Cardiovasular Flashcards by Izzy Harding

What is the treatment dose for a DVT/PE with rivaroxaban?

15mg BD for 21days then 20mg OD with food

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What is the dose of rivaroxaban for prophylaxis of DVT following hip and knee replacement?

Knee: 10mg OD for 2weeks
Hip: 10mg OD for 5 weeks
Both start 6-10 hours after surgery

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What is the mechanism of action for rivaroxaban?

Direct inhibitor or factor Xa

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When should rivaroxaban NOT be used for thromboprophylaxis?

Patients with prosthetic heart valves including patients who have undergone TAVR (transcatheter aortic valve replacement).

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Which DOAC should be taken with food?

Rivaroxaban - due to increased absorption with food (15 and 20mg tabs)

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What is the renal cutoff for rivaroxaban?

EGFR: less than 15ml/min/1.73m2
CrCl: 15ml/min

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What is the reversal agent for rivaroxaban?

Andexanet Alfa

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What is an appropriate alternative for patients who required VTE but have a history of HITT and DOACs/warfarin are contraindicated?

Fondaparinux - does not usually cause HITT but have been some cases reported

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What is the renal cutoff and dose adjustments for fondaparinux when used for treatment of ACS or prophylaxis of VTE?

Avoid if CrCl less than 20ml/min
For VTE prophylaxis only: Reduce dose to 1.5mg daily if CrCl 20-50ml/min

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What is the renal cut off and dose adjustment for fondaparinux when used for treatment of VTE?

Avoid if CrCl less than 30ml/min
Reduce dose to 1.5mg daily if CrCl 20-50ml/min

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What is the mechanism of action for fondaparinux?

Inhibits activated factor X

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What is the mechanism of action for dabigatran?

Reversible inhibition of free thrombin, fibrin bound thrombin, and thrombin-induced platelet aggregation.

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Which DOAC is not licensed for the prophylaxis of atherothrombotic events?

Edoxaban

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Which DOAC has no antidote?

Edoxaban

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What is the recommended dose for apixaban for prophylaxis of stroke in AF?

5mg BD

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When should the apixaban dose in AF be reduced to 2.5mg?

2 of the following characteristics:
Over 80 years
<60kg
SrCr >133 (or same as 133)

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What is the apixaban dose for treatment of VTE?

10mg BD for 7days; 5mg BD
For a minimum of 3 months

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What is the apixaban dose for VTE prophylaxis of recurrent DVT/PE? (Following 6 months completion of anticoagulant treatment)

2.5mg BD

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What is the recommended dose of dabigatran for treatment of VTE and when would you reduce it? What to?

150mg BD
Reduce to 110mg BD if:
Over 80
Concurrent treatment with verapamil
Reduce to 110-150mg BD if CrCl 30-50ml/min

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What is the typical starting dose of warfarin?

10mg OD for 2 days
5mg OD for elderly, frail, low body weight, liver disease, or cardiac failure

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What is the usual maintenance dose for warfarin?

3-9mg taken at the same time each day

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What is the minimum duration of treatment for distal calf DVT with warfarin?

Six weeks

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What measurements should be taken before starting warfarin treatment?

Baseline prothrombin (but initial dose should not be delayed while waiting for the result)

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Apart from warfarin, what are the other vitamin k antagonists (2)?

Acenocomarol
Phenidione

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What is the duration of treatment for proximal DVT/PE with known temporary risk factors and a low risk of reoccurrence?

3 months

When using warfarin in AF, if the patient undergoes cardioveraion, how long should the target INR be achieved before and after treatment?

3 weeks before and 4 weeks after

When is warfarin contraindicated? (6)

Haemorrhagic stroke Clinically significant bleeding Severe hepatic impairment Within 72 hours of major surgery Within 48 hours postpartum Pregnancy - teratogenic

What are the risk factors for bleeding?

History of GI bleeds or peptic ulceration Recent ischemic stroke Uncontrolled HTN Concurrent NSAID use Recent surgery Postpartum period (5-7 days after delivery)

Why should warfarin be introduced slowly in thrombophilia?

Risk of skin necrosis

Why is warfarin cautioned in thyroid conditions?

Levels of thyroid hormone can alter rate of warfarin metabolism

What non-pharmacological factors can exaggerate warfarin effect and necessitate a dose reduction?

Weight loss Acute illness Smoking cessation

What non-pharmacological factors can reduce the effect of warfarin and necessitate a dose increase?

Weight gain Diarrhoea Vomiting

Why is the antidote to warfarin?

Phytomenadione (vitamin k)

What are some of the rare but serious adverse effects of warfarin?

