Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

BCPS > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

HAS-BLED

A

Hypertension (SBP >160)
Abnormal renal or hepatic function
Stroke history
Bleeding tendency or predisposition
Labile INR
Elderly (>65)
Drug or alcohol excess

Renal = chronic dialysis, renal transplant, SCr >= 2.26

Hepatic = Chronic hepatic disease, bilirubin >2x ULN, AST/ALT/ALP >3x ULN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Initiate warfarin 2-3mg in these groups

A

-Advanced age
-Low body weight (<45kg)
-Drug interactions
-Malnutrition
-Heart failure
-Hyperthyroid
-Low albumin, liver disease
-Ethnic groups (Asian)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Ideal Time in Therapeutic Range (TTR)

A

65-70%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

S warfarin metabolism, common DI

A

CYP2C9 > CYP3A4

metronidazole, bactrim, fluconazole, isoniazid, fluoxetine, sertraline, amiodarone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

R warfarin metabolism, common DI

A

CYP1A2, CYP3A4 > CYP2C19

clarithromycin/erythromycin, azoles, fluoxetine, amiodarone, cyclosporine, sertraline, grapefruit juice, FQs, PIs, diltiazem/verapamil, isoniazid, metronidazole

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Dabigatran dosing, adjustment AFIB

A

Standard: 150mg BID

CrCl 15-30 ml/min: adjust to 75mg BID
CrCl 30-50 ml/min IN combo with ketoconazole or dronaderone: adjust to 75mg BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Avoid dabigatran

A

CrCl <15 ml/min

Dialysis

CrCl 15-30 ml/min IN COMBO with verapamil, ketoconazole, dronedarone, clarithromycin

P-gp inducers (rifampin)

Chemo agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Chemo agents that interact with all DOACs

A

Vinblastine, doxorubicin, imatinib, crizotinib, vandetanib, sunitinib, abiraterone, enzalutamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Dabigatran metabolism

A

Renal, interactions occur w/ P-gp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Rivaroxaban dosing, adjustment AFIB

A

Standard: 20mg daily with food

CrCl 15-50 ml/min or dialysis: adjust to 15mg daily with food

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Avoid rivaroxaban

A

Strong CYP3A4 and P-gp inducers or inhibitors

Chemo agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Apixaban dosing, adjustments AFIB

A

Standard: 5mg BID

Adjust to 2.5mg BID:
If 2/3 criteria met (>= 80 y/o, weight <=60kg, SCr >= 1.5),
Use with strong CYP3A4 and P-gp inhibitors
Dialysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Avoid apixaban

A

Strong CYP3A4 and P-gp inducers

Strong CYP3A4 and P-gp inhibitors (dose reduce or avoid if already on 2.5mg BID)

Chemo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Edoxaban dosing, adjustment AFIB

A

Standard: 60mg daily

CrCl 15-50 ml/min: adjust to 30mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Avoid edoxaban

A

CrCl > 95 ml/min

CrCl < 15 ml/min

Dialysis

P-gp inducers

Chemo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Dabigatran to Warfarin conversion

A

CrCl >= 50 = initiate warfarin 3 days before discontinuing

CrCl 31-50 = initiate warfarin 2 days before discontinuing

CrCl 15-30 = initiate warfarin 1 day before discontinuing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Warfarin to Dabigatran

A

D/C warfarin, initiate dabigatran when INR <2.0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Dabigatran to Parenteral Anticoagulant

A

Wait 12 hr (CrCl > 30) or 24 hr (CrCl <30) after dabigatran to initiate parenteral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Parenteral Anticoagulant to Dabigatran

A

Initiate dabigatran 0-2 hours before next dose of parenteral dose due OR when UFH is discontinued

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Rivaroxaban or Apixaban to Warfarin

A

D/C rivaroxaban. Start parenteral anticoagulant and warfarin as bridge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Warfarin to Rivaroxaban

A

D/C warfarin, start rivaroxaban when INR <3.0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Parenteral Anticoagulant to Rivaroxaban

A

Initiate rivaroxaban 0-2 hours before next scheduled administration

If on UFH, D/C heparin and start rivaroxaban at the same time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Warfarin to Apixaban

A

D/C warfarin and start apixaban when INR <2.0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Parenteral Anticoagulant to Apixaban

A

D/C anticoagulant and start apixaban at usual time of next dose

If on UFH infusion, DC infusion and start apixaban at same time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Edoxaban to Warfarin

A

If on edoxaban 60mg: reduce to 30mg and start warfarin at the same time. Once daily INR >=2.0, d/c edoxaban

If on edoxaban 30mg: reduce to 15mg and follow same as above

OR

D/C edoxaban and bridge warfarin with parenteral anticoag

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Warfarin to Edoxaban

A

D/C warfarin and start edoxaban when INR <= 2.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Parenteral Anticoagulant to Edoxaban

