AF and anticoagulation

Question 1

When is an INR target of 3.5 indicated in warfarin therapy?

Answer 1

In recurrent DVT/PE already on warfarin with a target >2

Question 2

What is the INR target for treatment of DVTs/PEs and AF?

Answer 2

2.5

Question 3

When is AF classed as persistent?

Answer 3

> 7 days

Question 4

What are the symptoms of AF?

Answer 4

Syncope, palpitations, breathlessness, chest tightness, dizziness

Question 5

What orbit score is classed as medium bleeding risk?

Answer 5

3

Question 6

What investigation needs to be carried out to confirm diagnosis of AF?

Answer 6

12 lead ECG- characteristic P waves

Question 7

How is acute life threatening haemodynamic instability from AF treated?

Answer 7

Cardioversion

Question 8

How is acute AF treated if the onset is <48 hours?

Answer 8

Rate or rhythm control (Fleicanide and amiodarone options)

Question 9

How is acute AF treated if onset >48 hours?

Answer 9

Rate control preferred (BB or rate-limiting CCB) or electrical cardioversion

Question 10

How should a patient be prepared before cardioversion (non-emergency)?

Answer 10

anti-coagulation 3 weeks prior, and continued 4 weeks after + rate control

Question 11

How should a patient be prepared before cardioversion (emergency)?

Answer 11

Rule out left atrial thrombus and commence on heparin

Question 12

First-line therapy for AF?

Answer 12

BB or rate-limiting CCB

Question 13

Second line therapy if not tolerated or monotherapy failed?

Answer 13

2 of the following- digoxin, diltiazem, BB

Question 14

When is digoxin indicated as monotherapy?

Answer 14

If predominantly sedentary, non-paroxysmal AF, and other rate control drugs unsuitable

Question 14

What CHADSVASC score means anticoagulation is indicated in men?

Answer 14

1

Question 15

What procedure is indicated if anticoagulation is unsuitable for a patient?

Answer 15

left atrial appendage occlusion

Question 16

Reduction criteria apixaban 2.5mg in the treatment of non-valvular AF?

Answer 16

Non-valvular AF and at least 2 of the following:
- 80+
- Cr 113+
- 60kg or less

OR if CrCl 15-29ml/min

Question 17

Reduction criteria edoxaban 30mg in the treatment of non-valvular AF?

Answer 17

• <61kg
• CrCl 15-50ml/min
• On strong P-gp inhibitors e.g., ketoconazole, erythromycin, dronedarone

Question 18

Reduction criteria rivaroxaban 15mg in the treatment of non-valvular AF?

Answer 18

CrCl 15-49ml/min

Question 19

Reduction criteria Dabigatran from 150mg BD in the treatment of non-valvular AF?

Answer 19

If patient qualifies for lower dose- switch to alternative Apixaban

Question 20

How long should warfarin be used in an isolated calf DVT?

Answer 20

6 weeks minimum

Question 21

What is the reversal agents for heparins?

Answer 21

Protamine sulphate

Question 22

What are the reversal agents for vitamin K antagonists?

Answer 22

Phytomenadione or Octaplex

Question 23

What is the reversal agent for Dabigatran?

Answer 23

Idararucizamab

Question 24

Rivaroxaban, Edoxaban, and Apixaban reversal agent?

Answer 24

Andexanet alfa (off-label for Edoxaban)

Question 25

How do you manage a patient with an INR of >8, but with no bleeding?

Answer 25

Stop warfarin, give Phytomenadione IV prep orally. Repeat after 24h if still high. Re-start warfarin when INR <5

Question 26

How do you manage a patient with an INR of 5-8, but with no bleeding?

Answer 26

Withold 1-2 doses of warfarin and adjust subsequent maintenance dose

Question 27

How do you manage a patient with an INR of 5-8, with minor bleeding?

Answer 27

Stop warfarin + give Phytomenadione IV. Restart warfarin when INR <5

Question 28

If a a patient is on warfarin and needs emergency surgery that can't be delayed- What is the course of action?

Answer 28

IV Phytomenadione + Octaplex- check INR before surgery

Question 29

If a a patient is on warfarin and needs emergency surgery that can be delayed 6-12 hours- What is the course of action?

Answer 29

IV Phytomenadione

Question 30

How long before elective surgery should warfarin be stopped?

Answer 30

5 days before

Question 31

If a patient at high risk of thrombus formation needs elective surgery and has stopped warfarin- what is the course of action?

Answer 31

Bridge with a LMWH- stop 24 hours before the surgery

Question 32

How long after a high bleeding risk surgery should a LMWH be re-started?

Answer 32

48 hours minimum

Question 33

What is the course of action if a patient has stopped warfarin 5 days prior to an elective surgery but INR 1.5+ the day before surgery?

Answer 33

Give IV Phytomenadione orally.

Question 34

Which antiplatelet in combination with warfarin has a lower bleeding risk?

Answer 34

Aspirin