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IDT Winter > Ambu Care Anticoag > Flashcards

Ambu Care Anticoag Flashcards

1
Q

what are the names of the 2 molecular weight heparins?

A

enoxaparin and dalteparin

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2
Q

what does afib predispose someone to?

A

stroke and systemic arterial thromboembolism

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3
Q

T/F CHADSCASc can only be used to determine if we should use anticoags for patients with afib

A

true

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4
Q

T/F female sex by itself does not increase risk, but it is a factor with multiple risk factors

A

true

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5
Q

which DOAC has evidence of use in end-stage renal disease?

A

eliquis (apixaban)

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6
Q

patients with valvular afib can only use which anticoag(s)?

A

warfarin only

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7
Q

patients with nonvalvular afib should use which anticoag(s)?

A

usually DOAC over warfarin

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8
Q

in patients with valvular heart disease and afib with rheumatic mitral stenosis, they should use what anticoag therapy?

A

long-term warfarin

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9
Q

what therapy should be used if a pt has afib with hepatic disease?

A

warfarin, possibly eliquis

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10
Q

what therapy should be used if a pt has afib with renal disease with CrCl less than 25-30?

A

warfarin or eliquis

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11
Q

what therapy should be used if a pt has afib with history of GI bleed?

A

eliquis as first-line (lowest GI bleed risk), or warfarin

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12
Q

what therapy should be used if a pt has afib who is over 90 years old?

A

eliquis as first-line, or other DOACs

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13
Q

what therapy should be used if a pt has afib who wants a once daily med?

A

rivaroxaban (xarelto), edoxaban (savaysa), or warfarin

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14
Q

what therapy should be used if a pt has afib who is non-complaint with taking meds

A

warfarin

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15
Q

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a mechanical valve versus a bioprosthetic valve?

A

mechanical valves increases clotting more than bioprosthetic valves

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16
Q

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between using a disk/ball valve versus a bileaflet valve?

A

disk/ball valves increase clotting more than bileaflet valves

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17
Q

valve position and type affect thrombogenicity (increased chance of clotting), what is the consideration between replacing the mitral valve versus the aortic valve?

A

replacing the mitral valve has a greater impact on clotting than the aortic valve

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18
Q

T/F we should consider using DOACs (eliquis as first-line) for mechanical heart valves

A

false, not recommended for mechanical valves

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19
Q

what is the therapy treatment/goal for a mechanical aortic valve replacement?

A

warfarin with an INR goal of 2.5 (range 2-3)

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20
Q

what is the therapy treatment/goal for a mechanical mitral valve replacement?

A

warfarin with an INR goal of 3 (range 2.5-3.5)

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21
Q

what is the therapy treatment/goal for a mechanical aortic and mitral valve replacement?

A

warfarin with an INR goal of 3 (range 2.5-3.5)

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22
Q

CHEST 2012 recommends low-dose aspirin in all mechanical valves when?

A

patient has a low bleeding risk

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23
Q

we can add low-dose aspirin in addition to warfarin for mechanical valve replacements when?

A

there is an indication and we have assessed patients bleeding risk

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24
Q

what is ACC/AHA’s guidelines for treatment/goal of bioprosthetic valve replacement?

A

Warfarin for 3-6 months with an INR goal of 2.5 (range 2-3), then lifelong aspirin of 81mg daily

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25
Q

what is CHESTs guidelines for treatment/goal of bioprosthetic valve replacement?

A

for MVR: same as ACC/AHA
for AVR: aspirin 81mg qd only, no warfarin

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26
Q

what is ACC/AHA’s guidelines for treatment/goal of transcatheter aortic valve replacement?

A

lifelong aspirin with 6 months of clopidogrel overlap

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27
Q

what is CHESTs guidelines for treatment/goal of transcatheter aortic valve replacement?

A

lifelong aspirin with 3 months of clopidogrel overlap

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28
Q

what are common risk factors for venous thromboembolism?

A

surgery
acute illness
immobility (4 or more hours)
cancer
increased estrogen

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29
Q

what is deep vein thrombosis?

A

when a blood clot forms in deep vein

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30
Q

proximal DVTs have the highest risk of?

A

embolizing

31
Q

what are the signs/symptoms of DVT?

A

unilateral leg pain, warmth, discoloration, and swelling

32
Q

what is a pulmonary embolism?

A

when a DVT embolizes and lodges in lungs, most common with proximal DVT

33
Q

what are common symptoms of a pulmonary embolism?

A

dyspnea, pleuritic chest pain, tachypnea (rapid breathing

34
Q

what is the primary treatment of VTE?
when should DOACs be used for VTE?

A

DOACs, immediately with higher initial dosing

35
Q

which DOACs require initial low molecular weight heparin (lovenox) before starting the DOAC to treat VTE?

A

dabigatran (pradaxa) and edoxaban (savaysa)

36
Q

if starting warfarin for treatment of VTE, what are the considerations/goals of treatment?

