Ambu Care Anticoag Flashcards
what are the names of the 2 molecular weight heparins?
enoxaparin and dalteparin
what does afib predispose someone to?
stroke and systemic arterial thromboembolism
T/F CHADSCASc can only be used to determine if we should use anticoags for patients with afib
true
T/F female sex by itself does not increase risk, but it is a factor with multiple risk factors
true
which DOAC has evidence of use in end-stage renal disease?
eliquis (apixaban)
patients with valvular afib can only use which anticoag(s)?
warfarin only
patients with nonvalvular afib should use which anticoag(s)?
usually DOAC over warfarin
in patients with valvular heart disease and afib with rheumatic mitral stenosis, they should use what anticoag therapy?
long-term warfarin
what therapy should be used if a pt has afib with hepatic disease?
warfarin, possibly eliquis
what therapy should be used if a pt has afib with renal disease with CrCl less than 25-30?
warfarin or eliquis
what therapy should be used if a pt has afib with history of GI bleed?
eliquis as first-line (lowest GI bleed risk), or warfarin
what therapy should be used if a pt has afib who is over 90 years old?
eliquis as first-line, or other DOACs
what therapy should be used if a pt has afib who wants a once daily med?
rivaroxaban (xarelto), edoxaban (savaysa), or warfarin
what therapy should be used if a pt has afib who is non-complaint with taking meds
warfarin
valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a mechanical valve versus a bioprosthetic valve?
mechanical valves increases clotting more than bioprosthetic valves
valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a disk/ball valve versus a bileaflet valve?
disk/ball valves increase clotting more than bileaflet valves
valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between replacing the mitral valve versus the aortic valve?
replacing the mitral valve has a greater impact on clotting than the aortic valve
T/F we should consider using DOACs (eliquis as first-line) for mechanical heart valves
false, not recommended for mechanical valves
what is the therapy treatment/goal for a mechanical aortic valve replacement?
warfarin with an INR goal of 2.5 (range 2-3)
what is the therapy treatment/goal for a mechanical mitral valve replacement?
warfarin with an INR goal of 3 (range 2.5-3.5)
what is the therapy treatment/goal for a mechanical aortic and mitral valve replacement?
warfarin with an INR goal of 3 (range 2.5-3.5)
CHEST 2012 recommends low-dose aspirin in all mechanical valves when?
patient has a low bleeding risk
we can add low-dose aspirin in addition to warfarin for mechanical valve replacements when?
there is an indication and we have assessed patients bleeding risk
what is ACC/AHA’s guidelines for treatment/goal of bioprosthetic valve replacement?
Warfarin for 3-6 months with an INR goal of 2.5 (range 2-3), then lifelong aspirin of 81mg daily
what is CHESTs guidelines for treatment/goal of bioprosthetic valve replacement?
for MVR: same as ACC/AHA
for AVR: aspirin 81mg qd only, no warfarin
what is ACC/AHA’s guidelines for treatment/goal of transcatheter aortic valve replacement?
lifelong aspirin with 6 months of clopidogrel overlap
what is CHESTs guidelines for treatment/goal of transcatheter aortic valve replacement?
lifelong aspirin with 3 months of clopidogrel overlap
what are common risk factors for venous thromboembolism?
surgery
acute illness
immobility (4 or more hours)
cancer
increased estrogen
what is deep vein thrombosis?
when a blood clot forms in deep vein
proximal DVTs have the highest risk of?
embolizing
what are the signs/symptoms of DVT?
unilateral leg pain, warmth, discoloration, and swelling
what is a pulmonary embolism?
when a DVT embolizes and lodges in lungs, most common with proximal DVT
what are common symptoms of a pulmonary embolism?
dyspnea, pleuritic chest pain, tachypnea (rapid breathing
what is the primary treatment of VTE?
when should DOACs be used for VTE?
DOACs, immediately with higher initial dosing
which DOACs require initial low molecular weight heparin (lovenox) before starting the DOAC to treat VTE?
dabigatran (pradaxa) and edoxaban (savaysa)
if starting warfarin for treatment of VTE, what are the considerations/goals of treatment?
warfarin must be co-administered (bridged) with low molecular weight heparin until INR is 2 or more for 5 or more days
what situation can we stop using anticoag after treatment of VTE?
with a provoked VTE by transient risk factor ex. knee replacement
what situations should indefinite anticoag therapy be recommended for VTE?
a provoked VTE by a chronic risk factor, or recurrent
or unprovoked VTE (if bleeding risk not high)
what are the considerations for treating VTE if the patient has cancer?
DOAC>LMWH>warfarin
what are the considerations for treating VTE if the patient has hepatic disease?
