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PR3154: Haematological & Musculoskeletal Systems > SPAF > Flashcards

SPAF Flashcards

1
Q

Can you give antiplatelet for SPAF?

A

NO

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2
Q

Criterias in mCHA2DS2VASc

A

CHF: 1
HTN: 1
DM: 1
Prior stroke or TIA: 2
Vascular disease (prior MI, PAD or aortic plaque): 1
Age 65-74: 1
Age >=75: 2

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3
Q

What does mCHA2DS2VASc estimate?

A

Stroke risk

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4
Q

What should you do if mCHA2DS2VASc score = 0?

A

No need anticoagulant or antiplatelet agents

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5
Q

What should you do if mCHA2DS2VASc score = 1?

A

Consider anticoagulation
No antiplatelet agents

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6
Q

What should you do if mCHA2DS2VASc score >= 2?

A

Recommend warfarin or a NOAC if not CI

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7
Q

What does HASBLED estimate?

A

Bleeding risk

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8
Q

Criterias in HASBLED

A

HTN (SBP>160): 1
Abnormal renal function: 1
Abnormal liver function: 1
Stroke (Hx): 1
Bleeding (Hx or predisposition) : 1
Labile INRs: 1
Elderly (>65y/o): 1
Drugs (eg. antiplatelet, NSAID): 1
Alcohol: 1

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9
Q

What is the goals of therapy for AF?

A

ABC pathway:
A- avoid stroke
B- better symptom control
C- CV and other comorbs or RFs

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10
Q

What is LAA occlusion?

A

Reserved for very high bleeding risk. Watchman device- “Umbrella” to catch broken off clots .

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11
Q

What is the dose of dabigatran

A

150mg BD

110mg BD if >=80y/o, using PGP inhibitors or high risk of bleeding

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12
Q

What is the dose of rivaroxaban?

A

20mg QD

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13
Q

What is the dose of apixaban?

A

5mg BD

2.5mg BD for any 2:
- >=80y/o
- <=60kg
- SCr >= 1.5mg/dl or 13.6mmol/L

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14
Q

What is the dose of edoxaban?

A

60mg QD

30mg QD if any 1:
- CrCL 30-50ml/min
- <=60kg
- concom verapamil, quinidine, dronedarone

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15
Q

How to renally dose adjust dabigatran?

A

CrCl 30-50ml/min: no dose adj unless have DDI
CrCl < 30ml/min: CI

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16
Q

How to renally dose adjust rivaroxaban?

A

CrCl 30-50ml/min: 15mg QD
CrCl 15-30ml/min: use with caution
CrCl <15ml/min: CI

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17
Q

How to renally dose adjust apixaban?

A

CrCl 15-29 ml/min: 2.5mg BD

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18
Q

How to renally dose adjust edoxaban?

A

CrCl <15ml/min: not recommended

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19
Q

Which DOAC is recommended in elderly?

A

Apixaban based on RCTs

20
Q

Which DOACs require dose adj for lower BW <60kg?

A

Apixaban and edoxaban

21
Q

Why are DOACs preferred over warfarin?

A

1) Ease of dosing: easier to dose, no need for titration
2) Monitoring: warfarin has a narrow TI and requires tight monitoring. DOACs wide TW.
3) Safer: less major bleeding while non-inferior to warfarin
4) Drug Interaction: significantly less DDI

22
Q

What PGx impacts warfarin?

A

VKOR, 2C9 polymorphisms

23
Q

How does bacteria affect warfarin dose?

A

Disruption of gut bacteria due to AB killing the bacteria= less menadione (type of Vit.K from gut) ->
Less clotting factors -> Increases INR -> increase bleeding so might need to adjust dose.

24
Q

Which ABs will affect warfarin dose and what is the dose adjustment?

A

Bactrim (sulfamethoxazole/trimethoprim): 25-50% reduction
Ciprofloxacin: 20-30% reduction

25
How is INR affected by alcohol binging, chronic alcoholism, sudden incr in physical activity and smoking?
Alcohol binge: increase INR Chronic alcoholism, sudden incr in physical activity and smoking: increase warfarin metabolism --> decrease INR
26
How does liver disease, fever, thyroid disease and fluid retention affect INR?
Liver disease, fever, fluid retention in liver, hyperthyroidism: increase INR Fluid retention in gut, hypothyroidism: decrease INR
27
What conditions would warfarin be used instead of DOACs?
Left ventricular thrombus Prosthetic heart valve/mitral stenosis Antiphospholipid syndrome related VTEs
28
Which clotting factor that warfarin inhibits has the shortest t1/2?
Factor VII
29
If CrCl < 60ml/min, how to determine when will be the next blood test?
CrCl/10
30
What should be reviewed at every follow up session?
Adherence, TE S&S, bleeding, SE, Co-meds, blood tests PRN, screen and mitigate for RFs for bleeding, assess optimal DOAC choice/dosing
31
Which TB AB has DDI with DOACs and warfarin?
Rifampicin
32
How to switch warfarin to NOAC?
INR <=2: start NOAC immediately INR 2-2.5: start NOAC immediately or next day INR 2.5-3: recheck INR in 1-3days INR >=3: postpone NOAC
33
How to switch NOAC to warfarin?
Continue NOAC while starting on warfarin and check INR after 3-5days If INR is still <2, continue NOAC If INR is >=2, stop NOAC
34
Which anti-seizure meds have DDI/CI with DOACs?
Dabi + riva: Carbamazepine, phenytoin Riva: Phenobarbital Valproic acid: all DOACs
35
Which herbal meds is CI with all DOACs?
St. John's wort inducers PGP and CYP3A4
36
What type of drugs should be avoided with rivaroxaban and apixaban?
Potent dual inhibitors/inducers Examples of potent dual inhibitors of CYP3A4 and PGP are azoles, ritonavir, clarithromycin
37
How should the warfarin dose be adjusted if taken with metronidazole?
20-30% reduction
38
How should warfarin dose be adjusted if taken with amiodarone?
Pre-emp reduce warfarin dose by 30-50%
39
How to manage bleeding while using a NOAC?
Mild bleeding: wait first Non-life threatening major bleeding: supportive meausres or consider hemodialysis / idarucizumab (for dabigatran) but it is v. ex Life threatening or bleeding into critical site: idarucizumab (for dabigatran) or PCC
40
How to manage DOACs during unplanned invasive procedures?
High bleeding risk during procedure: hold off DOAC Low bleeding risk: can just give DOAC
41
What is the target INR for mechanical heart valve?
2.5-3.5
42
At what INR do we have to reverse warfarn and what can we give?
INR > 10: give PO Vit. K 2-5mg If major bleeding and INR > 1.5, give IV Vit.K 5-10mg Note: fresh frozen plasma and PCC can also be used to reverse warfarin. PCC is more effective if urgent reversal is needed
43
Why should we avoiding giving high levels of Vit. K?
Confer resistance when you try to redose warfarin
44
Are azole antifungals CI with DOAC?
Yes. Only keto/intraconazole for dabi
45
Which DOAC is CI in ESRD?
Dabi, riva
46
Are warfarin and DOACs CI in severe hepatic dysfunction, esp with coagulopathy?
Yes

PR3154: Haematological & Musculoskeletal Systems (10 decks)

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