Week 13: Anticoagulation

Question 1

What tool is used to assess stroke risk? (1)

Answer 1

CHA2DS2VASc

Question 2

What does CHA2DS2VASC mean?

Answer 2

Congestive HF/ LV Dysfunction = 1
Hypertension = 1
Age ≥75yrs = 2
Diabetes = 1
Stroke/TIA/TE = 2
Vascular Disease (prior MI, PAD, Aortic Plaque) = 1
Age 65-74 yrs = 1
Female = 1

Question 3

When would it be appropriate to assess the bleeding risk in AF? (2)

Answer 3

Starting anticoagulation
Reviewing patients on anticoagulants.

Question 4

What is the main advantage of the ORBIT tool vs. HASBLED? (1)

Answer 4

Higher accuracy in predicting bleeding risk.

Question 5

What is the ORBIT tool? (2)

Answer 5

Has 5 predictors that can link with major bleeds.
Scores can range from 0-7.

Question 6

What factors can give an ORBIT score of 2? (3)

Answer 6

Males Hb = <130g/L or HCT = < 40%
Female Hb < 120g/L or HCT = < 36%
People with Hx of bleeding (GI/ICbleeding or haemorrhagic stroke)

Question 7

What factors can give an ORBIT score of 1? (3)

Answer 7

> 74 yrs
eGFR = < 60ml/min/1.73m2
Treated with antiplatelets

Question 8

What are severity ranges in ORBIT tool? (3)

Answer 8

0-2 = low
3 = Medium
4-7 = High

Question 9

What are the limitations of ORBIT tool? (3)

Answer 9

1. Doesn’t consider choice of anticoagulant.
2. Doesn’t include all modifiable risk factors.
3. Tends to place more patients on the lower category = under-predicting major bleeding risk.
4. Not recommended as a bleeding risk tool for other conditions e.g. VTE.
5. Not used in GP systems.

Question 10

What conditions would HAS-BLED tool be used? (2)

Answer 10

Pulmonary Embolism (PE)
Venous Thromboembolism (VTE)

Question 11

What does HAS-BLED stand for? (9)

Answer 11

Hypertension (Systolic ≥ 160mmHg)
Abnormal renal function
Abnormal liver function
Age ≥ 65yrs
Stroke (past)
Bleeding
Labile INR
Taking other drugs
Alcohol intake at the same time.

Question 12

What does a HAS-BLED score of 3 indicate? (2)

Answer 12

Increased one year bleed risk on anticoagulants.

Risk for intracranial bleed, bleed needs hospitalisation or haemoglobin drop >2g/L or need transfusion.

Question 13

What are the risk factors for bleeding? (5)

Answer 13

1. Uncontrolled Hypertension
2. Poor INR control in patients with Vit. K Antagonist
3. Medication incl. antiplatelets, SSRIs, NSAIDs
4. Harmful alcohol consumption
5. Reversible causes of anaemia.

Question 14

What should the CHA2DSC-VASc score be to be offered anticoagulation in AF?

Answer 14

2.

Question 15

What should the CHA2DSC-VASc score be to be considered anticoagulation in AF for males? (1)

Answer 15

1.

Question 16

Give e.g. of anticoagulants that can be given for patients with AF. (4)

Answer 16

Apixaban
Dabigatran
Edoxaban
Rivaroxaban

Question 17

What alternative treament options is given to patients where DOAC is contraindicated, not tolerated or unsuitable for them? (2)

Answer 17

Offer Vitamin K antagonist.

If already on warfarin, discuss options of switching treatment in next routine appointment, taking into acc. patient’s time in Time Therapeutic Range (TTR)

Question 18

In what situation would anticoagulation would not be offered to patients? (1)

Answer 18

< 65 yrs with AF and no other risk factors besides their gender.

Question 19

In what situation should anticoagulation NOT be witheld? (2)

Answer 19

Solely because of person’s age and risk of falls.

Question 20

How is shared decision making applied to anticoagulation? (7)

Answer 20

Discuss the risks and benefits of anticoagulation so that the
person can make an informed choice about their treatment.

– Inform the person that:
* The risk of a stroke is five times higher in a person with AF than in a
person in sinus rhythm. Stroke severity is usually greater when stroke
is associated with AF than with other causes.

• Accounts for approx. 20% of all strokes.
• Anticoagulation treatment reduces the risk of stroke by about 2/3rds.
• For most people, the benefit of anticoagulation outweighs the risk of
  bleeding.
• For people with an increased risk of bleeding, the benefit of
  anticoagulation may not always outweigh the bleeding risk, and
  careful monitoring of bleeding risk is important

– Do not withhold anticoagulation solely because a person is at risk of falls.