Antithrombotic Diseases Flashcards
Acute Coronary Syndrome
Treatment
-Pts undergoing fibrinolysis (STEMI only) Enoxaprin for 7days
-Pts getting primary PCI: Heparin IV d/c after PCI (also give GPIIb/IIIa inhibitor (Eptifibatide) x12-18hrs after PCI)
OR
Bivalirudin continuous IV d/c after PCI
-Pts getting medical management: Heparin IV x48hrs
Acute Coronary Syndrome
Special Considerations
option 1: early invasive, high risk pts get PCI
- Immediate Primary PCI (w/in 90 mins)
- Fibinolytics if no PCI(w/in30 mins) Alteplase
option 2: conservative- (low risk pts) see if Sx resolve and get a stress test.
Acute Coronary Syndrome
Chronic treatment
Atiplatlets after initial Tx
- ASA daily X1mo w/mental stent
- ASA daily 3-6mo w/drug eluting stents
- ASA 81mg for life (ALL)
THEN 1 OF THESE
- Clopidogrel (loading dose then maintenance)
- Prasugrel (loading dose then maintenance)
- Ticagreglor (loading dose then maintenance)
Venous Thromboembolism (VTE): DVT and PE
Treatment
-Continuous Heparin infusion, start Warfarin also, continue IV X5days AND until INR 2-3 (warfarin)
OR
Enoxaparin (prego)
Fondaparinux, Rivaroxaban, Dabigatran, Edoxaban, Apixaban, Warfarin
Venous Thromboembolism (VTE): DVT and PE
Special considerations
- Monitoring: check baseline aPTT
- Check aPTT in 6hrs-adjust heparin dose based on aPTT result
INR Goal: 2.5 (2-3)
- Inpt: check INR daily and adjust warfarin dose
- Outpt: check INR w/in 3-4days
Venous Thromboembolism (VTE): DVT and PE
Chronic Treatment
Duration
- 1st occurrence: 3mo
- 2nd occurrence: lifelong
Dose Adjustment based on WEEKLY dose
*INR goal x2: DECREASE weekly dose 10-20%
Options for prevention
- Unfractionated Heparin
- Enoxaparin
- Fondaparinux
- Rivaroxaban
- Apixaban
- Dabigatran
Stroke: Hemorrhagic and Ischemic (MC)
special considerations
Goals: reduce neurologic injury to prevent mortality/disability
-2ndary stroke prevention
Stroke protocol:
- ONLY give t-PA if you KNOW the Sx of stroke started w/in last 4.5hrs of them presenting to you
- CT to r/o hemorrhage
Stroke: Hemorrhagic and Ischemic (MC)
Treatment
- Acute Ischemic Strok:
- IV t-PA (Altepase)
- ASA daily: IF IV t-PA wait 24hrs before starting ASA
- Secondary Stroke Prevention
- ASA daily OR Clopidogrel OR ASA plus ER dipyridamole
- Warfarin for pts w/cardiobembolic stroke (pts w/Afib)
Peripheral Artery Disease
special considerations
Goals: improve walking, prevent CV complications
-Primary Sx: intermittent claudication, pain at rest
Peripheral Artery Disease
treatment
- ASA daily OR Clopidogrel (for pts who can’t take ASA)
- Can add Cilostazol for pts w/intermittent claudication
AFib: prevention of strok and systemic embolism
treatment
Depends on Pt characteristics
- Mechanical heart valve: Warfarin
- ACS: warfarin
- Severe Kidney Dysfunction (CrCl /=2: Warfarin, dabigatran, rivaroxaban, apixaban, edoxaban
1: Anticoagulant, ASA, OR no antithrombotic
0: NO antithrombotic
AFib: prevention of strok and systemic embolism
special considerations
-Decide antithrombotic tx based on stroke/bleeding risk
CHA(2)D(2)VASc Score
- CHF/LV dysfunction 1
- HTN 1
- Age >75 2
- DM 1
- Stroke 2
- Vascular Dz 1
- Age 65-74 1
- Sex: F 1
HAS-BLED (score >3)
AFib: prevention of strok and systemic embolism
- Pt preferences that may determine choice of antithrombotic therapy in Afib/flutter
- Regular INR monitoring
- Inconsistent Diet
- Cost/ins coverage
- Drug-drug interactions w/other meds
- Difficulty remembering doses
What anticoagulant do pts undergoing PCI get?
Heparin- Eptifibatide (GP IIb/IIIa)
stents:
ASA longer for drug eluding- (higher clot risk than bare metal)
