Class 2 CV Flashcards
Coagulation modifiers
-Anticoagulants
-Antiplatelets
Coagulation modifiers: General overview
-Anticoagulants, antiplatelet & thrombolytic drugs
-Hemorheological drugs→ alter platelet function (don’t block)
-Antifibrinolytic drugs→ promote coagulation and manage conditions with excessive bleeding
Anticoagulant drugs and functions (SCDHg)
-Heparin & glycosaminoglycans; inhibit clotting factors IIa (thrombin) and Xa
-Direct thrombin (IIa) inhibitors
-Selective factor Xa inhibitor
-Coumadins; inhibit vitamin K clotting factors II, VII, IX & X
Heparin drugs
-“parins”
Coumadin drugs
Warfarin Na+
Glycosaminoglycan drugs
Danaparoid Na+
Direct thrombin inhibitor drugs (BDHA)
-Human antithrombin III
-Argatroban
-Bivalirudin
-Dabigatran etexilate mesylate
Selective factor Xa inhibitor drugs (FAR)
-Fondaparinux
-“abans”
Antiplatelet drugs (MGAP)
-P2Y12 inhibitors
-Aggregation inhibitors/vasodilators
-Glycoprotein IIb/IIIa inhibitors
-Miscellaneous
Aggregation inhibitors/vasodilators
Treprostinil
P2Y12 inhibitors
-“grel”
Glycoprotein IIb/IIIa inhibitors (TEA)
-Abciximab
-“fib”: Eptifibatide,Tirofiban
Miscellaneous antiplatelet drugs
-Anagrelide hydrochloride
-Dipyridamole
Coagulation modifiers
-Lyse clots
-Thrombolytics
-Promote clot formation
-Antifibrinolytics
-Reversal drugs
Thrombolytic functions
-Dissolve thrombi
-Activate plasminogen
-“plase”
Antifibronolytics
-Prevent lysis of fibrin
-Reduce blood viscosity
Prevent lysis of fibrin
-Systemic hemostats
-Tranexamic acid, aprotinin
Reduce blood viscosity (HP)
-Hemorheological
-Pentoxifyline
Reversal drugs
-Heparin Na+ antagonist; protamine sulphate
-Warfarin Na+ antagonist; vitamin K
Anticoagulants: General overview
-Prevent formation of a clot
-Remember, they cannot lyse any clot that has already been formed (as in the case of a stroke or pulmonary embolism)
Common anticoagulants
-“parins”, “abans”
-Warfarin (Coumadin)
-Argatroban, Bivalirudin, Dabigatran
-Fondaparinux
Low molecular weight heparin (LMWH); enoxaparin, dalteparin, tinzaparin: Indications for use
-AMI, UA, stroke
-Immobility, DVT, PE
-Indwelling devices such as heart valves
-Pre-op to prevent pooling of blood
Warfarin, rivaroxaban, or apixaban indications for use
Atrial fibrillation
Dabigatran indications for use
Prevention of strokes and thrombosis in patients with nonvalvular atrial fibrillation
Argatroban indications for use
Treatment of active or risk for HIT and PCI operation
About heparin (half-life, onset, peak, duration)
-1-2 hour half-life
-Onset:
-SC: 20-60 minutes
-IV: Immediate
-Peak
-SC: 2-4 hours
-Duration: Dose-dependent
Heparin (Hepalean, Heparin LEO, Hep LOK)
-Prevents
-“heparin” refers to “unfractionated heparin”
-Q6H measurement of PTT until anticoagulant effect is reached
Heparin (Hepalean, Heparin LEO, Hep LOK): SC & IV therapy indications for use
-S.C., dosing used post-op or with decreased mobility
-I.V. therapy: DVT, PE, AMI, A fib
Heparin (Hepalean, Heparin LEO, Hep LOK) toxicity symptoms
-hematuria, melena, petechiae, ecchymoses, and gum or mucous membrane bleeding
Heparin induced thrombocytopenia (HIT)
-Thrombocytopenia- low platelet count
-Allergic reaction mediated by the production of IgG antibodies
-Immune complexes bind to platelets, resulting in platelet activation and thrombin generation
Heparin induced thrombocytopenia (HIT) types of increased
-HIT I→ gradual reduction in platelets (heparin is usually continued)
-HIT II→ >50% acute drop in platelet level
Treatment of heparin induced thrombocytopenia (HIT)
thrombin inhibitors bivalirudin and argatroban
Nursing considerations of heparin induced thrombocytopenia (HIT)
-Thrombosis in the presence of HIT can be fatal
Low molecular weight heparin (LMWH) (form, function, why its better than heparin)
-Enoxaparin, dalteparin, tinzaparin
-Synthetic SC injection
-Greater affinity for factor Xa
-Higher bioavailability and longer half-life than unfractionated Heparin
-More predictable anticoagulant response than heparin
-Frequent lab monitoring not required
-Patients can be “bridged” with Coumadin therapy (warfarin)
Low molecular weight heparin reversal
Protamine, same as heparin reversal
About Warfarin (Coumadin) (half-life, onset, peak, duration, form, use, monitoring)
