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Patient PCP > DOACs and AF > Flashcards

DOACs and AF Flashcards

1
Q

Why is anticoagulation therapy necessary in AF?

A

The risk of a stroke is five times higher in a person with AF than in a person in sinus rhythm.

Stroke severity is usually greater when stroke is associated with AF than with other causes.

Anticoagulation treatment reduces the risk of stroke by about two-thirds.

For most people, the benefit of anticoagulation outweighs the risk of bleeding

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2
Q

What are the advantages of using DOACs instead of warfarin ?

A
  • Risks associated with treatment — DOACs are associated with a reduced risk of haemorrhagic stroke and intracerebral haemorrhage compared with warfarin.
  • ## DOACs have predictable pharmacokinetics, so coagulation control does not need to be monitored. Warfarin, on the other hand, needs regular blood tests to monitor coagulation control.
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3
Q

What two things can you try and control in a patient with AF?

A

Rate and rhythm control

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4
Q

In patients without life-threatening haemodynamic instability, if a patient has onset of AF less than 48 hours ago, what can be offered to the patient?

A- rate control
B- rhythm control
C- both

A

C - both

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5
Q

If a patient presents with AF and the onset is more than 48 hours ago or uncertain, is it preferable to control rate or rhythm?

A

Rate

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6
Q

What beta blocker should you not use in rate control for AF?

A

Sotalol

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7
Q
  1. How can ventricular rate be controlled in AF?

2. If this does not work, what can be used?

A
  1. Monotherapy:

Standard beta blocker (not sotalol)
Rate limiting CCB e.g. verapamil
Diltiazem is used but unlicensed
Digoxin

  1. Combination of beta blocker, digoxin or diltiazem
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8
Q

What group of patients should digoxin monotherapy be used for ventricular control in AF?

A

Only effective for controlling the ventricular rate at rest, so should only be used as monotherapy in sedinetary (inactive) patients with non-paroxysmal atrial fibrillation.

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9
Q

What is meant by paroxysmal AF?

A

Episodes come and go

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10
Q

If dual ventricular rate therapy does not control symptoms in AF, what can then be considered?

A

Rhythm control

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11
Q

In patients with AF and diminished ventricular function, what should be used to control rate?

A

Beta blockers that are licensed for use in heart failure and digoxin

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12
Q

Post cardioversion in AF, what is used to maintain sinus rhythm?

A

Beta blocker

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13
Q

What is 1st line for long term rhythm control in AF?

A

Beta blocker (not sotalol)

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14
Q

If amiodarone is needed in an electrical cardioversion patient, how long before and after the procedure can they be on it for?

A

4 weeks before and up to 12 months after

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15
Q

For rhythm control in AF, when what group of patients would flecainide acetetate or propafenone NOT be suitable for?

A

Known ischaemic or structural heart disease

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16
Q

When would dronedarone be used in rhythm control for AF?

A

As an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:

  • whose atrial fibrillation is not controlled by first‑line therapy (usually including beta‑blockers), that is, as a second‑line treatment option and after alternative options have been considered and who have at least 1 of the following cardiovascular risk factors:
  • hypertension requiring drugs of at least 2 different classes
  • diabetes mellitus
  • previous transient ischaemic attack, stroke or systemic embolism
  • left atrial diameter of 50 mm or greater or
  • age 70 years or older and

And:
who do not have left ventricular systolic dysfunction and
who do not have a history of, or current, heart failure.
(consider amiodarone in these patients)

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17
Q

What group of patients would you consider amiodarone for in rhythm control for AF?

A

Left ventricular impairment or heart failure

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18
Q

What tool do you use to assess for stroke risk in AF patients?

A

CHADVASC

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19
Q

What tool do you use to assess for bleeding risk?

A

HAS BLED

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20
Q

At what CHADVASC score in men would you consider anticoagulation in AF?

At what score should you offer (taking into account bleeding risk)?

A

1

2

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21
Q

At what CHADVASC score in females would you consider anticoagulation to in AF?

A

2

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22
Q

Is aspirin monotherapy recommended for stroke prevention in AF?

A

NO

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23
Q

Anticoagulation should be considered post stroke if the patient has AF. When should you consider aspirin before considering anticoagulation treatment?

A

If it is a disabling ischaemic stroke, give the aspirin 300mg for 2 weeks

Then, consider the value of anticoagulation for prevention of stroke in AF

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24
Q

When do you reduce dose of apixaban in terms of weight?

