Cardiovascular Part 5 Flashcards
What is the treatment for an acute ischaemia stroke?
- Alteplase if administered within 4.5 hours of symptom onset and intracranial haemorrhage excluded
- Aspirin should be started within 24 hours of symptom onset with a PPI if history of dyspepsia with aspirin
- ONLY if high risk of VTE = parenteral anticoagulant
What drugs should you avoid in ischemic stroke?
Warfarin
Anticoagulants
What is the aspirin treatment for patients with disabling ischaemic stroke and atrial fibrillation?
Aspirin for at least 2 weeks before anticoagulants
What is the long-term management of TIA or ischaemic stroke (not associated with AF?
Clopidogrel
If clopidogrel not tolerated or contraindicated: MR dipyridamole and aspirin
if aspirin and clopidogrel not tolerated or contraindicated: MR dipyridamole alone
If clopidogrel and dipyridamole contraindicated or not tolerated: aspirin alone
Also, add high-intensity statin within 48 hours after stroke symptoms if not already taking irrespective of serum-cholesterol concentration
What class of drugs should not be used in the management of hypertension following stroke?
Beta-blockers unless they are indicated for co-existing conditions
What is the onset of action of vitamin k antagonist?
48-72 hrs
Within how many units is INR considered generally satisfactory?
0.5 units
What is the course of action for a patient who has a major bleed while on warfarin?
- stop warfarin
- give IV phytomenadione
- give dried thrombin complex (if unavailable - give fresh frozen plasma can be given but less effective)
What is the course of action for a patient with an INR of >8 and who has a minor bleed while on warfarin?
- stop warfarin
- give IV phytomenadione
- after 24 hours: if INR still high repeat phytomenadione dose
- when INR <5, restart warfarin
What is the course of action for a patient with an INR of >8 but has no bleeding while on warfarin?
- stop warfarin
- give phytomenadione orally (but using the intravenous preparation orally)
- after 24 hours: if INR still high repeat phytomenadione dose
- when INR <5, restart warfarin
What is the course of action for a patient with an INR of 5-8 with minor bleeding while on warfarin?
- stop warfrain
- give IV phytomenadione
- when INR <5, restart warfarin
What is the course of action for a patient with an INR of 5-8 but has no bleeding while on warfarin?
Withhold 1 or 2 doses and reduce subsequent maintenance dose
When should warfarin be stopped before elective surgery?
5 days before
If INR more than or equal to 1.5 the day before surgery - give phytomenadione orally
If hemostasis adequate - resume normal warfarin dose evening of surgery or next day
What should you do if a warfarin patient requires surgery but is at high risk of VTE?
bridge with LMWH treatment dose but stopped 24 hours before the surgery
If surgery carries high risk of bleeding, LMWH should not be restarted until at least 48 hours after
What should you do if a warfarin patient requires emergency surgery?
If surgery can be delayed by 6-12 hours: give IV phytomenadione to reverse warfarin effects
If surgery cannot be delayed: give IV phytomenadione and dried thrombin complex and check INR before surgery
What is used for the reversal of dabigatran?
Adarucizumab
What is used for the reversal of apixaban or rivaroxaban?
Andexanet
What must be controlled before aspirin is given in primary prevention?
Hypertension
How long after opening MR dipyridamole must they be discarded?
6 weeks
Can you use apixaban in renal impairment?
Avoid in less than 15ml/min
Reduce dose to 2.5mg BD if serum creatinine 133micromol/L (CrCl 15-29ml/min) and over and is 80 or over or has a body weight of 60kg or less
