At day 3-5: measure INR → INR >2 stop DOAC, continue warfarin
40
Q

when is the first follow up?

A

1 mth

41
Q

subsequent follow up duration

A
  • Yearly
  • Every 4mths: ≥75yo (especially on dabigatran or edoxaban) or frail
  • CrCl/10 mths: eGFR/CrCl ≤60ml/min
42
Q

what to monitor

A
  • Adherence
  • Thrombo-embolism
  • Bleeding
  • Side effects
  • DDI with other medications
  • Assess and minimise modifiable risk factors for bleeding (uncontrolled HTN, other anticoagulant/antiplatelets, labile INR, excessive alcohols, falls)
  • Assess for optimal DOAC choice and dosing
43
Q

DOAC reversal tx (mild)

A

delay or discontinue next dose

44
Q

DOAC reversal tx (Non-life threatening major bleeding)

A

delay or discontinue next dose + supportive measures
(on dabigatran) idarucizumab/ hemodialysis

45
Q

DOAC reversal tx (Life threatening major bleeding)

A

(Darbi) IV idarucizumab 5g (expensive)
(FXa inhibitors) Andexanet alpha

otherwise:
- PCC (prothrombin complex concentrate)
- aPCC (activated PCC)

46
Q

warfarin reversal

A

no major bleeding
- INR <4.5: investigate
- INR >4.5: consider vit K

major bleeding: IV vit K
minor bleeding: assess bleeding, consider vit K

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