-Half-life: 0.5-3 days
-Onset: 12-24 hours
-Peak: 3-4 days
-Duration: 2-5 days
-PO, long-term anticoagulation
-Monitor PTT/INR
-A ‘normal’ INR is 1, for someone receiving Coumadin a therapeutic INR is usually 2-3 OR 2.5-3.5 for a mechanical valve
Warfarin (Coumadin) antidote (when to discontinue, how it works & how long to resynthisize, drug reversal, resistance time)
-Discontinued if INR is high
-Coumadin inactivates the vitamin K-dependent clotting factors which are synthesized in the liver; discontinuing therapy may take 36-42hrs before it can be resynthesized
-10-15 mg vitamin K IV can reverse anticoagulation effects within 6 hrs; risk of anaphylaxis
-Fresh Frozen Plasma to reverse the anticoagulation effects during an acute bleed
-Redraw INR
-After administration of vitamin K, warfarin resistance will occur for up to 7 days
Dibagatran: Thromboprophylaxis after elective hip or knee replacement
-150-220mg daily
-14 days for knees and 30 days for hips
Dabigatran dosing: Non-valvular atrial fibrillation
-110 or 150mg BID
-CR Cl>30mL/min
Rivaroxaban: Thromboprophylaxis after elective hip or knee replacement
-10mg daily
-14 days for knees, 30 days for hips
Rivaroxaban dosing: Non-valvular atrial fibrillation
-15 or 20mg daily
-CR Cl 30-49mL/min
Rivaroxaban dosing: Venous thromboembolism
-15mg BID for 21 days then 20mg daily
Anticoagulant contraindications
-Thrombocytopenia
-Pregnancy
-LMWHs cannot be administered to patients with indwelling epidural catheter; epidural hematomas
Anticoagulant adverse events
-Bleeding, no IM injections, be cognizant of surgery
-Use of aspirin or other drugs that impair platelet function
-N/V, abdominal cramps, thrombocytopenia
-Warfarin (Coumadin); bleeding, lethargy, muscle pain, necrosis, and “purple toes” syndrome
Warfarin: Drug to drug interactions: Acetaminophen, amiodarone, bumetanide
-Displacement from inactive protein-binding sites
-Increased anticoagulant effect
Warfarin: Drug to drug interactions: Furosemide, ASA/NSAIDs, broad spectrum anitbiotics
-Decreased platelet activity
Warfarin: Drug to drug interactions: Barbiturates, carbamazepine, rifampin, phenytoin
-Enzyme induction
-Decreased anticoagulant effect
Warfarin: Drug to drug interactions: Amiodarone, cimetidine, ciprofloxacin, erythromycin, ketoconazole, metronidazole, omeprazole, sulfonamides, macrolides
-Enzyme inhibition
-Increased anticoagulant effect
Warfarin: Drug to drug interactions: HMG-CoA reductase inhibitors (statins), cholestyramine, sucralfate
-Impaired warfarin, Na+ absorption
-Decreased anticoagulant effect
Warfarin: Drug to drug interactions: Natural Health Products: dong quai, garlic, ginkgo biloba
-Increased INR
-Increased bleeding risk
Warfarin drug to food interactions: St. John’s Wort, ginseng (alone & in cold-FX)
-Decreases INR
-Increased risk for clotting
Heparin Na+ drug to drug interactions: Aspirin & other NSAIDs
-Decreased platelet activity
-Increased bleeding risk
Heparin Na+ drug to drug interactions: Oral anticoagulants & thrombolytics
-Additive
-Increased anticoagulant effect
Antiplatelet drug to drug interactions: Aspirin & other NSAIDs
-Decreased platelet activity
-Increased bleeding risk
Antiplatelet drug to drug interactions: Warfarin, heparin Na+. thrombolytics, rifampin
-Additive
-Increased bleeding risk
Antiplatelet drug to drug interactions: Natural health products; garlic, ginkgo, kava
-Increased effects
-Increased bleeding risk
Antipatelet drug to food interactions
-Foods high in vitamin K increase risk of clotting
Anticoagulant nursing considerations
-Will administration increase or decrease bleeding or clotting, what conditions do I need to monitor for in this patient post administration, are there any procedures that warrant holding the medication
-Monitor labs daily when on anticoagulants; know what is important to follow for trends and why INR vs PTT
-Understand what bridging patient therapy means for management of conditions
-Monitor for treatment outcomes
Anticoagulant patient teaching
-Regular lab testing
-Avoid foods high in vitamin K
-Consume with 1 cup of water
Antiplatelet therapy: General overview
-Prevent clot formation by inhibiting platelet aggregation at the site of injury
-Each drug has unique mechanism of action properties
