B&l: Test 2: 2. Maloney : Anticoagulants I

Front 1

What are the two major types of thrombi?

Back 1

Red and white

Front 2

What causes red thrombus formation?

Back 2

Typical hemostasis leading to thrombin, firbrin, and thrombus

Front 3

Where do red thrombi tend to occur?

Back 3

Atria (eg atrial fib)

Veins (eg DVT)

Front 4

where are the 2 ways to prevent red clots

Back 4

stop the formation of thrombin

work on the clot itself and dissolve it (thrombus)

Front 5

Deep vein thrombosis/Pulmonary embolism, initial tx?then what 2 other things should you do?

Back 5

initial: Fibrinolysis

Immediate anticoagulation: parental agent

Long term anticoagulation: oral agent

Front 6

If a pt presents with atrial fibrilation, you need to get rid of the clot, do you use a fibrinolytic?

Back 6

NO-high risk of bleeding

you use an immediate anticoagulant and long term anticoagulant

Front 7

how do you get a white thrombus?

Back 7

Coagulation + Platelet plug

platelets is what give it the name

Front 8

Where do white thrombi tend to occur?

Back 8

Arteries (eg MI)

Front 9

what 3 places can you stop a white clot

Back 9

Platelet aggregation

Thrombin

Thrombus

Front 10

in general, what 3 things can help treat a STEMI?

Back 10

Fibrinolysis

Immediate anticoagulation

Antiplatelet

Front 11

Compared to a STEMI, what is the difference in tx for NSTEMI, and unstable angina?

Back 11

you DO NOT GIVE fibrinolytic with NSTEMI and UA

Front 12

will cardiac enzymes be + or - in UA, NSTEMI, and STEMI?

Back 12

UA: negative

NSTEMI: +

STEMI: +

Front 13

What is the main difference between the pharmacological treatment of STEMI and NSTEMI?

use of anticoagulants
use of antiplatelets
use of thrombolytics

Back 13

use of thrombolytics

not used in NSTEMI

Front 14

if you see -parin what type of drug do you have?

Back 14

LMW heparin

Front 15

Enoxaparin (Lovenox)
Dalteparin (Fragmin)
Ardeparin (Normiflo)
Tinzaparin (Innohep)

what kind of drug

Back 15

Low Molecular Weight Heparin

Front 16

what are the 2 types of heparin?

Back 16

Unfractionated Heparin (UFH)
Low molecular weight heparin (LMWH)

Front 17

MOA for unfractionated Heparin?

Back 17

Accelerates the reaction between:
Antithrombin and thrombin
Antithrombin and Factor Xa

Heparin forms a complex with Antithrombin (AT). Approximately one‑third of heparin molecules contain a unique pentasaccharide sequence with high‑affinity binding to AT.
This accelerates the reaction between AT and factor IIa (thrombin) or factor Xa by at least 1000 fold.

Front 18

what is the ternary complex?

Back 18

unfractionated heparin + thrombin+ antithrombin

Front 19

MOA for LMW heparin?

Back 19

Accelerates the reaction between:
Antithrombin and Factor Xa

Front 20

What is the big difference between UFH and LMWH?

Back 20

they have equivalent anti-coagulant effects

SO: Pharmacokinetics!

Front 21

IV (usually) or subcutaneous
Unpredictable anticoagulant effect
Monitor the aPTT

UFH or LMWH?

Back 21

UFH

Front 22

Subcutaneous (usually) or IV
Predictable anticoagulant effect
No monitoring of the aPTT
Can be used at home
Expensive

UFH or LMWH?

Back 22

LMWH

Front 23

How are UFH and LMWH adminstered?

**

Back 23

UFH: IV (usually) or subcutaneous

LMWH: Subcutaneous (usually) or IV

Front 24

UFH or LMWH has an UNpredictable anticoag effect and must be monitored with aPTT?

Back 24

UFH

Front 25

Anti-coagulant of choice for pregnant ladies?