LMWH, maybe DOACs
what are the considerations for treating VTE if the patient has renal disease with CrCl less than 25-30?
warfarin
what are the considerations for treating VTE if the patient has history of GI bleed?
eliquis (lowest GI bleed risk), or warfarin
what are the considerations for treating VTE if the patient wants a once daily med?
warfarin, rivaroxaban (xarelto), or edoxaban (savaysa)
what are the considerations for treating VTE if the patient is non-compliant with taking meds?
warfarin
what does the INR tell us?
the time it takes for blood to clot on warfarin
as a INR goal overview, every indication has an INR target range of 2.5 (2-3) except for?
mechanical mitral valve or mechanical aortic valve (optional if other risk factors) target INR of 3 (2.5-3.5)
why do we use low molecular weight heparin combined with warfarin?
decreases risk of an embolism
why do we need an INR over 2 for at least 5 days when starting treatment?
Factor II is still highly active until around the 5 day mark
how long does it take for warfarin weekly dose adjustments to reach steady state?
2-4 weeks
counseling points with warfarin
-take around the same time once daily
-can take any time of the day (usually evening)
-with or without food is okay
-tablets can be split or crushed
what variables can increase INR and what is their interaction with warfarin?
-acute use of alcohol (inhibits warfarin metabolism)
-diarrhea (decreases secretion of vitK by gut flora)
-infection, inflammation, or fever (increase sensitivity)
-stress or pain (metabolic changes)
-liver disease (decreases clearance)
-heart failure
-renal disease
-hyperthyroidism
what variables can decrease INR and what is their interaction with warfarin?
chronic use of alcohol (induces warfarin metabolism)
smoking (induces warfarin metabolism via cyp1A2)
-hypothyroidism
what variable increases sensitivity to warfarin?
older age
what are the FAB-Four drug-warfarin interactions, what should we do if we know a patient is starting one of these drugs?
Fluconazole, amiodarone, bactrim, and flagyl
25-50% preemptive reduction in warfarin dose
which drugs increase INR but don’t req dose adjustment?
fluoroquinolones
allopurinol
thyroid hormones
corticosteroids
which drugs decrease INR but don’t req dose adjustment?
rifampin
primidone
phenytoin
carbamazepine
cholestyramine
sucralfate
why is acetaminophen first line for pain control if pt is using warfarin?
it may increase INR, but it is predictable/adjustable
what are other pain controllers besides acetaminophen while taking warfarin?
lidocaine patch/cream and gabapentin for nerve pain
what pain drug class should we avoid with warfarin?
NSAIDs and aspirin
what is the recommended daily intake of vitamin K?
90-120mcg
what vitamin K therapy is used to stabilize INR?
low-dose VitK1
what are the recommendations for vitamin K use when:
INR is less than 10 and patient is not bleeding
INR is more than 10 and patient is not bleeding
less than 10: no vitK
more than 10: 2.5-5mg vitK
what supplements increase INR which increases bleeding risk?
*which one decreases INR?
turmeric
ginkgo
garlic
ginger
CoQ10
cannabis
*st. john’s wort
what should patients do if they miss their dose of warfarin?
can take within 12 hours of missing dose to stay on schedule
what are rare adverse effects of warfarin?
necrosis (purple toe syndrome)
rare hair loss (alopecia)
what is dosing for eliquis for acute VTE (DVT/PE)?
10mg bid for 7 days then 5mg bid
what is dosing for eliquis for nonvalvular afib?
5mg bid, but do 2.5mg bid if patient has 2 of the following: age 80 or over, less than 60kg, or SCr 1.5 or higher
what is dosing for eliquis for renal disease who have afib?
2.5mg bid if patient has 2 of the following: age 80 or over, less than 60kg, or SCr 1.5 or higher
what is dosing for xarelto for acute VTE (DVT/PE)?
15mg bid w/f for 21 days, then 20mg qd w/f
what is dosing for xarelto for nonvalvular afib?
what if CrCl = 15-20?
20mg qd w/f
15mg qd w/f
what is dosing for xarelto for renal disease who have afib?
15mg qd if CrCl 15-50
what does a patient need to do to prepare for a procedure if they are taking warfarin?
-stop warfarin 5 days prior
-start LMWH when INR <2
-stop LMWH at least 24 hours before procedure time
what is the warfarin management for after a procedure?
if low bleed risk: restart warfarin and LMWH
if high bleed risk: restart warfarin within 24 hours, then LMWH within 48-72 hours
-stop LMWH when INR at goal
if patients risk of clotting is high, what should we consider and why?
bridging with anticoag. we’d rather have increased bleeding risk than increased clotting risk