Antiplatelet common medications
-Acetylsalicylic acid (ASA/aspirin)
-Dipyridamole, pentoxyfylline
-“grels”
-GP IIb/IIIa Inhibitors
Aspirin MOA
-Used for antiplatelet & analgesic, anti-inflammatory and antipyretic properties
-Effects last lifespan of platelet which is 7 days
-Prevents the formation of thromboxane A2 from leading to dilation of blood vessels and platelet aggregation
Dipyridamole MOA
-Prevent release of substances that stimulate platelet aggregation
Clopidogrel MOA
-ADP inhibitors
-Inhibits platelet aggregation by altering the platelet membrane so that it doesn’t receive signals to form a clot
Pentoxifylline MOA
-Reduces blood viscosity by increasing flexibility of red blood cells and reduces the aggregation of platelets
-Inhibits ADP, serotonin, and platelet factor IV
GP IIb/IIIa inhibitors MOA
-Block receptor protein GP IIb/IIIa that occurs in the platelet wall membranes
Aspirin indications for use
-CAD
-First line of defense for acute coronary syndrome
-Chronic stable angina
-Post PCI, CABG, prosthetic valve insertion, TIA, & cardiac endarterectomy
-Patients with PAD, secondary prevention for venous thrombosis events
-Daily doses of 75 mg to 160 mg
Dipyridamole indications for use
-Used with warfarin to prevent postoperative thromboembolisms
Clopidogrel indications for use
-Post AMIs prevention of thrombosis, reducing thrombotic strokes
Pentoxifylline indications for use
-Peripheral vascular disease
GP IIb/IIIa inhibitors indications for use
-UA & AMI, angioplasty procedures (typically have arrhythmias after PCI)
Antiplatelet contraindications
-Thrombocytopenia, leukemia
-Traumatic injury, GI Bleed, recent stroke
-Vitamin K deficiency
Aspirin adverse events (CNS)
Drowsiness, dizziness, confusion, flushing
Aspirin adverse events (GI)
-N/V, bleeding, diarrhea
Aspirin adverse events (hemotalogical)
-Thrombocytopenia, leukopenia, neutropenia, hemolytic anemia, agranulocytosis, bleeding
Clopidogrel adverse events (CV)
-Chest pain, edema
Clopidogrel adverse events (CNS)
-Flu-like symptoms, fatigue, headache, dizziness
Clopidogrel adverse events (GI)
-Abdominal pain, diarrhea, nausea
Clopidogrel adverse events (miscellaneous)
Epistaxis, rash, pruritus
Ticagrelor adverse events (respiratory & miscellaneous)
Dyspnea (on initiation)
Elevated uric acid levels
GP IIb/IIIa inhibitors adverse events (CV)
-Bradycardia, hypotension, edema
GP IIb/IIIa inhibitor adverse events (CNS)
Dizziness
GP IIb/IIIa inhibitor adverse events (hematological)
-Bleeding, thrombocytopenia
Antiplatelet nursing considerations
-aBleeding
-Withhold drugs 5-7 days prior to surgical procedures
-Perform baseline CV assessment for medications and document pre-existing chest pain, edema, headache, dizziness, epistaxis or flu like symptoms
Aspirin contraindications
-Aspirin not to be used in young ppl or patients with with any bleeding disorder, vit K deficiency or with peptic ulcer disease
Antiplatelets + Pt teaching
-2-3 months for therapeutic effect
-Change position slowly d/t dizziness and orthostatic hypotension
Thrombolytics overview
-“Clot Busters”
-Streptokinase, tissue plasminogen activator [t-PA (alteplase and Tenecteplase (TNK)]
Thrombolytics indactions for use
-MI, arterial thrombosis, DVT, PE
-Occlusion of catheter or shunts
-Acute ischemic stroke
Thrombolytic adverse effects
-Internal, intracranial, and superficial bleeding
-N/V, hypotension, dysrhythmias
Thrombolytic interactions
-Increased bleeding tendency from use of anticoagulants, antiplatelet, or other drugs that affect platelet function
Anti-thrombolytics
-Tranexamic acid
-Aprotinin
-DDAVP
Thrombolytic nursing considerations
-Monitor IV sites, no IM injections
-Monitor bleeding from wounds or from the GI, GU, or respiratory tract
-Monitor for internal bleeding (decreased BP, restlessness, increased pulse)
Thrombolytic nursing considerations when monitoring labs (aspirin)
Monitor CBC (Hgb, hematocrit, platelet counts), PTT and INR
Nursing considerations when monitoring labs: Clopidogrel
-Monitor CBC (Hgb, hematocrit, platelet counts), PTT and INR
-Contact healthcare provider if platelet levels are less than 90 x 109 /L
Nursing considerations when monitoring labs: GP IIb/IIIa inhibitor
-Monitor PTT levels
