NOAGs + Disease

Question 1

CHADS2

Answer 1

	Congestive Heart Failure
	Hypertension
	Age ≥ 75 years
	Diabetes mellitus
	Prior stroke/TIA/thromboembolism

Question 2

CHADS2 > 2 =

Answer 2

High risk
Oral anticoag
Dabigatran 150 mg BID preferred over warfarin

Question 3

CHADS2 = 1 =

Answer 3

Intermediate Risk

Oral anticoagulant recommended over aspirn

Question 4

CHADS2 = 0 =

Answer 4

Low Risk

Can consider ASA 81 mg

Question 5

CHA2DS2-VASc

Answer 5

	Congestive Heart Failure
	Hypertension
	Age ≥ 75 years (2)
	Diabetes mellitus
	Prior stroke/TIA/thromboembolism (2)
	Vascular disease (MI, PAD, aortic plaque)
	Age 65-74 years
	Sex (category) - female

Question 6

CHA2DS2-VASc >/= 2 =

Answer 6

Oral anticoagulant therapy recommended

Warfarin (A), then dabigatran, rivaroxaban, apixaban (B)

Question 7

CHA2DS2-VASc = 1 =

Answer 7

None

Consider ASA

Question 8

CHA2DS2-VASc = 0 =

Answer 8

None

Question 9

RE-LY Trial for A Fib

Answer 9

• Dabigatran is SUPERIOR to warfarin
• More GI bleeding with dabigatran
• More intracranial bleeding with warfarin

Question 10

ROCKET AF Trial for A Fib

Answer 10

• Rivaroxaban is NON-INFERIOR to warfarin
• More GI bleeding with rivaroxaban
• More intracranial hemorrhage with warfarin

Question 11

ARISTOLE Trial for A Fib

Answer 11

• Apixaban is SUPERIOR to warfarin
• More major bleeding with warfarin
• Less risk of intracranila bleed with apixaban

Question 12

ENGAGE Trial for A Fib

Answer 12

• Edoxaban is NON-INFERIOR to warfarin
• More majro bleed with warfarin
• Less risk of intracranila bleed with edoxaban

Question 13

Recover Trial for DVT/PE

Answer 13

• Dabigatran is equal to warfarin

* Similar bleed risk

Question 14

EINSTEIN Trial for DVT/PE

Answer 14

• Rivaroxaban is NON-INFERIOR to warfarin

* Same bleed risk in DVT and less bleed with R in PE

Question 15

AMPLIFY Trial for DVT/PE

Answer 15

• Apixaban is NON-INFERIOR to warfarin/LMWH

* Apixaban had a 69% decrease in bleeds

Question 16

Hokusai-VTE Trial for DVT/PE

Answer 16

• Edoxaban is NON-INFERIOR to warfarin

* Higher rate of bleed with warfarin

Question 17

AMPLIFY-ETC Trial for DVT/PE

Answer 17

o Extended Use of TSOACs in VTE Management

o No increase in major bleed with apixaban

Question 18

EINSTEIN-Extension Trial for DVT/PE

Answer 18

o Extended Use of TSOACs in VTE Management

o No increase risk for major bleed but higher risk of non-major bleed with rivaroxaban

Question 19

RE-MEDY Trial for DVT/PE

Answer 19

o Extended Use of TSOACs in VTE Management

o Lower bleed events with dabigatran

Question 20

Coagulation Cascade

Answer 20

Plaque rupture → activation of coagulation cascade →release of tissue factor → activation of factor X → prothrombin is convert to thrombin → conversion of fibrinogen to fibrin → thrombus formation

Question 21

APPRAISE-2 Trial for ACS

Answer 21

• Apixaban vs aspirin + clopidogrel
• Stopped early because of bleed
• Risks do not outweigh benefits

Question 22

ATLAS ACS 2 TIMI 51

Answer 22

• Rivaroxaban vs aspirin + thienopyridine
• Decreased CV death, MI or stroke
• Less bleeding than with apixaban but still increased risk of major bleeding

Question 23

Warfarin VS Newer Agents

Answer 23

W: cheap, can check blood levels, reversible with vit K, years of clinical experience, slow onset, no need for renal dose adjustment
NOAGs: very costly, little clinical experience, no monitoring, no anecdote, rapid onset, fewer drug interactions, MUST renal dose adjust

Question 24

If patient is already on warfarin…

Answer 24

 Well managed with goal INR 2-3 then continue warfarin

 Not well managed then consider another oral anticoagulant

Question 25

If patient is NOT already on warfarin...

Answer 25

 If patient has poor compliance then warfarin may not be good choice  If patient has good compliance then warfarin or another oral anticoagulant

Question 26

Mild Renal Impairment > 50 mL/min

Answer 26

Dabigatrain, rivaroxaban, edoxaban or apixaban

Question 27

Moderate Renal Impairment 30-50 mL/min

Answer 27

Dabigatrain, rivaroxaban, edoxaban or apixaban WITH DOSE ADJUSTMENTS

Question 28

Severe Renal Impairment Less than 30 mL/min

Answer 28

Warfarin but still could dose adjust rivaroxaban, edoxaban or apixaban

Question 29

If on dialysis then...

Answer 29

Warfarin is only option