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Notes > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

CHADS2-VASC calculation

A

C - congestive heart failure/ left ventricle dysfunction
H - hypertension
A - age >75
D - diabetes
S - stroke, TIA x 2
V - vascular disease (MI, PAD, aortic plaque)
A - age >65 - 74
S - sex (female gets a point)

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2
Q

HAS Bled Score

A

H - hypertension >160mmHg
A - abnormal renal/liver (1 pt each) (scr >2.2)
S - stroke
B - bleeding hx (anemia, bleeding disorder, prior bleed)
L - labile INR (time in range <60%)
E - elderly >65 years old
D - drug or alcohol excess (1 pt each)

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3
Q

What disease state do we use CHADS2-VASC and HAS-BLED?

A

Non valvular A fib

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4
Q

CHADS2 Score and treatment options

A

Men 0 / Female 1 - ASA or nothing
Men 1 / Female 2 - ASA or DOAC or nothing
Men >2 / Female 3 - DOAC

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5
Q

HAS BLED Score to worry about bleeding with Afib DOAC treatment

A

> =3
try to reduce risk factors if you can

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6
Q

Warfarin goal time in range

A

> 65%

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7
Q

duration of needed anticoagulation before cardioversion of Afib

A

3 weeks

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8
Q

duration to anticoagulated after cardio version of afib

A

4 weeks

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9
Q

more potent isomer of warfarin

A

S is 5 x more potent

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10
Q

indication to start lower dosing of warfarin initially

A

> age
low body weight
liver / heart / thyroid disorder
low albumin

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11
Q

warfarin drug interactions

A

decreased absorption - cholestyramine and sucralfate

CYP2C9 hits S enantiomor harder than 3A4

fevers eat up clotting factors faster

OTC - garlic and ASA

reduce INR - phenytoin, phenobarbital, carbamazepine, rifampin, St John’s wort

reduced clearance - flagyl, bactrim, fluconazole, isoniazid, fluoxetine, sertraline, amiodarone

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12
Q

Dabigatran Dosing

A

Afib - 150mg BID
Total Hip - dabigatran 110mg BID, then 220 daily
VTE - 5 days injection then 150mg BID

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13
Q

Rivaroxaban Dosing

A

Afib - 20mg PM
Total Hip/Knee - 10mg daily (don’t need food)
VTE: 15mg BID x 21 days, then 20mg PM, cut to 10mg after 6 mo.

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14
Q

Dabigatran renal dosing cutoff

A

Afib: CrCl <30 use 75mg BID, CrCl <15 do not use
VTE: CrCl <30 do not use

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15
Q

Rivaroxaban renal dosing cutoff

A

Afib - CrCl <50 - 15mg PM
VTE: avoid if CrCl <15

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16
Q

Apixaban Dosing

A

Afib - 5mg BID
Total Hip/Knee - apixaban 2.5mg BID (Hip x 35, Knee x 12)
VTE: 10mg BID x 7 days, then 5mg BID, 2.5mg after 6 mo.

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17
Q

Apixaban renal dosing cutoff

A

Afib - 2.5mg BID if >80yo, <60kg, sCr >1.5
VTE: avoid if CrCl <15, sCr >2.5

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18
Q

Edoxaban Dosing

A

Afib - 60mg daily
VTE - 5 days injectable then 60mg daily

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19
Q

Edoxaban renal dosing cutoff

A

Afib - <50 - 30mg daily, avoid if CrCl >95

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20
Q

dialysis effects on DOACs

A

Do Not Use - edoxaban, dabigatran

Reduce Dose - apixaban, rivaroxaban

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21
Q

INR to start DOAC

A

rivaroxaban <3
edoxaban <2.5
apixaban and dabigatran <2

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22
Q

Afib + PCI anticoagulants of choice

A

DOAC and clopidogrel x 1 yr, then DOAC only

if high bleed risk may do 6 months or 3 months of plavix

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23
Q

bioprosthetic valve replacement - anticoagulant choice and duration

A

ASA - could do warfarin for 3 - 6 months - but should do ASA for life

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24
Q

transcatheter aortic valve replacement (TAVR) Less invasive

A

ASA only but could do aspirin/plavix x 6 mo. or warfarin x 3 mo.

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25
Q

bioprosthetic valve replacement in Afib

A

guidelines say to use warfarin within the first 3 months of replacement, but clinically we use DOACs

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26
Q

mechanical heart valve replacement

A

warfarin only

increase target INR to 2.5 - 3.5 if in the mitral position

can add ASA low dose if indication for anti-platelet therapy

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27
Q

VTE Risk Factors (13)

A

THE DICE SHOES

elderly (>40)
surgery
cancer
trauma
immobile
Central Line
Estrogen
ESA
Obese
Hx
Smoker
hypercoagulable
disease states (pregnancy, infection, CHF)

28
Q

Hip Fracture Anticoagulants

A

Warfarin
Enoxaparin 30mg SC BID
Fondaparinux 2.5mg SC daily

29
Q

Total Hip Surgery Anticoagulation Options

A

enoxaparin 40mg SC daily
Dalteparin 5000 SC daily
Fondaparinux 2.5mg daily
apixaban 2.5 BID
rivaroxaban 10mg
dabigatran 110mg, then 220mg daily
warfarin

30
Q

Total Knee Surgery Anticoagulation Options

A

Lovenox 30mg SC BID
Fondaparinux 2.5mg daily
dalteparin 2500, then 5000 daily
warfarin
apixaban 2.5mg BID
rivaroxaban 10mg daily

