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Cardiology 2 > Pharm - Anticoagulants > Flashcards

Pharm - Anticoagulants Flashcards

1
Q

What are the two acronyms to assess for risk of cardio embolic stroke

A

CHADS2 and CHA2DS2-VASc

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2
Q

What are the components of CHADS2

A 
CHF
HTN
Age >75 yo
Diabetes
Stroke/TIA (2 points)
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3
Q

What are the components of CHA2DS2-VASc

A 
CHF
HTN
Age 65-74 1 point
Age >75 2 point
Diabetes
Stroke/TIA/systemic embolism
Vascular disease (MI, PAD, aortic plaque)
Gender: Female 1 point
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4
Q

what is the elevated risk associated with a mechanical mitral valve

A

greater risk for cardioembolism

22% chance/year

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5
Q

what is the elevated risk associated with a bioprostheitc aortic valve

A

elevated (but not high) risk for cardioembolism

12% chance/year

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6
Q

MoA Heparin

A
  • Heparin binds to antithrombin
  • Increases the effect of antithrombin on factors II, IX, X, X,I, and XII by >1000 fold
  • Antithrombin inhibits coagulation by lysing thrombin (II) and other factors ultimately hindering formation of fibrin
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7
Q

Contraindications of Heparin for pt with clot medical hx

A
  • Active uncontrollable bleeding

- History of HIT

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8
Q

Routes (2) of admin for UFH

A

IV

SubQ

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9
Q

When use IV route for UFH

A
  • continuous effusion is best when a rapid and confirmed effect is needed.
  • easier to titrate that IV bolus or subq
  • use an empiric initial dose followed by titration based on response
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10
Q

UFH - how to use subq route

A

initial bolus and then maintenance dosing

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11
Q

appropriate monitoring parameter to assess heparin therapy

A

aPTT

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12
Q

Given a patient’s INR or aPTT result and the target range, identify the result as therapeutic, subtherapeutic, or supratherapeutic

A

I think we can all do this :)

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13
Q

What are the diagnostic criteria for heparin-induced thrombocytopenia (HIT)

A
  1. absolute thrombocytopenia (pat <150,000 OR >50% decrease from baseline)
  2. Occurs 5-10 days after initiation of heparin (if heparin naive) and can occur within 12 hours after dose if have used heparin in last 3 months.
  3. initial dx is clinical
  4. conformational assays drawn for HIT antibodies
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14
Q

Describe pathogenesis of heparin-induced thrombocytopenia

A
  • Heparin forms complex with platelet factor 4 (PF4)
  • Body forms antibodies against the heparin-PF4 complex
  • Complexes aggregate and are removed from circulation prematurely, resulting in thrombocytopenia
  • Venous or arterial thrombosis can occur – likely due to release of procoagulant particles from complex (counterintuitive)
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15
Q

What is the appropriate treatment for heparin-induced thrombocytopenia

A
  • discontinue heparin
  • anticoagulant with non-heparin product
  • do not start warfarin until thrombocytopenia is resolved
  • platelet transfusions are contraindicated, aggravate the problem (add fuel to the fire)
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16
Q

UFH reversal agent

A

protamine sulfate

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17
Q

MoA LMWH

A
  • Interacts with antithrombin to accelerate inactivation of clotting factor Xa (mostly) and IIa (less so)
  • Focus on Xa is major difference from UFH
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18
Q

Indication for LMWH

A
  • Acute treatment of DVT/PE

- Prophylaxis of VTE in acutely ill pts or pts following some ortho procedures

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19
Q

What are the contraindications for LMWH for a pt with DVT

A
  • history of HIT
  • hypersensitivity to LMWH, UFH, or pork
  • active major bleeding
  • spinal puncture (black box!!)
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20
Q

Route for LMWH

A

subq

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21
Q

Reversal agent LMWH

A

protamine sulfate

22
Q

What is the LWMH dosing regimen based on?

A

weight and renal function

23
Q

MoA fondaparinux

A

Synthetic based on structure of heparin. Enhances antithrombin’s effect on Xa but no effect on IIa

24
Q

MoA Warfarin

A

Vitamin K antagonist → inhibits the production of clotting factors II, VII, IX, and X (vitamin K dependent factors)

25
Q

Indications for Warfarin

A
  • Treatment or prevention of VTE
  • Prevention of cardioembolic VCVA in pts with afib, left heart thrombus, or prosthetic heart valves
  • only oral anticoagulant indicated for prevention of stroke in pts with mechanical heart valves!
  • Prevention of secondary CVA
  • Prevention of recurrent MI
26
Q

starting dose of warfarin and the timeframe for monitoring for efficacy

A

5-10 mg daily for 1-3 days, then measurement of effect (PT/INR)

27
Q

List the 6 medications that interact with Warfarin

A
  1. Fluconazole
  2. Bactrim
  3. Metronidazole
  4. Amiodarone
  5. Aspirin
  6. Carbamezepine
28
Q

What 4 medications that interact with Warfarin increase INR, why?

