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PR3154 CA1 > IC5: Management of Anticoagulants in VT Disorders > Flashcards

IC5: Management of Anticoagulants in VT Disorders Flashcards

1
Q

Explain how AF can cause stroke

A

turbulent flow is created by the uncoordinated fibrillation of the left atrium

This causes a concentration of clotting factors in the left atrial appendage (LAA)

When a clot breaks off, it can enter the LV and travel along the aorta towards the cerebral circulation

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2
Q

What is the CHADS-VASc score used for?

A

To identify patients at low stroke risk who should not be offered antithrombotic therapy and identify patients who should be started on DOACs

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3
Q

What are the components of CHA2DS2-VASc?

A

C: congestive heart failure → signs and symptoms for reduced LV EF (+1)
H: hypertension → resting BP > 140/90mmHG on at least two occasions or current antihypertensive treatment (+1)
A: age 75 years or older (+2)
D: diabetes mellitus with fasting glucose > 125mg/dl (7mmol/l) or treatment with oral hypoglycemic agents and/or insulin (+1)
S: previous stroke, transient ischemic attack of thromboembolism (+2)
V: vascular disease → previous MI, periperhal artery disease or aortic plaque
A: age 65-74 years (+1)
S: sex category → female (+1)

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4
Q

What are the recommendations for different CHA2DS2-VASc risk scores?

A
  • 0 pts → do not start antiplatelets nor anticoagulants
  • 1 pt → do not start antiplatelets, consider anticoagulation based on risk factors (not all are equal) (offer warfarin or DOAC if not contraindicated)
  • 2 or more pts → offer warfarin or DOAC if not contraindicated, discuss and address bleeding risk factors and treatment options
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5
Q

What are the factors favouring warfarin use? (4)

A
  • pts who can maintain at least 6/10 INR readings within therapeutic range while on warfafin
  • pts unable to tolerate DOAC SEs (such as epigastric discomfort)
  • pts with moderate to severe liver or renal impairment
  • pts with clinically significant DDIs with DOACs
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6
Q

What are the factors favouring DOAC use? (3)

A
  • pts with less than 6/10 INR readings within therapeutic range while on warfarin
  • pts with difficult assess to INR monitoring (eg. venous access or laboratory access)
  • pts reluctant to have frequent INR monitoring
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7
Q

What is the HASBLED score used for?

A

mainly used to identify and modify the modifiable risk factors like treating BP and stopping antiplatelet agents

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8
Q

What are the components of HASBLED?

A
  • H: hypertension SBP > 160mmHg
  • A: abnormal renal function (dialysis, renal transplant, SCr > 200micromol/L), abnormal liver function (cirrhosis or bilirubin > 2x ULN or AST/ALT/ALP > 3x ULN) (each oprgan impairment is worth 1 point)
  • S: stroke history
  • B: bleeding history or predisposition to bleeding
  • L: labile INRs (unstable or high INRs or less than 6/10 being within therapeutic range)
  • E: elderly (age > 65yo)
  • D: drugs (antiplatelets or NSAIDs) or alcohol ≥ 8 units per week
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9
Q

Explain apixaban dosing and the criteria (3) for special dosing

A

Normally 5mg BD
2.5mg BD if any 2 of the following:
age ≥ 80yo,
weight ≤ 60kg,
SCr ≥ 1.5mg/dL or 132.6 mmol/L [memorise]

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10
Q

Explain edoxaban dosing and the criteria (3) for special dosing

A

Normally 60mg OD
30mg OD if any 1 of the following:
CrCl 30-50ml/min,
weight ≤ 60kg,
comcomitant verapamil, quinidine, dronedarone

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11
Q

What are the 2 drugs that require dosage adjustment in CrCl 30-50ml/min

A

Rivaroxaban and edoxaban

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12
Q

What is the drug of choice (and second line) for elderly?

A

Apixaban (edoxaban second line)

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13
Q

What is the drug of choice in low BW?

A

Apixaban (edoxaban second line)

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14
Q

What is the drug of choice in high BW?

A

Rivaroxaban

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15
Q

Which warfarin enantiomer is more active?

A

S-warfarin

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16
Q

How should wafrarin dose be adjusted in 2C9 polymorphism

A

More metabolism, therefore needs a. higher warfarin dose

17
Q

How should wafrarin dose be adjusted in VKORC1 polymorphism

A

More sensitive, therefore needs a lower warfarin dose

18
Q

When is warfarin still required (cannot use DOACs) (3)

A

left ventricular thrombus
prosthetic heart valve
antiphospholipid syndrome-related VTEs

19
Q

What is the slowest factor to decrease in level?

A

Factor II

20
Q

What is the slowest factor to decrease in level?

A

Factor II

21
Q

What is hypercoagulable state?

A

Protein C and S are natural anticoagulants that are reduced by warfarin and confers a hypercoagulable state taking about 4-5 days to ease away (this can be covered with the use of clexane (LMWH enoxaparin brand name)

22
Q

When should genotype testing for warfarin patients be conducted?

A

patients taking ≤ 21mg/week or ≥ 49mg/week

Test for VKORC1 and 2C9

23
Q

Which 2 drugs require preemptive drug adjustment of warfarin

A
  • Bactrim (sulfamethoxazole/trimethoprim) reduce warfarin by 25-50%
  • Ciprofloxacin, reduce warfarin by 20-30%
24
Q

How can lifestyle changes affect CYP450 and INR? (4)

A

Alcohol binging, inhibits CYP450, increase INR
Chronic alcoholism, induces CYP450, decreases INR
Sudden physical activity, increases metabolism, decreases INR
Smoking, induces CYP450, decreases INR

25
Q

How can diseases affect INR? (4)

A

Liver impairment - decreased CF synthesis, increasing INR
Fluid retention - if liver congestion, INR increases; if edematous gut, INR decreases
Fever - higher turnover of CF, INR increases
Hyperthyroidism - higher turnover of CF, INR increases

26
Q

What is the INR and TTR goal for warfarin patients?

A

INR of 2.0-3.0 is recommended with an individual TTR (time in therapeutic range) ≥ 70%

27
Q

What is the INR and TTR goal for warfarin patients?

A

INR of 2.0-3.0 is recommended with an individual TTR (time in therapeutic range) ≥ 70%

28
Q

What should warfarin patients with TTR < 70% be switched to?

A
  • recommended to switch to DOACs while ensuring good adherence and persistence with therapy
  • Also consider efforts to improve TTR such as education, counselling and more frequent INR checks

PR3154 CA1 (7 decks)

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