CACP Domain 2 Indications and Recommendations

Question 1

Which anticoagulant is used to treat peripheral arterial embolism?

Answer 1

UFH

Question 2

Which DOAC is used to treat acutely ill medical patients?

Answer 2

Rivaroxaban

Question 3

Which anticoagulant is used in ECMO, blood transfusions, and dialysis procedures?

Answer 3

UFH

Question 4

Which anticoagulant is used to treat DIC?

Answer 4

UFH

Question 5

Which anticoagulants are used for prophylaxis of DVT in abdominal surgery?

Answer 5

Enoxaparin and Fondaparinux

Question 6

Can enoxaparin be used for the outpatient treatment of acute DVT with PE?

Answer 6

No, only for outpatient treatment without PE

Question 7

Which anticoagulant is used for DVT prophylaxis in hip fracture surgery?

Answer 7

Fondaparinux only

(Rivaroxaban, Apixaban, Dabigatran, Enoxaparin, and Fondaparinux are used as DVT prophylaxis for hip replacement surgery.)

Question 8

When can fondaparinux be used to treat DVT or PE?

Answer 8

When it is given in conjunction with warfarin

Question 9

When can prasugrel be used to treat STEMI?

Answer 9

When used with PCI

Question 10

When can tirofiban be used?

Answer 10

Only in non-ST elevated ACS (UA and NSTEMI)

Question 11

Thrombolytics are approved for the treatment of

Answer 11

Acute myocardial infarction, acute ischemic stroke, acute massive PE (alteplase only)

Question 12

AHA/ACC/HRS 2019 recommendation for AF, CHA2DS2-VASC score of 2 in men, 3 in women, with CrCl < 15 mL/min or on dialysis

Answer 12

Warfarin or Apixaban (2b recommendation)

Question 13

Duration of anticoagulation for cardioversion for patients with AF/atrial flutter not < 48 hours (AHA/ACC/HRS 2019)

Answer 13

3 weeks before and 4 weeks after cardioversion at least

If having to start immediately due to hemodynamic instability, then continue for at least 4 weeks

Question 14

ACS - underwent PCI with stent - AF with CHA2DS2-VASc 2+ - now on triple therapy - which P2Y12 inhibitor?

Answer 14

Clopidogrel preferred to prasugrel

Question 15

ACS - underwent PCI with stent - AF with CHA2DS2-VASc 2+: triple or double therapy?

Answer 15

Double therapy (clopidogrel or ticagrelor + warfarin) preferred

Question 16

ACS - underwent PCI with stent - AF with CHA2DS2-VASc 2+: what double therapy with DOACs is reasonable?

Answer 16

Clopidogrel with
Rivaroxaban 15 mg daily OR
Dabigatran 150 mg BID
(can consider dabigatran 110 mg BID if bleeding risk is high)

Question 17

ACS - PCI with stent - AF with CHA2DS2-VASc 2+ on triple therapy, when can transition to double therapy be considered?

Answer 17

At 4 - 6 weeks

Question 18

INR goal of 3.0 for warfarin patients with what indications

Answer 18

mechanical MVR, older generation mechanical AVR, mechanical AVR with risk factors (AF, previous VTE, LV dysfunction, or hypercoagulable conditions)

Question 19

When to use ASA and what dose for valvular heart disease

Answer 19

ASA 81 mg daily in conjunction with warfarin for mechanical valve (recommended) or bioprosthetic valve (reasonable)

Question 20

When does Chest 2017 for valvular heart disease recommend INR goal 1.5 - 2.0?

Answer 20

Mechanical On-X AVR and no VTE risk factors

Question 21

Chest 2017 TAVR recommendation

Answer 21

Clopidogrel 75 mg daily + ASA 81 mg daily first 6 months, then ASA 81 mg daily lifelong

Anticoagulation with warfarin is reasonable for 3 months and low risk of bleeding

Question 22

Anticoagulant of choice if patient also takes PGP inhibitors or inducers

Answer 22

Warfarin or Enoxaparin

Question 23

Anticoagulant of choice if patient also takes strong CYP inhibitors or inducers

Answer 23

Warfarin or Enoxaparin

Question 24

When does ASH 2018 suggest against using anti-Xa monitoring for LMWH?

Answer 24

CrCl < 30 mL/min or obesity

Question 25

Duration of anticoagulation therapy for first unprovoked VTE with low or moderate bleeding risk

Answer 25

Indefinite (extended)

Question 26

Duration of anticoagulation therapy for first unprovoked VTE with high bleeding risk

Answer 26

3 months

Question 27

CHEST 2016 recommendation if stopping anticoagulant therapy for unprovoked proximal VTE

Answer 27

ASA 81 mg daily for long term VTE prophylaxis

Question 28

Should compression stockings be routinely used in acute DVT to prevent post-thrombotic syndrome?