A

<61 kg - reduce dose to 2.5 mg BD for stroke prophylaxis in AF

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25
Q

How many days before is warfarin usually stopped before elective surgery?

If they are at high risk of clot e.g. VTE in last 3 months, AF with previous stroke, what would you do?

A

5 days

Bridge with LMWH and stop this 24 hours before surgery

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26
Q

What is the only DOAC that has a reversal agent?

A

Dabigatran

27
Q

What is the reversal agent for dabigatran?

A

Idarucizumab

28
Q

Are DOACs recommended in patients with prosthetic heart valves?

A

No- efficacy has not been established

29
Q

Can apixaban be crushed?

A

Yes- mix with water or apple juice/puree

30
Q

Is apixaban once or twice daily dosing?

A

Twice daily

31
Q

Is edoxaban once or twice daily dosing?

A

Once daily

32
Q

If a patient is taking one of the following drugs:

  • ciclosporin
  • dronedarone
  • erythromycin
  • ketoconazole

And needs to be on edoxaban, what is the maximum daily dose?

A

30mg OD

33
Q

What DOACs are black triangle drugs?

A

Rivaroxaban and edoxaban

34
Q

When would you reduce the dose of edoxaban in renal impairments?

A

15-50 mL/min

Max 30mg OD

35
Q

What is the cut off point for renal impairment for edoxaban?

A

Avoid if < 15mL/min

36
Q

When do you reduce dose of edoxaban in terms of weight?

A

<61 kg reduce to 30mg OD

37
Q

What is the cut off point for renal impairment for rivaroxaban?

A

Avoid if < 15mL/min

38
Q

Can rivaroxaban be crushed?

A

Yes in water/apple juice or puree

39
Q

Which DOAC should be taken with food?

A

Rivaroxaban

40
Q

Which DOAC cannot be put in a blister pack?

A

Dabigatran

41
Q

What is the cut off point for renal impairment for dabigatran?

A

Avoid if < 30 mL/min

42
Q

When would you reduce dose of dabigatran in renal impairment?

A

30-50 mL/min

43
Q

What is the advice around a patient on dabigatran who is taking one of the following:

  • Verapamil
  • Amiodarone
A

Reduce dabigatran dose

Take doses at the same time

44
Q

When do you take anti factor Xa levels?

A

3-4 hours after dose

45
Q

Are multidose or single vials of dalteparin and enoxaparin recommended in pregnancy and why?

A

Single vials

Multidose vials contain benzyl alcohol

46
Q

Are DOACs licensed in cancer patients?

A

NO

47
Q

Are DOACs licensed in antiphospholipid syndrome?

A

NO

48
Q

Do DOACs interact with alcohol?

A

NO

49
Q

Which DOAC has the least risk of GI bleed?

A

Apixaban

50
Q

Do DOACs or warfarin carry higher GI bleed risk?

A

DOACs (apart from apixaban which has same risk as warfarin)

51
Q

What sort of AF are DOACs licensed in?

A

Non valvular

52
Q

What is valvular AF?

A

AF + artificial heart valve

Mitral stenosis

53
Q

What would you use for prophylaxis of stroke in valvular patients?

A

Vit K antagonists

Not DOACs

54
Q

Why is missing a DOAC dose more dangerous than missing a warfarin dose?

A

DOACs have a shorter half life

55
Q

What is the dose for rivaroxaban in AF?

A

20mg OD

56
Q

What is the dose for apixaban in AF?

A

5mg BD

57
Q

Is dabigatran OD or BD?

A

BD

58
Q

What are the counselling points for missed doses in BD preps?

A

> 6hrs till next dose take ASAP

< 6 hours till next dose omit (skip)

59
Q

What can missed doses increase the risk of?

A

Missed doses can increase the risk of insufficient anticoagulation, which can lead to a clot

60
Q

What are the counselling points for missed doses in OD preps?

A

> 12 hours till next dose take ASAP

<12 hours till next dose omit (skip)

61
Q

What are the 4 classes for AF?

A
  1. Paroxysmal: self limiting, less than 7 days
  2. Persistent: more than 7 days or requires cardioversion
  3. Long standing persistent: continuous AF, more than a year
  4. Permanent: decision made not to attempt cure of persistent AF
62
Q

What are the signs of bleeding?

A

o Bruising, haematuria, haemoptysis, malaena
o Minor bleeds/malaena, visit GP
o Major trauma/bleeds >15m, go to A&E

63
Q

What do chromogenic anti-factor Xa assays do?

A

measure plasma concentration of apixaban (due to overdose)

Patient PCP (15 decks)

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