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134 Cards in this Set
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Evidenced Based Practice : General Changes 9th Edition
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VKA10 mg x2 days for healthy output, f/b INR
Rec against routine pharmacogenetic testing for initiation Consistently stable pts on vka, suggest inr q 12 weeks, rather than q 4 weeks Suggest against routine vit K supp APLS w/ prior venous or art thromboembolism rec INR 2-3, rather than 2.5-3.5 IV UFH for VTE - wt adj bolus 80u/kg f/b 18u/hr IV UFH for cardiac, stroke- 70 u/kg bolus, f/b 15u/hr Or use of fixed dose 5000 u bolus, f/b 1000u/hr Outputs VTE RX w/ SC UFH suggest at adjusted first dose 333u/kg, then 250u/kg, w/o monitoring LMWH - crcl<30mL/min dose reduction suggest Fondaparinux > 100 kg - 10 mg INR 4.5 to 10 w/o bleed - against vit K INR > 10 w/o bleed - vit K po VKA major bleed - rapid reversal w/ 4 factor PCC rather than plasma. Add vit K 5-10 mg slow if injection rather than reversal w/PCC alone |
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VTE Prevention Non-surgical patients: acutely ill group
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Acutely ill Hosp medical pts at inc risk thrombus - thromboprophylaxis w/ LMWH, low dose UFH bid or fondaparinux ( 1B)
Low risk thrombosis - against mech or pharm proph (1B) Bleeding or high risk of bleed - against anticoag proph (B) If Inc risk of thrombosis and bleeding - use mech prophylaxis until bleeding/risk of stops and then to go chem prophylaxis |
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VTE Prevention Non - Surgical pts: critically ill
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LMWH or LDUH rec over no prophy
If bleeding or high risk of bleed - use mech prophy until bleeding/risk of bleed stops Cancer pts w/o additional risk factors for VTE - rec against routine prophylaxis w/ lmwh or lduh (2B) and against via (1B) Pts w/ solid tumors and additional risk factors for vte and low risk for bleed rec lmwh or lduf ( add risk factors in this group are prior vote, immobilization, hormonal RX, angiogenesis inhibitors, thalidomide, lenalidomide) Asymptomatic thrombophilia (w/o prior vte), rec against long term much or pharm prophylaxis. |
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VTE Prevention: Non Orthopedic Surgical Patients
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Very low risk VTE - no pharm prop (1B) or mech (2C) - just ambulate early
Low risk VTE - mech proph only Moderate risk VTE (and not high risk bleed) LMWH or LDUH Moderate risk VTE (and high risk bleed) use mech prophy High risk VTE (not high risk bleed) LMWH or LDUH (1B) High risk VTE (not high risk bleed) having surgery for cancer rec extending LMWH to 4 weeks (1B) |
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What drug can be used in general abdominal -pelvic surgery if LMWH or LDUH are contraindicated or not available ( and pt is not high risk for bleed)
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Low dose ASA, fondaparinux , or mech prophylaxis
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Cardiac surgery patients w/ uncomplicated post op course recommendations
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Mechanical prophylaxis over no proph or pharma proph
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Cardiac patient whose hospital course is prolonged by one or more non-hemorrhagic complications
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LMWH or LDUH
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Thoracic surgery patient moderate risk VTE and not high bleed risk
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LMWH, LDUH ( 2B)
Or mech prophy (2C) |
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Thoracic surgery patients high risk VTE and not high risk bleed
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LMWH or LDUH (1B)
Add mech proph to chemical (2C) |
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Craniotomy patients undergoing surgery for cancer ( high risk VTE)
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Suggest adding pharm proph to mech proph once hemostasis established and bleeding decreases
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Major trauma patients
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LDUH or LMWH or mech prophl over no prophylaxis
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Major trauma patients at high risk for VTE ( including acute spinal cord injury, TBI, spinal surgery for trauma)
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Add mech prophylaxis to chemical when not cobtraindicated
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Are IVC filters recommended for primary prevention in major trauma patients
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No
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VTE prevention in Orthopedic Patients:
What is the minimum number of days that VTE prophylaxis is recommended for THR, TKR |
10 to 14 days (over no prophylaxis)
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What agents are recommended so TKR, THR
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LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, adjusted dose VKA, ASA ( 1B)
Or IPC (1C) One panel member felt ASA shouldn't be included |
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What is the only type of IPC boots recommended
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Battery powered, portable, IPCDs capable of recording compliance. 18 hours per day
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What is recommendation re HFS?