Answer 28

No

Question 29

Chest 2016 recommendation for subsegmental PE (no DVT) and low risk of VTE recurrence

Answer 29

No anticoagulation

Question 30

Chest 2016 recommendation for massive PE (acute PE with hypotension)

Answer 30

Thrombolytic therapy, specifically systemic thrombolytic therapy

Question 31

Chest 2016 recommendations for recurrent VTE (2)

Answer 31

Switch to LMWH if taking warfarin or DOAC | Increase LMWH dose if taking LMWH

Question 32

Antiplatelet of choice with aspirin for elective surgery PCI

Answer 32

Clopidogrel

Question 33

Antiplatelet of choice with aspirin for ACS

Answer 33

Ticagrelor or Prasugrel

Question 34

If warfarin is chosen for antithrombotic management post-PCI, what is the INR goal range with triple anticoagulant therapy?

Answer 34

2.0 - 2.5

Question 35

Duration of oral anticoagulation post-PCI

Answer 35

Lifelong

Question 36

Patients on DOAC going for elective or nonemergent procedure should withhold anticoagulation therapy for

Answer 36

24 hours (48 hours if impaired renal function and taking dabigatran)

Question 37

Anticoagulation therapy for stable, non-invasive CAD, no AF

Answer 37

ASA or | ASA + rivaroxaban

Question 38

Anticoagulation therapy for stable, invasive CAD, no AF

Answer 38

ASA + P2Y12 inhibitor or | ASA + P2Y12 inhibitor + rivaroxaban

Question 39

Anticoagulation therapy for ACS (noninvasive or invasive), no AF

Answer 39

ASA + P2Y12 inhibitor or | ASA + P2Y12 inhibitor + rivaroxaban

Question 40

Anticoagulation therapy for stable, non-invasive CAD, with AF

Answer 40

ASA + any DOAC

Question 41

Anticoagulation therapy for stable, invasive CAD, with AF

Answer 41

ASA + P2Y12 inhibitor + Dabigatran or Rivaroxaban

Question 42

Anticoagulation therapy for ACS (noninvasive or invasive), with AF

Answer 42

ASA + P2Y12 inhibitor + Dabigatran or Rivaroxaban

Question 43

Cangrelor (Kengreal) FDA approved indication and dosing

Answer 43

30 mcg/kg prior to PCI, then 4 mcg/kg/min IV for 2 hours or duration of procedure, whichever is Longer to reduce risk of periprocedural MI, repeat coronary vascularization, and stent thrombosis in patients who have Not been treated with a P2Y12 inhibitor (do not use clopidogrel or prasugrel during cangrelor infusion) and are not being given GP2b/3a inhibitor

Question 44

ASH 2020 for DVT/PE: if VTE is provoked by a transient risk factor and patient has a history of another VTE provoked by a transient risk factor, what is duration of therapy for this transient risk factor?

Answer 44

Primary treatment of 3 - 6 months only (instead of indefinite)

Question 45

Does ASH recommend the routine use of compression stockings in a patient with PTS?

Answer 45

No, ASH recommends against the routine use as many patients may not benefit from it

Question 46

If a patient with a mechanical heart valve is undergoing a procedure that requires warfarin interruption, do you always bridge?

Answer 46

Yes, always bridge for mechanical heart valve if warfarin is needing to be held

Question 47

Acute ischemic stroke (not mild, nondisabling or acute stroke or head trauma or intracranial/spinal surgery within 3 months or who have received full treatment LMWH) within 4.5 hours, first drug and dose of choice?

Answer 47

IV alteplase 0.9 mg/kg (max dose 90 mg), 10% given over the first minute, the rest given over the remaining 50 mins

Question 48

Should you give a GP2b3a inhibitor concurrently with IV alteplase?

Answer 48

No

Question 49

If a patient has been given a fibrinolytic, when to give ASA?

Answer 49

Avoid within the first 90 mins, generally delayed until 24 hours later

Question 50

When to start DAPT if minor noncardioembolic ischemic stroke and did not receive IV alteplase? How long to continue?

Answer 50

Within 24 hours after symptom onset, continue for 21 days and up to 90 days

Question 51

Recommended antithrombotic therapy for mechanical valve patients

Answer 51

VKA + ASA 81 mg daily lifelong

Question 52

Reasonable antithrombotic therapy for bioprosthetic valve patients (drug and duration)

Answer 52

VKA + ASA 81 mg daily OR DOAC + ASA 81 mg daily Duration 3 - 6 months, then ASA 81 mg daily lifelong

Question 53

Reasonable antithrombotic therapy for TAVR

Answer 53

``` VKA (at least 3 months if low bleeding risk) + Clopidogrel 75 mg daily (first 6 months) + ASA 81 mg daily lifelong ```

Question 54

If bileaflet mechanical AVR and no other risk factors for surgical thrombosis and patient is taking VKA and INR is subtherapeutic, do you bridge for invasive procedures?

Answer 54

No, interruption without bridging agents is recommended

Question 55

Recommended antithrombotic therapy for atherosclerotic lower extremity PAD

Answer 55

ASA 81 mg daily + Clopidogrel 75 mg daily