A

Fluconazole
Bactrim
Metronidazole
Amiodarone

  • inhibit metabolism of Warfarin, Warfarin increases which increases INR
29
Q

What medication that interacts with Warfarin has no affect on INR

A

Aspirin

- platelet inhibition

30
Q

What medication that interacts with Warfarin decreases INR, why?

A

Carbamezepine

  • induces metabolism of Warfarin, Warfarin decreases which decreases INR
31
Q

Effect of dietary vitamin K on warfarin dosing

A
  • If increase vitamin K intake, INR will decrease, if decrease vitamin k intake, INR will increase
  • If eat consistent amt of vitamin K, can titrate to stable INR
32
Q

Reversal agent for warfarin

A

vitamin K

33
Q

MoA of dabigatran

A

Orally active direct thrombin (II) inhibitor, inhibits conversion of fibrinogen to fibrin

34
Q

Indications for dabigatran

A
  • Prevention of stroke and systemic embolism in non-valvular afib
  • Treatment of actute DVT and PE in patients who have been treated with a parenteral anticoagulant for 5-10 days
  • Prevention of recurrent DVT and PE
35
Q

Contraindications for dabigatran

A
  • Active pathological bleeding

- Prosthetic mechanical heart valve

36
Q

Reversal agent for dabigatran

A

Idarucizumab (Praxbind)

37
Q

MoA of rivaroxaban, apixaban, edoxaban

A

Selectively block the active site of factor Xa, inhibiting its activation within the intrinsic and extrinsic pathways. Mechanism is independent of antitrhombin (unlike heparin, LMWH, fondaparinux)

38
Q

Indication for factor Xa inhibitors

A
  • Prevention of cardioembolism in nonvalvular afib
  • Treatment of DVT and PE
  • Prevention of recurrence of DVT and PE
  • Prevention of DVT and PE in patients undergoing knee or hip replacement sx
39
Q

Contraindications for factor Xa inhibitors

A

active pathologic bleeding

40
Q

ID goals of therapy for the treatment of acute venous or arterial thromboembolism

A
  • Prevent PE (venous)
  • Prevent extension of thrombus (venous or arterial)
  • Prevent post-thrombotic syndrome (venous or arterial)
  • Prevent recurrence of thromboembolism (venous or arterial)
41
Q

Appropriate anticoagulant for a pt with a:

  1. bioprosthetic mitral valve
  2. mechanical mitral valve
A
  1. bioprosthetic : warfarin for 3 months, then aspirin

2. mechanic: warfarin w/INR target 2.5-3.5

42
Q

Appropriate anticoagulant for a pt with a:

  1. bioprosthetic aortic valve
  2. mechanical aortic valve
A
  1. bioprosthetic: aspirin
  2. mechanical: no additional risk: Warfarin w/INR target 2-3
    additional risk: Warfarin with INR 2.5-3.5
43
Q

If a pt has a mechanical aortic or mitral valve with low bleed risk what med should add to Warfarin

A

low-dose ASA

44
Q

What medication should not be used with pts who have heart valve replacements?

A

direct oral anticoagulants

45
Q

CHADS2 score of 0 is treated with what

A

ASA 75-325 mg/day

46
Q

CHADS2 score of 1 is treated with what

A
  • oral anticoagulant

- ASA 75-325 mg/day is non-anticoagulant alternative

47
Q

CHADS2 score of 2-6 is treated with what

A

oral anticoagulant

48
Q

Patient with a first, provoked DVT/PE

  • duration of treatment
  • target INR
A
  • 3 months

- INR target 2-3

49
Q

Acronym for risk of major hemorrhagic event

A

HAS-BLED

50
Q

What are the risk factors for HAS-BLED

A

H: hypertension (BP>160 mmHg) (1 pt)
A: abnormal renal or liver function (1 or 2 pts)
S: stroke hx (1 pt)
B: bleeding hx (1 pt)
L: Labile INRs (1 pt)
E: Elderly (>65) (1 pt)
D: drugs that increase bleeding risk (ASA, NSAIDs, etc.) or alcohol (1 or 2 points)

51
Q

Appropriate uses for Heparin (6)

A
  1. Acute tx or prophylaxis of venous or arterial thrombosis
  2. DIC
  3. Venous catheter occlusion
  4. Atrial fibrillation
  5. Cardiac surger
  6. ACS

Cardiology 2 (13 decks)

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