Lecture 9 - Cardioembolic Thromboembolism

Question 1

UFH & LMWH info Stroke

Answer 1

used in acute setting when warfarin cannot (have to sue therapeutic lvl dosing)

Question 2

When to not bridge UFH & LMWH?

Answer 2

if no prior history of thromboembolism, can start warfarin outpatient without bridging

not necessary w/ non-vit K antagonists

Question 3

When to bridge UFH & LMWH?

Answer 3

High risk of thromboembolism
Low risk of intracranial hemorrhage

reasonable to start warfarin with heparin bridge

Question 4

Limitations for Warfarin In stroke

Answer 4

Narrow TI
Bleeding risk
DD and Drug-food interactions

Question 5

Dabigatran stroke info

Answer 5

FDA approved for 150/75 mg BID

75mg BID for CrCl 15-30ml/min (no clinical data support

Renal function assessed annually

SE = Dyspepsia, bleeding

usually used in young, no comorbidities, and insurance only covers this

Question 6

Rivaroxaban stroke info

Answer 6

20mg QD, 15 if CrCl 30-49

CrCl < 30 = avoid use

** once daily = good if bad w/ adherence **

Question 7

Apixaban stroke info

Answer 7

5mg BID

2.5mg if meet 2 of 3 of the following….
< 60kg
>80 yr old
SCr >1.5

*Afib** only

Question 8

Edoxaban Stroke info

Answer 8

30/60mg daily

Less effective in pts w/ CrCl > 95 = don’t use
Dose reduce CrCl < 50 = 30 mg
Don’t use CrCl < 30

Question 9

Cardioembolism info

Answer 9

• most devastating complication of AF
• Risk of stroke 5 X higher in those with AF
• 15% of all stroke attributed to AF

Question 10

Cardioembolsim predominantly due to….

Answer 10

blood stasis, primarily in LAA ~ 90%

Question 11

CHA2DS2 - VASc Score

Answer 11

C = CHF = 1
H = HTN = 1
A = Age > 75 = 2
D = DM = 1
S2 = Prior stroke or TIA/ Thromboembolism = 2
V = Vascular disease = 1
A = Age 65-74 = 1
Sc = Female = 1

** Only for A.fib**

Question 12

CHA2DS2-VASc score

Answer 12

Score > 2 = Inc risk of stroke

Question 13

CHA2DS2-VASc score 1 (men), 2 (women) then…..

Answer 13

consider oral anticoagulants or aspirin (Class IIb rec)

Question 14

CHA2DS2-VASc score >2 (men), >3(women) then….

Answer 14

oral anticoagulants (Class 1 rec)

Question 15

Oral Anticoags for Stroke

Answer 15

DOACs

Dabigatran
Rivaroxaban
apixaban
edoxaban

Pref over Warfarin

Question 16

Why choose warfarin for Stroke A.Fib prevention

Answer 16

• comfortable w/ regimen and monitoring
• stable INR
• Adherence is issue ie BID
• Cost
• Cant take other meds based on renal function
• CKD
• CI (higher risk of bleeding so we can monitor them)
  SAMe-TT2R2 score can be helpful

Question 17

SAMe-TT2R2 scores

Answer 17

Sex (Female) = 1
Age (<60) = 1
Medical History (> 2 comorbidities) = 1

Treatment Strat (Rhythm control) = 1
Tobacco use = 2
Race (non-white) = 2

Do well = 0-1
Less likely to do well > 2

Question 18

Anticoagulants monitoring every visit

Answer 18

Adherence
Thromboembolism
Bleeding
Side effects
Drug interactons
Manageable modifiable risk factors for bleeding
Reassess if anticoagulants appropritate

Question 19

Anticoagulant monitoring Blood sampling

Answer 19

6-months/yearly

~ 4 months if > 75

Divide CrCl/10 = how often if its <60