Warfarin-related skin necrosis (more likely with history of HIT or pre-existing protein C or S deficiency) Calciphylaxis - vascular calcification (occurs more with other risk factors: end-stage renal disease, protein C or S deficiency, hyperphosphataemia, hypercalcaemia, hypoalbuminaeia)

What should you do if a warfarin patient is starting and antibiotic or azole?

Measure INR 4-7 days after the new drug has been started and adjust dose accordingly

What is the likely dose adjustment of a warfarin patient is stated in thyroxine?

Reduce the dose

Why should people on warfarin be told not to change their diet?

Vitamin K containing foods e.g green vegetables can change effectiveness of warfarin

What is the duration of treatment with warfarin for an idiopathic proximal DVT/PE?

Minimum 6 months

What is the recommended dose of Edoxaban for VTE prophylaxis in AF and DVT/PE treatment?

60mg OD

When should the dose of Edoxaban be reduced to 30mg OD?

Weight <60kg CrCl 15-50ml/min Receiving concurrent treatment with P-gp inhibitors (ciclosporin, dronedarone, erythromycin, or ketoconazole)

At what INR can you switch a patient from warfarin to Edoxaban immediately?

Less than 2 If between 2 and 2.5, start Edoxaban the next day

How do you switch a person from Edoxaban to warfarin?

If person is on 60mg Edoxaban, prescribe 30mg OD withwarfarin If person is on 30mg Edoxaban, prescribe 15mg OD with warfarin Continue concurrent warfarin and Edoxaban until INR reaches target range (2 or more) then stop Edoxaban

How do you switch between DOACs?

Stop current DOAC and start the new one when the next dose is due

How long should a DOAC be held before a minor surgery with a minor bleeding risk?

They should not be held - in general the surgeries are performed 12-24 hours after the last dose was taken Minor surgery e.gs Dental Cataract Endoscopy without surgery Smaller dermatological excisions

What monitoring should be carried out before starting DOAC treatment?

Baseline clotting, renal, liver and full blood count

How long should a DOAC be held before a procedure with a low bleeding risk?

At least 24 hours before If CrCl 15-29ml/min then 36 hours before Low risk e.gs Endoscopy with biopsy Prostate or bladder biopsy Angiography Pacemaker implantation

How long should a DOAC be held before a surgery with a high bleeding risk?

48 hours High risk e.gs Complex endoscopy e.g polypectomy Spinal or epidural anaesthesia Lumbar diagnostic Thoracic or abdominal surgery Major orthopaedic surgery Liver or kidney biopsy Transurethral prostate resection

Is aspirin licensed for primary prevention of CVD?

Why is aspirin contrindicated in under 16 years?

Reye’s syndrome - acute syndrome causing swelling of the brain and liver Symptoms: repeatedly vomiting, seizures, fatigue, rapid respiratory rate, hallucinations, loss of consciousness

In what condition can aspirin be used in children under 16?

Kawasaki disease - inflammation of blood vessels

What is the 1st line anti-platelet/s for secondarily CVD prevention in ACS?

DAPT - aspirin 75mg plus ticagrelor 90mg BD for 12 months

What is the 1st line anti-platelet for secondary prevention in ACS undergoing a PCI?

Aspirin 75-100mg plus one of the following: Prasugrel 10mg OD (5mg if <60kg or >75) Ticargrelor 90mg BD Clopidogrel 75mg OD (if prasugrel and ticagrelor not suitable) Treat for 12 months after procedure then continue aspirin alone

What is the 1st line antiplatete for secondary prevention of CVD following a stroke or TIA?

Clopidogrel 75mg OD

What is the 1st line antiplatete for secondary prevention of CVD following a stroke or TIA if clopidogrel is contraindicated ?

Dipyridamole MR 200mg BD combined with low dose aspirin

When is Prasugrel contraindicated?

History of stroke or TIA Severe hepatic impairment Active bleeding

Which anti-platelet is preferred in peripheral arterial disease?

Clopidogrel 2nd choice low dose aspirin

Which antiplatelet interacts with omeprazole?

Clopidogrel Use lansoprazole instead

When should the following antiplatelets be held before surgery: ticargrelor, clopidogrel, prasugrel?

Ticargrelor: 3-7 days before Clopidogrel: 5-7 days before Prasugrel: at least 7 days before

What is 1st for secondary prevention of CVD in stable angina?

Aspirin If contraindicated clopidogrel

Is aspirin contraindicated in pregnancy?

No - but manufacturer advises avoid in 1st and 2nd trimesters and use a max of 100mg/day in third trimester

Can aspirin be used while breastfeeding?

No - low quantities found in breast milk - discontinue breastfeeding if low dose aspirin is used short term

In what condition is dipyridamole contraindicated?

Cardiac conduction difficulties or arrhythmias

When is ticagrelor contraindicated?

Active bleeding History of intracranial haemorrhage Severe hepatic impairment