Back 25

HEPARIN (LMWH or UFH)

does not cross placenta

Front 26

Pulmonary embolism
Deep vein thrombosis
Thromboembolism during pregnancy
Postoperative venous thrombosis
Arterial embolism (eg. from atrial fibrillation)
ST-elevation myocardial infarction (STEMI)
Unstable angina (UA) and Non ST-elevation myocardial infarction (NSTEMI)
Percutaneous coronary interventions (PCI)

what can you use?

Back 26

Heparin

Front 27

Short term anti-coag: Heparin or Warfarin?

Back 27

Heparin

Front 28

Immediate anticoagulant for STEMI? long term?

Back 28

Short term: Heparin

long term: Warfarin

Front 29

Adverse side effects of Heparin?

Back 29

Bleeding

HIT- Type II

Front 30

What is HIT? Tx

Back 30

Heparin induced thrombocytopenia

a few days (5-10) after giving heparin for the first time you have an IMMUNE reaction

Tx: TAKE THEM OFF THE DRUG, this can kill you!

Huge drop in platelet count

Front 31

UFH and LMWH can bind to what in HIT?

Back 31

platelet factor 4 (PF4)

Front 32

Please describe the mechanism of HIT

Back 32

platelet releases PF4 and binds to heparin

this generates an Ab to the heparin/PF4 complex

Platelets have a Fc receptor that can bind the Ab+Heparin+PF4 complex

leads to strong platelet activation

Front 33

HIT type II summary in her words

Back 33

Platelet factor 4 is released from activated platelets and binds to heparin
Antibodies are produced to the heparin-PF4 complex
These antibodies bind to the heparin-PF4 complex
This immune complex (heparin-PF4-IgG) binds to platelet Fc receptors resulting in platelet activation

Front 34

What will happen to the platelet count with HIT type 2?

Back 34

go down

Front 35

What is the predominant clinical presentation with HIT type 2?

B)Excessive Bleeding
A)Thrombosis

Back 35

Predominant is THROMBOSIS

platelets get activated and start causing a clot...

Front 36

Possible consequences of HIT?

Back 36

Platelet count can decrease by 50%
1-5% of patients with UFH
About 1% with LMWH

Thromboembolic complications
20% of HIT patients
Mortality in this group - as high as 30%
Permanent morbidity (e.g. limb loss) - 20-30%

Front 37

Tx for HIT? what if they have a clot?

Back 37

Heparin must be stopped

Thrombosis can be treated with other agents
Direct thrombin inhibitors

Front 38

if you are on heparin for 3-6 weeks..what can happen? What population do you see this in? which heparin causes less of this adverse effect?

Back 38

OSTEOPOROSIS

seen in preggo women who are on heparin for a while

UFH stimulates bone resorption and decreases bone formation
LMWH appears to only decrease bone formation

Front 39

Why do you not use Heparin after brain surgery

Back 39

prevent stroke!

Front 40

Heparin antidote?

Back 40

Protamine sulfate

Forms a stable complex with heparin
With life threatening bleeding

Front 41

What are some of the precautions you must think of with use of protamine (what was protamine again)

Back 41

Heparin antidote

Can have anticoagulant effects
Anaphylactic reactions - diabetics who take protamine containing insulin

Front 42

Fondaparinux (Arixtra) does what?

Back 42

Synthetic pentasaccharide that is a selective factor Xa inhibitor

Front 43

Homework for Fondaparinux (Arixtra)

Compare the MOA of fondaparinux with heparin
Will fondaparinux need monitoring by the aPTT?
Will fondaparinux cause as much HIT as UFH or LMWH?

Back 43

MOA is very similar, binds with antithrombin to selectively affect factor Xa

It will NOT need monitoring by aPTTT

NO RISK OF HIT

look at slides 59-64

Front 44

Hirudo medicinalis is a leech that has what in it?

Back 44

Hirudin - anticoagulant

Front 45

if you see -RUDIN what are they

Back 45

leech derived recombinants of hirudin

direct thrombin inhibitor

Front 46

Bivalirudin (Angiomax)
Lepirudin (Refludan)

what kind of drugs?
***

Back 46

hirudin (from leeches)

direct thrombin inhibitor