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Prophylaxis for minimum of 10 to 14 days ( over no prophylaxis)
LMWH, fondaparinux, LDUH, adjusted dose VKA, ASA ( 1B) or IPCD (1C) |
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When should LMWH be started with TKR, THR or HFS?
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Either 12 hours preop or 12 or more post op (1B)
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What is the preferred drug to be used for THR and TKR
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LMWH
Next choose: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (2B) Then choose: adjusted dose VKA, or ASA (2C) |
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What is preferred drug for HFS?
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LMWH
Next choose: Fondaparinux, LDUH (2B) Then choose: Adjusted dose VKA or ASA (2C) |
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For patients having major orthopedic surgery what is the suggested length of thromboembolism prophylaxus?
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Up to 35 days in the outpatient area (rather for only 10-14 days (2B)
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Does CHEST recommended dual prophylaxis with mechanical and chemical agents during hospital stay for major orthopedic pts?
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Yes
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For asymptomatic patients following major orthopedic surgery, does CHEST recommended Doppler screening prior to hospital discharge?
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No (1B)
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What is CHEST recommendation regarding interruption of VKA prior to surgery?
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Stop VKA 5 days before surgery (1C)
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When should VKA be resumed post op?
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12 to 24 hours after surgery (evening of next morning) and when adequate hemostasis has occured
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What is recommendation re bridging in patients with a mechanical heart valve, AF or VTE at HIGH risk for thromboembolism? VKA pts
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Suggest bridging
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What is recommendation re bridging in patients with mechanical heart valve, AF or VTE and LOW risk for thromboembolism? VKA pts
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Suggest AGAINST bridging
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What is CHEST recommendation re VKA administration with minor dental procedures?
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Continue VKA and use oral prohemostatic agent
OR Stop VKA 2 to 3 days prior to procedure:-) |
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CHEST rec re minor derm procedure or cataract extraction
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Rec continue VKA
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CHEST rec re patients on ASA for secondary prevention of CAD, who are having minor derm or dental procedures?
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Continue ASA (2C)
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If patient at mod to high risk of cardiovascular event on ASA requires non cardiac surgery , what should be done with the ASA?
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Suggest continuing ASA rather than stopping 7-10 days prior
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If patient at low risk of cardiovascular event on ASA requires non cardiac surgery, what should be done with the ASA?
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Suggest stopping 7-10 days prior to surgery
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If patient is on ASA and requires CABG, should the ASA be stopped 7-10 prep?
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No, it should be continued
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If patient on dual antiplatelet therapy requires CABG, what should be done with these drugs?
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1. Continue ASA
2. Stop clopidrigel (plavix) or prasurgel 5 days preop |
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In patients with coronary stent receiving dual antiplatelet therapy who require surgery, what are the recommendations?
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Recommend deferring surgery for 6 weeks after placement of BMS or 6 months after placement of DES if possible instead of having surgery (1C)
If unable to defer surgery for those time frames, , suggest continuing dual anti platelet therapy around the time of surgery rather than stopping dual antiplatelet therapy 7 to 10 days prior.(2C) |
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In patients receiving heparin bridge prior to surgery, when should it be stopped?
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4-6 hours preop
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In patients receiving lovenox bridge preop, when should it be stopped?
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24 hours preop
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If patient is receiving therapeutic dose LMWH and is having a high bleeding risk procedure when should it be restarted postop?
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48 to 72 hours (2C)
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What does the A,B and C mean in the CHEST guidelines?
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A = high quality and amount of supporting evidence
B = moderate quality or amount of supportive evidence C = poor or small amount of supporting evidence |
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What does the 1 and 2 refer to in the CHEST guidelines?
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1= benefit clearly outweighs the risk
2= benefit is balanced with the risk |
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What is strongest recommendation ?
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1A
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What is weakest recommendation?
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2C
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CHEST rec re acute VTE rxed with VKA; what is the recommendation re parenteral anticoagulation?
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Initial treatment with LMWH, fondaparinux, IV UFH or SC UFH (1B)
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High clinical suspicion of VTE, while awaiting results of diagnostic tests?
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Recommended start parenteral anticoagulation
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Intermediate suspicion of VTE while awaiting results of diagnostic tests?
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Rec start parenteral anticoagulation if results are expected to be delayed for more than 4 hrs
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Low suspicion of VTE while awaiting results of diagnostic tests?
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Rec starting parenteral anticoagulation if diagnostic test results expected to be delayed for more than 24 hrs
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Acute DVT of leg, what is suggested for initial anticoagulant?