A

D/C anticoagulatn and start edoxaban at next scheduled time

If UFH, d/c infusion and start edoxaban 4 hours later

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Trial results for DOAC vs Warfarin in AFIB

A

-Noninferior for stroke/stroke embolism

-ALL DOACS significantly lower rate of hemorrhagic stroke

-Dabigatran only DOAC w/ sig reduction of ischemic stroke

-Apixaban/edoxaban had sig reduction in major bleeding

-Apixaban only agent to show sig reduction in mortality compared to warfarin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Avoid/Caution DOACs in AFIB

A

Pregnancy
Breastfeeding
Severe hepatic dysfunction (Child-Pugh B or C)
Antiphospholipid syndrome
Bariatric surgery (Variable PKs)

Caution in obesity (BMI >40) or low body weight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Bioprosthetic valve placement AND AFIB anticoag

A

-Afib onset > 3 months after valve = DOAC

-Afib onset <3 moths after valve = warfarin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Valve replacements when INR 2.5-3.5 recommended

A

-Aortic mechanical valve with risk factors for thromboembolism, older generation valve

-On-X aortic valve with no risks for TE (for 3 months, then reduce INR to 1.5-2.0 w/ aspirin)

-Mitral mechanical valve

-Aortic & mitral heart valve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Mechanical heart valve bridging with surgeries

A

-No interruption in therapy needed for minor procedure (dental, cataract)

-Interrupt w/o bridge in invasive procedure w/ mechanical aortic valve & no risk for TE

-Interrupt w/ bridge if invasive procedure w/ mechanical aortic valve w/ risk factor or mechanical mitral valve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Caprini Scale

A

Scale for non-ortho, abdominal pelvic surgery VTE ppx need

Risk of >=3 = pharmacologic vte ppx if avg bleed risk

Risk >= 5 = pharmacologic and mechanical VTE ppx

34
Q

Anticoagulants for general surgery vte ppx

A

LMWH > LDUH
If unavailable, aspirin 160mg or fondaparinux

35
Q

Bariatric surgery VTE ppx dosing

A

Higher than all others

LDUH: 5000unit SC q8h
Enoxaparin: 40mg q12h
Dalteparin: 7500 units SC q24h
Fondaparinux: 5mg SC q24h

36
Q

PADUA Prediction Score Factors

A

Active cancer (3)
Previous VTE (3)
Reduced mobility (3)
Known thromboembolic condition (3)
Recent (<1mo) trauma/surgery (2)
>= 70 y/o (1)
Cardiac/respiratory failure (1)
Acute MI or ischemic stroke (1)
Acute infection and/or rheumo disorder (1)
BMI >= 30 (1)
Active hormonal treatment (1)

37
Q

PADUA >= 4

A

Low bleed risk: VTE ppx with LDUH, LMWH, fondaparinux (alt: low-dose rivaroxaban)

High bleed risk: mechanical ppx

38
Q

Extended prophylaxis after hospitalization

A

Rivaroxaban 10mg daily for 35 days, including time in hospital if >=75, prolonged immobilization, cancer hx, VTE hx, HF, thrombophilia, active infectious disease, BMI >=35

*enoxaparin had higher bleed events

39
Q

VTE ppx in pregnancy

A

LMWH or LDUH

Warfarin = teratogenic in first trimester
DOACs = no role

40
Q

VTE ppx in obesity

A

BMI >40 or >120kg reasonable to use:

Enoxaparin 40mg BID
Enoxaparin 0.5mg/kg BID
Dalteparin 7500 units daily
Fondaparinux 5mg daily
LDUH 7500 q8h

41
Q

VTE ppx duration postop for GI/GU/gyno cancer

A

up to 28 days

42
Q

VTE ppx duration in general surgery & pts with prior VTE

A

Duration of hospital stay if no prior VTE

up to 28 days if prior VTE

43
Q

VTE ppx duration in patients with major trauma

A

Up to 8 weeks if impaired immobility in rehab.

Otherwise, duration of hospital stay

44
Q

VTE ppx duration in spinal cord injury

A

Incomplete injury: hospital discharge

Uncomplicated complete motor injury: 8 weeks

Rehab if complete motor injury: 12 weeks or until discharge

45
Q

Homan sign

A

Pain in back of knee with dorsiflexon of foot – sign of DVT

46
Q

Wells Model for DVT Scores

A

0 = low risk (3%)
1-2 = moderate risk (17%)
>=3 = high risk

47
Q

Massive PE

A

Hemodynamic instability
SBP < 90
Cardiogenic shock

48
Q

Submassive PE

A

Normal SBP
Right ventricular dysfunction
Positive biomarkers

49
Q

Nonmassive PE

A

Hemodynamically stable

50
Q

Wells Model for PE Scores

A

0-1 = low risk (3-10%)
2-6 = moderate risk (15-35%)
>= 7 = high risk

51
Q

Dabigatran and Edoxaban bridge therapy for VTE

A

Injectable anticoagulant for 5 days, then switch to dabigatran or edoxaban

52
Q

UFH dosing VTE

A

-80 units/kg bolus (max 10,000 units), then 18 units/kg/hr (max 2,000 units/hr)