31
Q

difference in Ortho surgery anticoagulations

A

40mg SC daily in total Hips
dabigatran in Total Hip Only
Hip Fracture is only Warfarin for Oral options
fondaparinux is the same across the board
dabigatran is only for total hip
edoxaban has no place in therapy

32
Q

inpatient DVT prophylaxis

A

dalteparin 5000 units daily
enoxaparin 40mg SC daily
rivaroxaban 10mg daily - extended treatment
heparin 5000 SC q8h or q12h
fondaparinux 2.5mg daily

33
Q

contraindications to Xarelto as inpatient DVT prophylaxis

A

active cancer causing stay
GI ulcer in last 3 months
bleed in last 3 months
pulomonary cavity, bleeds, etc
dual antiplatelet therapy

34
Q

VTE prophylaxis as an inpatient and renal dysfunction

A

dialysis - heparin
CrCl < 15 - avoid rivaroxaban and apixaban
CrCl <30 - avoid fondaparinux and dabigatran

35
Q

LMWH dosing in obese and weight cutoffs

A

> 120kg or BMI >40

enoxaparin 40mg SC BID
heparin 7500 units SC q8hH
fondaparinux 5mg

36
Q

Heparin dosing VTE

A

80units/kg bolus, then 18u/kg/hr infusion

37
Q

Enoxaparin dosing VTE

A

1mg/kg SC q12h or 1.5mg/kg q24h
CrCl <30 1mg/kg q24h

38
Q

dalteparin dosing VTE

A

100units/kg SC q12h
200units/kg SC q24h

39
Q

fondaparinux dosing VTE

A

weight <50kg: 5mg
weight 51-100kg: 7.5mg
weight >100kg: 10mg

40
Q

treatment of VTE with dabigatran or edoxaban

A

start injectable x 5 days then start dabigatran 150mg BID or edoxaban 60mg daily

41
Q

what dose does rivaroxaban not need food?

A

10mg daily or less

42
Q

duration of anticoagulation with provoked and unprovoked DVT

A

provoked - 3 months
idiopathic - lifetime

43
Q

INR Risk Levels

A

INR < 1.8 increases clot risk by 60%

INR > 4.0 starts to increase bleed risk

44
Q

dabigatran expiration date and most common ADR

A

dyspepsia and 4 months after opening

45
Q

when to give edoxaban after a heparin infusion

A

4 hours after stopping

46
Q

which DOACs safer for bleeding than warfarin

A

apixaban and edoxaban

47
Q

who to avoid DOACs in

A

pregnant
hepatic dysfunction
antiphospholipid syndrome
low body weight
bariatric surgery

48
Q

which DOAC has best data with obesity

A

rivaroxaban or apixaban

49
Q

duration of time SCDs have to be on to be effective

A

18 hours/day

50
Q

DOC for burns in medically ill

A

heparin is best

51
Q

duration of hip replacement and knee replacement VTE prophylaxis

A

Knee x 10 days
Hip x 35 days

52
Q

DOC for hemodialysis

A

Heparin

53
Q

pregnancy DOC

A

LMWH or heparin

54
Q

duration of VTE treatment

A

1st - 3 mo. if known reason
cancer - 3-6mo. or longer
2nd - indefinite
1st w/o cause - 3 mo. +

55
Q

1 unit PRBCs raises Hgb _____ g/dl

A

1 - 2

56
Q

FFP

A

fresh frozen plasma
spun out all the protein - mostly clotting factors
similar risks as blood and has to thaw out
must type and cross

57
Q

Warfarin Reversal

A

prothrombin complex concentrate
25x more clotting factors than plasma

Factors II, IX, X, VIIa, C and S

does not require type and crossing

Balfaxar and KCentra

25 units/kg INR 2 - 3.9, max 2500 units
35 units/kg INR 4 - 6, max 3500 units
50 units/kg INR >6, max 5000 units

58
Q

Factor Xa Reversal Agent

A

Andexanet alfa (Andexxa)
400mg bolus then 4mg/min x 2 hours for apixaban 5 or rivaroxaban 10 or if dose was > 8 hours ago of any strength

800mg bolus then 8mg/min x 2 hours for > apixaban 5mg or rivaroxaban >10mg or if unknown dose/timing of anticoagulant

max dose 1750mg/event, no repeat dosing safety/efficacy data

59
Q

risk of activated vs inactivated factors

A

clotting

60
Q

risks of massive blood transfusions

A

acidosis
hyperkalemia
citrate-induced hypocalcemia
dilution-induced thrombocytopenia

61
Q

UFH Reversal

A

protamine 1mg for every 100 units of heparin
if continuous drip: last 1 hour = full dose, 2nd hour 1/2 of dose, 3rd hour 1/4 of dose

never administer more than 50mg in a single dose

62
Q

protamine ADR

A

hypotension, bradycardia
NPH insulin use, vasectomy, sensitivity to fish

63
Q

LMWH Reversal

A

protamine will reverse 50-60% of LMWH
Within 8 hours of last dose:
1mg = 1mg enoxaparin = 100 anti-Xa units

> 8 hours from last dose:
0.5mg = 1mg enoxaparin = 100 anti-Xa units

64
Q

dabigatran reversal

A

KCentra 25-50 units/kg
idarucizumab 5g IV x 1
reverses in 15 minutes and remains 12 - 24 hours

65
Q

DOAC Reversal

A

can use Andexanet alfa or aPCC 25 - 50 units/kg

66
Q

time to hold DOACs prior to surgery

A

dabigatran - 1-2 days unless CrCl <50 then 3 - 5 days

apixaban, rivaroxaban, edoxaban
minor or vascular procedures: 1 - 2 days
vascular surgery CrCl <30: 3 - 4 days

Notes (12 decks)

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