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LMWH or fondaparinux over IV UFH (2C) and over SC UFH
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In patient with acute DVT of the leg and in whom home circumstances are adequate, where is initial treatment recommended?
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At home (1B)
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Which is preferred treatment of acute proximal DVT of leg? Anticoagulant therapy alone or catheter directed therapy?
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Anticoagulant therapy alone
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Which is preferred for treatment of acute proximal DVT of leg? Anticoagulant therapy or systemic thrombolysus?
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Anticoagulant alone
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Which is prefered treatment of acute proximal DVT of leg?Anticoagulant alone or operative venous thrombectomy?
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Anticoagulant therapy alone
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If patient does undergo thrombosis removal of an acute DVT, is anticoagulant therapy recommended?
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Yes, for the same intensity and duration of anticoagulant therapy as someone who doesn't undergo thrombosis.
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When would an IVC filter be recommended for an acute proximal DVT?
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If anticoagulant therapy was contraindicated (1B)
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Which is recommended in acute proximal DVT? Bed rest or early ambulation?
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Early ambulation
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What is duration of therapy for proximal DVT?
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1. Provoked by surgery - 3 months
2. Provoked by nonsurgical transient risk factor - 3 months 3. Unprovoked DVT - 3 months and eval ( If high risk of bleed prefer 3 months only over extending duratioin of therapy) 4. Second unprovoked VTE rec extending therapy over 3 months if low bleeding risk. If high risk of bleed and second unprovoked bleed, suggest 3 months of therapy over extending therapy. |
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If patient has a DVT of leg and active cancer, if bleeding risk is not high, how long is treatment recommended?
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Suggest extending therapy beyond 3 months
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Are compression stockings recommended for acute symptomatic DVT?
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Yes
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What is recommended for initial parenteral treatment acute PE?
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LMWH, fondaparinux, IV UFH or SC UFH (1B)
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Do the same rules apply for PE as is true for DVT in waiting for test results and starting parenteral anticoagulants?
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Yes
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What parenteral anticoagulant is recommended for acute PE?
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LMWH or fondaparinux
Then IV UFH |
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In patient with acute PE associated with hypotension, who don't have bleeding risk, what is suggested?
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Thrombolytic therapy
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If acute PE not associated with hypotension, is thrombolytic therapy recommended?
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No ( 1C)
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If acute PE not initially associated with hypotension with low bleeding risk, started on anticoagulant therapy, then begins to suggest high risk of hypotension, is thrombolytic therapy then recommended?
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Yes
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Is a short (2 hr) or long course (24 hr) of thrombolytic therapy recommended?
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Short course and via peripheral vein rather than pulmonary artery catheter
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Is IVC filter recommended in patients who are treated with anticoagulants?
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No; IVC filter rec only if there is a contraindication to anticoagulants
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Patients with PE and active cancer, treatment time recommendation?
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If low or moderate bleeding risk, rec extended anticoagulant therapy over 3 months of therapy (1B)
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In patients receiving heparin with risk if HIT >1% how often should platelet count be checked?
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every 2-3 days from day 4 to 14 or until heparin is stopped
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HIT complicated by thrombosis ( HITT) /what is recommended?
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Lepirudun, argatroban and danaparoid over cont use of heparin, LMWH or starting vka
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HITT and renal insufficiency
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Argatroban rec over others
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HITT and platelet transfusions?
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Only give if bleeding or during a procedure with high bleeding risk
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HIT and VKA initiation?
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Only when platelets recovered to > 150k
Start with low dose (5 mg max) |
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If VKA already started before HIT diagnosed, what should be administered?
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Vit K
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Confirmed HIT - how long should VKA be overlapped with nonheparin anticoagulant?
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5 days minimum and then recheck INR after the anticoagulant effect of non heparin anticoagulant has resolved
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HIT without thrombosis therapy?
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Lepirudin, argatroban or danaparoid
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HIT w/o thrombosis w/ normal renal fx
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Argatroban, lepirudin or danaparoid
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Acute HIT ( thrombocytopenia, HIT antibodies positive) or sub acute HIT ( platelets recovered, but HIT antibodies positive), who require urgent surgery, which agent is recommended?
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Bivalrudin
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HIT (acute or sub acute ) who require PCI, what is recommended?
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Bivalrudin
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Pregnant patients with HIT (acute or sub acute), what is recommended?
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Danaparoid,
Lepirudin or fondaparinux only if danaparoid not available |
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AF, including PAF at low risk stroke (CHADS score of 0) what is recommended?
