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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
Q

How is INR affected by alcohol binging, chronic alcoholism, sudden incr in physical activity and smoking?

A

Alcohol binge: increase INR
Chronic alcoholism, sudden incr in physical activity and smoking: increase warfarin metabolism –> decrease INR

26
Q

How does liver disease, fever, thyroid disease and fluid retention affect INR?

A

Liver disease, fever, fluid retention in liver, hyperthyroidism: increase INR
Fluid retention in gut, hypothyroidism: decrease INR

27
Q

What conditions would warfarin be used instead of DOACs?

A

Left ventricular thrombus
Prosthetic heart valve/mitral stenosis
Antiphospholipid syndrome related VTEs

28
Q

Which clotting factor that warfarin inhibits has the shortest t1/2?

A

Factor VII

29
Q

If CrCl < 60ml/min, how to determine when will be the next blood test?

A

CrCl/10

30
Q

What should be reviewed at every follow up session?

A

Adherence, TE S&S, bleeding, SE, Co-meds, blood tests PRN, screen and mitigate for RFs for bleeding, assess optimal DOAC choice/dosing

31
Q

Which TB AB has DDI with DOACs and warfarin?

A

Rifampicin

32
Q

How to switch warfarin to NOAC?

A

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
Q

How to switch NOAC to warfarin?

A

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
Q

Which anti-seizure meds have DDI/CI with DOACs?

A

Dabi + riva: Carbamazepine, phenytoin
Riva: Phenobarbital
Valproic acid: all DOACs

35
Q

Which herbal meds is CI with all DOACs?

A

St. John’s wort inducers PGP and CYP3A4

36
Q

What type of drugs should be avoided with rivaroxaban and apixaban?

A

Potent dual inhibitors/inducers

Examples of potent dual inhibitors of CYP3A4 and PGP are azoles, ritonavir, clarithromycin

37
Q

How should the warfarin dose be adjusted if taken with metronidazole?

A

20-30% reduction

38
Q

How should warfarin dose be adjusted if taken with amiodarone?

A

Pre-emp reduce warfarin dose by 30-50%

39
Q

How to manage bleeding while using a NOAC?

A

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
Q

How to manage DOACs during unplanned invasive procedures?

A

High bleeding risk during procedure: hold off DOAC
Low bleeding risk: can just give DOAC

41
Q

What is the target INR for mechanical heart valve?

A

2.5-3.5

42
Q

At what INR do we have to reverse warfarn and what can we give?

A

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
Q

Why should we avoiding giving high levels of Vit. K?

A

Confer resistance when you try to redose warfarin

44
Q

Are azole antifungals CI with DOAC?

A

Yes.

Only keto/intraconazole for dabi

45
Q

Which DOAC is CI in ESRD?

A

Dabi, riva

46
Q

Are warfarin and DOACs CI in severe hepatic dysfunction, esp with coagulopathy?

A

Yes

PR3154: Haematological & Musculoskeletal Systems (10 decks)

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