A

warfarin must be co-administered (bridged) with low molecular weight heparin until INR is 2 or more for 5 or more days

37
Q

what situation can we stop using anticoag after treatment of VTE?

A

with a provoked VTE by transient risk factor ex. knee replacement

38
Q

what situations should indefinite anticoag therapy be recommended for VTE?

A

a provoked VTE by a chronic risk factor, or recurrent
or unprovoked VTE (if bleeding risk not high)

39
Q

what are the considerations for treating VTE if the patient has cancer?

A

DOAC>LMWH>warfarin

40
Q

what are the considerations for treating VTE if the patient has hepatic disease?

A

LMWH, maybe DOACs

41
Q

what are the considerations for treating VTE if the patient has renal disease with CrCl less than 25-30?

A

warfarin

42
Q

what are the considerations for treating VTE if the patient has history of GI bleed?

A

eliquis (lowest GI bleed risk), or warfarin

43
Q

what are the considerations for treating VTE if the patient wants a once daily med?

A

warfarin, rivaroxaban (xarelto), or edoxaban (savaysa)

44
Q

what are the considerations for treating VTE if the patient is non-compliant with taking meds?

A

warfarin

45
Q

what does the INR tell us?

A

the time it takes for blood to clot on warfarin

46
Q

as a INR goal overview, every indication has an INR target range of 2.5 (2-3) except for?

A

mechanical mitral valve or mechanical aortic valve (optional if other risk factors) target INR of 3 (2.5-3.5)

47
Q

why do we use low molecular weight heparin combined with warfarin?

A

decreases risk of an embolism

48
Q

why do we need an INR over 2 for at least 5 days when starting treatment?

A

Factor II is still highly active until around the 5 day mark

49
Q

how long does it take for warfarin weekly dose adjustments to reach steady state?

A

2-4 weeks

50
Q

counseling points with warfarin

A

-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

51
Q

what variables can increase INR and what is their interaction with warfarin?

A

-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

52
Q

what variables can decrease INR and what is their interaction with warfarin?

A

chronic use of alcohol (induces warfarin metabolism)
smoking (induces warfarin metabolism via cyp1A2)
-hypothyroidism

53
Q

what variable increases sensitivity to warfarin?

A

older age

54
Q

what are the FAB-Four drug-warfarin interactions, what should we do if we know a patient is starting one of these drugs?

A

Fluconazole, amiodarone, bactrim, and flagyl
25-50% preemptive reduction in warfarin dose

55
Q

which drugs increase INR but don’t req dose adjustment?

A

fluoroquinolones
allopurinol
thyroid hormones
corticosteroids

56
Q

which drugs decrease INR but don’t req dose adjustment?

A

rifampin
primidone
phenytoin
carbamazepine
cholestyramine
sucralfate

57
Q

why is acetaminophen first line for pain control if pt is using warfarin?

A

it may increase INR, but it is predictable/adjustable

58
Q

what are other pain controllers besides acetaminophen while taking warfarin?

A

lidocaine patch/cream and gabapentin for nerve pain

59
Q

what pain drug class should we avoid with warfarin?

A

NSAIDs and aspirin

60
Q

what is the recommended daily intake of vitamin K?

A

90-120mcg

61
Q

what vitamin K therapy is used to stabilize INR?

A

low-dose VitK1

62
Q

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

A

less than 10: no vitK
more than 10: 2.5-5mg vitK

63
Q

what supplements increase INR which increases bleeding risk?

*which one decreases INR?

A

turmeric
ginkgo
garlic
ginger
CoQ10
cannabis

*st. john’s wort

64
Q

what should patients do if they miss their dose of warfarin?

A

can take within 12 hours of missing dose to stay on schedule

65
Q

what are rare adverse effects of warfarin?

A

necrosis (purple toe syndrome)
rare hair loss (alopecia)

66
Q

what is dosing for eliquis for acute VTE (DVT/PE)?

A

10mg bid for 7 days then 5mg bid

67
Q

what is dosing for eliquis for nonvalvular afib?

A

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

68
Q

what is dosing for eliquis for renal disease who have afib?

A

2.5mg bid if patient has 2 of the following: age 80 or over, less than 60kg, or SCr 1.5 or higher

69
Q

what is dosing for xarelto for acute VTE (DVT/PE)?

A

15mg bid w/f for 21 days, then 20mg qd w/f

70
Q

what is dosing for xarelto for nonvalvular afib?
what if CrCl = 15-20?

A

20mg qd w/f
15mg qd w/f

71
Q

what is dosing for xarelto for renal disease who have afib?

A

15mg qd if CrCl 15-50

72
Q

what does a patient need to do to prepare for a procedure if they are taking warfarin?

A

-stop warfarin 5 days prior
-start LMWH when INR <2
-stop LMWH at least 24 hours before procedure time

73
Q

what is the warfarin management for after a procedure?

A

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

74
Q

if patients risk of clotting is high, what should we consider and why?

A

bridging with anticoag. we’d rather have increased bleeding risk than increased clotting risk

IDT Winter (19 decks)

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