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no anticoagulant
If pt wants treatment, then ASA 75 to 325 or ASA and plavix |
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AF, including PAF with CHADS score 1 (mod risk)
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Rec anticoagulant treatment rather than no RX
Oral anticoag rather than ASA or ASA and plavix Rec ASA and plavix, if pt unsuitable or unwilling to take anticoag |
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AF, PAF, high risk stroke, CHADS score 2
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oral anticoag rather than no RX (1A) or ASA (1B) or a
ASA plavix (1B) If pt unwilling /unsuitable for anticoag, then rec ASA and plavix |
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What is recommended anticoag for patient w/ AF or PAF?
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Dabigatran 150 mg Bid rather than adjusted dose VKA
Contraindicated in severe renal imp w/ crcl < 30 ml/min No antidote |
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AF and mitral stenosis
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Adj dose VKA w/ range INR 2-3
If unable or unwilling to take vka, rec ASA and plavix rather than ASA alone |
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AF and stable CAD (no ACS w/I prior year)
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Adjusted dose VKA INR range 2-3 rather than adj dose VKA and ASA
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AF, high risk stroke CHADS score 2 or more who have BMS or DES placement, what is recommendation for anticoag and antithrombotic therapy?
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BMS after first month and DES after 3 to 6 months rec triple therapy w/ VKA, ASA and plavix rather than dual therapy w/ ASA and plavix.
After initial period of triple therapy, then VKA plus single antiplatelet drug rather than VKA alone. Then after 12 months rec per AF and stable CAD |
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AF, low or intermediate risk stroke (CHADS score 0-1) who have BMS or DES, what is rec for anticoag or antithrombotic therapy?
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Dual antiplatelet therapy rather than triple therapy for first 12 months
At 12 months, then antithrombotic therapy as for patient w/AF and stable CAD |
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AF being managed with rhythm controlling agent (pharmacological or catheter ablation)
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Follow same guidelines for general risk based recommendations with AF (CHADS)
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Atrial flutter follow same guidelines as for A fib?
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Yes
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AF of greater than 48 hours or unknown duration that is undergoing electrical or pharmacological cardio version.
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Adjusted dose VKA, INR 2-3
LMWH full VTE treatment dose Or Dabigatran For 3 weeks at least before CV Or TEE guided approach w/ abbreviated anticoag before CV |
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How long is rec for anticoagulation after cardio version from AF to NSR
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4 weeks (1 B)
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AF of documented duration of 48 hours or less undergoing cardio version (electrical or pharm) what is suggested for anticoagulation?
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Start anticoag at presentation with LMWH or UFH at VTE treatment dose
Proceed right to cardio version rather than delaying CV for three weeks of anticoagulation or TEE guided approach. Then 4 weeks of anticoag after CV |
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Rheumatic valve disease and NSR w/ L atrial diameter < 55 mm?
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No antiplatelet and no VKA
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Rheumatic valve , NSR and L atrial diameter > 55 mm?
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VKA INR 2-3 rec over no anticoag or antiplatelet
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Rheumatic heart disease and L atrial thrombus
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VKA w/ INR 2-3
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Patient being considered for PMBV (percutaneous mitral balloon valvotomy) w/ preprocedural TEE showing L atrial thrombus what is recommended?
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Postpone procedure; VKA w/ INR 2.5-3.5 be ADM until thrombus has resolved doc by TEE (1A)
If thrombus doesn't resolve w/ VKA rec that PMBV not be performed |
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Patient w/ PFO or atrial septal aneurysm
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Against anticoag
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Cryptogenic stroke and PFO or atrial septal aneurysm
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ASA 50-100 mg daily
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Cryptogenic stroke, PFO or atrial septal aneurysm w/ recurrent episodes despite ASA what is rec?
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VKA w/ INR 2-3 and consideration of device closure
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Cryptogenic stroke, PFO w/ evidence of DVT
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VKA 3 months INR 2-3 (1B)
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Bioprosthetic valve mitral position
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VKA 3 months INR 2-3
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Bioprosthetic valves aortic position and no other indication for VKA and in NSR
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Recommend ASA 50-100 mg daily over VKA in the first three months
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Bioprosthetic valves in NSR after the first three months postop.
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ASA
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Patients w/ mechanical heart valves, what is suggested for bridging postop ?
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Prophylactic UFH or
Prophylactic or therapeutic LMWH Over IV therapeutic UFH Until stable on VKA |
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How long for anticoagulation for mechanical heart valves?
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Lifelong
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INR for mech mitral valve
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2.5 - 3.5
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INR for mech aortic valve?
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2 - 3
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Mech heart valves in both aortic and mitral positions INR goal?
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2.5 - 3.5
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Mech aortic and mitral valve at low risk for bleeding, what is rec?
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Add low dose ASA 50-100 mg to VKA
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Mitral valve repair w prosthetic band in NSR?
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Antiplatelet over VKA for first 3 months
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Acute ischemic stroke
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IV tPA within 3 hours of symptom onset (1A)
IV tPA within 4.5 , but not 3 hours symptom onset (2C) Against IV tPA if can't be initiated w/in 4.5 hrs of symptom onset |
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Acute ischemic stroke or TIA
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ASA 160-325 mg w/in 48 hours (1A)
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Acute ischemic stroke and limited mobility?
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Prophylactic dose LMWH or UFH
Rec against compression stockings |
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Hx of noncardioembolic stroke or TIA long term rx
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ASA 75-100 mg daily or
Plavix 75 mg daily or Aspirin/ext release dipyramidole (25/200) or Cilastazol (100 mg bid) (All 1A) Or oral anticoagulants or plavix and ASA (1B) Triflusal |
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Ischemic stroke and AF
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Oral anticoagulation over no anticoagulation (1A)
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Hx of ischemic stroke or TIA and AF, incl PAF
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Dabigatran 150 mg BID over adjusted VKA
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ACS w/o PCI for first year after an ACS
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Dual antiplatelet RX (ticagrelor 90 mg bid plus low dose ASA 75-100 mg daily
or plavix 75 mg daily and low dose ASA 75-100 mg daily |
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ACS w/ PCI w/ stent placement first year
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Dual platelet RX
Ticagrelor 90 mg bid and low dose ASA 75-100 mg Or Plavix 75 mg daily and low dose ASA or Prasurgel 10 mg daily and low dose ASA (1B) |
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ACS w/ anterior MI and LV thrombus or LVEF < 40% , antsep WMA w/o stent
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Warfarin INR 2-3 plus ASA 75-100 mg daily
over single antiplatelet RX or dual antiplatelet RX For 3 months |
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Asymptomatic PAD
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ASA 75-100 mg daily
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Symptomatic PAD
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ASA 75-100 mg daily or
Plavix 75 mg daily (1A) |
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Intermittent claudication refractory to exercise and smoking cessation
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Cilastazol in addition to previously used medication such as ASA 75-100 mg daily or plavix 75 mg daily
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What lytic agent is recommended in pt w/ acute limb ischemia sec to arterial emboli or thrombosis?
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tPA over urokinase or streptokinase
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What antithrombotic recommended long term after peripheral artery PTCA w/ or w/o stenting?
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ASA 75-100 mg daily or
Plavix 75 mg daily (1A) |
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Long term treatment s/p peripheral artery bypass graft?
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ASA 75 -100 mg Daily
Or Plavix 75 mg daily |
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Asymptomatic carotid artery treatment?
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ASA 75 mg to 100 mg daily
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Pregnant patients for prevention and treatment of VTE
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LMWH, instead of UFH
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Women w/ VTE who become pregnant rec
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LMWH over VKA during all trimesters
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For pregnant women these po anticoagulants are not recommended
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oral DTI ( dabigatran)
Anti Xa ( rivaroxaban and apixaban) |
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Recommended for breast feeding women
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warfarin or UFH
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Pregnant women w/ acute VTE
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LMWH adj dose over adj dose UFH or VKA
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Pregnant women, no prior hx VTE who are homozygous for factor V Leiden or prothrombin 20210 A mutation and positive for FH VTE what is suggested?
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Antepartum prophylaxis w/ prophylactic or intermediate dose LMWH and postpartum prophylaxis for 6 weeks LMWH or VKA
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Recurrent early pregnancy loss (3 or more miscarriages before 10 weeks gestation) what is recommended?
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APLAs screening
If positive for this and early pregnancy loss, then Antepartum prophylactic or intermediate dose UFH or prophylactic LMWH combined with ASA 75-100 mg daily |
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Women at risk for pre-eclampsia should take this throughout pregnancy starting at the second trimester
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Low dose ASA
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Pregnant women with mechanical heart valves rec to take one of these anticoagulants during pregnancy
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Adjusted dose LMWH to achieve manufacturers' peak anti-Xa
UFH adjusted dose q12 hours to attain anti-Xa heparin level of .35 to .75 UFH or LMWH until 13th week with substitution by VKA until close to delivery when UFH or LMWH are resumed |