53
Q

Dalteparin dosing VTE

A

100 units/kg q12H
or
200 units/kg q24h

CrCl <30 ml/min = contraindicated

54
Q

Fondaparinux dosing VTE

A

<50kg: 5mg q24H
50-100kg: 7.5mg q24H
>100kg: 10mg q24H

CrCl <30 ml/min = contraindicated

55
Q

Apixaban and Rivaroxaban dose reduction after 6 months of VTE therapy

A

Can go to apixaban 2.5mg BID or rivaroxaban 10mg for extended-phase treatment

56
Q

Provoked VTE duration of therapy

57
Q

First episode of Provoked VTE by persistent risk factor

A

At least 3 months, then reassess for extended-phase -
If low risk of bleeding and adherent, then low-dose apixaban/rivaroxaban preferred

58
Q

First episode of VTE with thrombophilia (inherited or acquired) duration

A

At least 3 months, then reassess for extended-phase
Low risk of bleed = continue

59
Q

First episode of cancer-related VTE duration

A

At least 3-6 months, extended if active cancer

LMWH preferred over DOAC if GI cancer

60
Q

Second provoked/unprovoked VTE duration

A

Indefinite

61
Q

Provoked VTE risk factors

A

Surgery
Hospitalization
Plaster cast immobilization within 3 months
Estrogen
Pregnancy
Prolonged travel >8 hours
Lesser leg injuries
Immobilization within 6 weeks

62
Q

Fresh Frozen Plasma dose for warfarin reversal

A

15-20 mL/kg (around 1.2-1.6L)

Critically ill: 30 mL/kg

63
Q

3-factor Clotting factors

64
Q

4-factor Clotting factors

A

II VII IX X

65
Q

Activated PCC factors

A

II VIIa IX X

66
Q

Cryoprecipitate

A

Thaw 1 unit of FFP in cold conditions

Factor VII, XIII, von Willebrand factor, fibronectin, fibrinogen

0.2 units x kg = 1 g/dL increase in fibrinogen

67
Q

Recombinant activated factor VII

A

Reversal for UFH, LMWH, DOAC

90 mcg/kg
18-30 mcg/kg documented as ok and cheaper

68
Q

Protamine for UFH

A

Reversal for UFH

1mg protamine neutralizes ~100 units heparin received in past 2 1/2 hours

Max dose 50mg

69
Q

Packed RBCs

A

1 unit = Hgb increase 1-2 g/dL

70
Q

Platelets

A

1 unit = 300,000-600,000 platelets

71
Q

Protamine for LMWH

A

Reverses ~50-60%

1mg protamine neutralizes 1mg of enoxaparin

If LMWH administered <8 hours before, then give standard dose

If LMWH administered >8 hours before need for reversal, give 0.5mg protamine for every 1mg enoxaparin

72
Q

Vitamin K

A

Warfarin reversal

Delayed onset

PO takes 24-48 hours

IV (as slow infusion) takes 8-12 hours

Avoid SC/IM

73
Q

4PCC dosing for warfarin

A

ABW

INR 2-4: 25 units/kg (max 2500)
INR 4-6: 35 units/kg (max 3500)
INR >6: 50 units/kg (max 5000)
INR <2 with cerebral bleed: 12.5-25 units/kg

74
Q

aPCC dosing for DOAC

A

25-50 units/kg

75
Q

Dabigatran preprocedural hold time

A

Low/mod bleed risk surgery
CrCl >= 50 = 1 day
CrCl <50 = 2 days

High bleed risk surgery
CrCl >= 50 = 2 days
CrCl <50 = 4 days

76
Q

DOAC preprocedural hold time

A

Low/mod bleed risk surgery = 1 day

High bleed risk surgery = 2 days

77
Q

Idarucizumab

A

Antidote for DTI (dabigatran)

5g IV

78
Q

Andexanet alfa

A

Coagulation factor Xa (recombinant), inactivated

Antidote for factor Xa inhibitors

79
Q

Low dose andexanet alfa

A

400mg IVB followed by 4mg/min for 2 hours

Use if last dose of apixaban 5mg or less or rivaroxaban 10mg or less administered less than 8 hours earlier or unknown

80
Q

High dose andexanet alfa

A

800mg IVB followed by 8mg/min for 2 hours

Use if last dose of apixaban >5mg or rivaroxaban >10mg taken less than 8 hours before or unknown

BCPS (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions