Thromboembolic Disorders

Front 1

thromboembolic disorders includes:

Back 1

*DVT
*PE
*carioembolic stroke
*acute limb ischemia

Front 2

Risk assessment for cardioembolic stoke is broken down into what 2 assessments?

Back 2

Atrial Fibrillation - CHA2DS2-VAS

Prosthetic heart valves

Front 3

CHA2DS2-VAS risk for CE stroke

Back 3

CHF
HTN
AGE
DM
Stroke-TIA-Systemic embolism
Vascular Disease (MI, PAD, aortic plaque)
Gender - female

Front 4

high and lesser risk groups for CE stroke with prosthetic heart valves

Back 4

Higher risk:
*Mechanical Valve
*Mitral position
*Afib, low EF, hypercoag, atherosclerosis, STEMI, L atral enlargement

Less risk
*Bioprosthetic
*Aortic position

Front 5

complications of VTE

Back 5

DVT: PE, post-throm syndrome, recurrent, venous insuff

PE: death, pulm HTN, cor pulmonale, reccurent

Front 6

List drugs used to treat thromboembolic disorders

Back 6

UFH - heparin
LMWH - enoxaparin, tinzaparin, dalteparin
F10 inhib - Fondaparinux
Vit K Anta - Warfarin
Direct Throm Inhib - Dabigatran
PO F 10 inhib - Rivaroxaban & Apixaban

Front 7

MOA
increases 1000 fold antithrombin effect on 2,4,5,11,12

Back 7

UFH - heparin

Front 8

MOA
binds antithrombin and clotting factors 2 & 10 for neutralization

Back 8

UFH - heparin

Front 9

MOA
similar to UFH except more inactivation of clotting factor 10 and only some 2

Back 9

LMWH

Front 10

MOA
enhances antithrombin's effect on 10a

Back 10

Factor 10a inhibitor

Fondaparinux (Arixtra)

Front 11

MOA
inhibits Vit K reductase
inhibits production of 2,7,9,10
inhibits protein C and S

Back 11

Vit K antagonist
Warfarin - Coumadin

Front 12

MOA
competitive thrombin inhibitor
stops fibrinogen from converting to fibrin

Back 12

direct thrombin inhibitors

Dabigatran (Pradaxa)

Front 13

MOA
selectively blocks active site on 10a - intrinsic and extr
independent of antithrombin

Back 13

Orally active factor 10a inhibitors

Rivaroxaban & Apixaban

Front 14

CI: active bleeding

AE: major bleeding

Back 14

Orally active factor 10a inhibitors

Rivaroxaban and Apixaban

Front 15

CI: bleeding, posthetic mechanical heart valve

AE: major bleeding, GI upset

Back 15

direct thrombin inhibitor

dabigatran

Front 16

CI: preg, risk for bleeding, skin necrosis, purple toe

AE: bleeding - GI, ICH, GI, epitaxis, urinary tract, soft tissue
- purple toe, skin necrosis

Back 16

Warfarin

Vit K anta

Front 17

CI: RENAL (CrCL < 30), <50kg, bleeding, thrombocytopenia

AE: bleeding, thrombocytopenia

Back 17

Fondaparinux
(Arixtra)

Factor 10a inhibitor

Front 18

CI: HIT, hypersens to pork, bleeding, spinal puncture

AE: bleeding, epidural hematoma, HIT (less common)

Back 18

LMWH

Front 19

CI: uncontrollable bleeding, HIT, thrombocytopenia

AE: bleeding - surgical site, GI, soft tissue
- osteoporosis & vert fx
- thrombocytopenia - HAT and HIT

Back 19

UFH

Front 20

routes for UFH, LMWH, and Fondaparinux

Back 20

UFH - IV or SC

LMWH - SC

Fondaparinux - SC

Front 21

routes for warfarin, dabigatran, rivaroxaban & apixaban

Back 21

All oral

Front 22

discontinue UFH how long before surgery?

Back 22

4 hours

Front 23

This drug can be used in any degree of renal impairment

Back 23

UFH

Front 24

why does UFH vary between pts?

Back 24

protein bound - needs monitoring

Front 25

How to diagnose HIT

Back 25

usually appears as THROMBOSIS (not hem)
*pl <150,00 or 50% decrease
*5-10 d following hep (if naive) or 12 hours with hep tx
*HIT AB essays

Front 26

how to treat HIT

Back 26

stop heparin
*anticoag (not hep)
NOT warfarin until resolved
*NO PL transfusion

Front 27

INR stages for Warfarin - sub and supratherapuetic

Back 27

normal (no warf) = 1
INR 2-3 is therapeutic

*< 2 - sub - greater risk for clot
*> 3 - supra - greater risk for bleed

Front 28

What to monitor for UFH?

Back 28

aPTT
* increased - increased anticoag status
* 1.5-2.5 x normal control aPTT is therapeutic
* monitor 4-6 hours after

Toxicity - H&H & PL (every other day)

Front 29

what to monitor for LMWH?

Back 29

not necessary unless Renal CrCl<30, peds, or overwt
*Anti-factor 10a

Toxicity: H&H & PL & serum creatinine

Front 30

what to monitor for Fondaparinux?

Back 30

generally none

Toxicity: bleeding parameters, Pl, renal function

Front 31

what to monitor for warfarin?

Back 31

INR
*measured by day 3 and again in 2-3 days
*measure every 4 weeks

Front 32

what to monitor for Dabigatran?

Back 32

none

Front 33

what to monitor for Rivaroxaban and Apixaban?

Back 33

none required

Front 34

Which drugs do not have a reversal agent?

Back 34

Fondaparinux

Dabigatran

Rivaronxaban & Apixaban

Front 35

reversal agents for UFH, LMWH, and warfarin

Back 35

UFH - protamine sulfate

LMWH - protamine sulfate

warfarin - vitamin K (phytonadion, Mephyton)

Front 36

These drugs should not be used in severe renal impairment

Back 36

LMWH & Fondaparinux

Dabigatran & oral factor 10a inhib not < 15 CrCl

Front 37

how long do LMWH take for onset?

How long to discontinue before procedure?

Back 37

2-4 hours to see action

hold for 24 hours before procedure

Front 38

this drug has longer half-life, longer offset

not preferred in pts with pending surgery

Back 38

fondaparinux

Front 39

warfarin inhibits what clotting factors?

Back 39

2, 7, 9, 10

Front 40

indications of use with warfarin?

Back 40

treatment or prevention of VTE

prevention of cardioembolic CVA

Front 41

how long does warfarin take to produce full effects?

Back 41

several days or more
half life 40 hours

Front 42

warfarin is extrensively metabolized by?

Back 42

2C9

Front 43

how do the following interact with Warfarin and INR?
*Fluconazle (Diflucan)
*SMZ/TMP (Bactrim)
*Metronidazole (Flagyl)
*Amiodarone (Cordaron)

Back 43

inhibit metabolism of Warfarin

increase INR

Front 44

how does aspirin interact with warfarin and INR?

Back 44

platelet inhibition

does not change INR

Front 45

how does Carbamazepine (Tegretol) interact with warfarin and INR?

Back 45

induces metabolism

decreases INR

Front 46

increasing Vit K intake on warfarin will do what?

Back 46

decrease INR

Front 47

what foods effect warfarin metabolism and how?

Back 47

cranberry, grapefruit, and alcohol inhibit metabolism of warfarin

Front 48

diseases that can effect warfarin metabolism and how?

Back 48

fever - increasing INR
diarrhea - increasing INR
HF - increasing INR

Front 49

route of Vit K (reversal) preferred if bleeding:

if not bleeding?

Back 49

IV - bleeding

Oral >5 INR

Front 50

Dabigatran is indicated for prevention of stroke and embolism in who?

Back 50

pt with non-valvular atrial fibrillation

Front 51

How is dosing of Dabigatran changed with renal function?

Back 51

CrCl > 30 - 150 mg BID

CrCl 15-30 - 75 mg BID

less than 15 don't use

Front 52

discontinuation of this drug has a black box warning of increased risk for thrombotic events

and for spinal/epidural hematoma

Back 52

oral factor Xa - Rivaroxaban and Apixaban

Rivaroxaban

Front 53

how is Rivaroxaban dosed?

Back 53

15 mg BID with food for first 21 days

then 20 mg ONCE daily

Front 54

how is Apixaban dosed?

Back 54

5 mg BID

Front 55

drugs that interact with oral factor 10a inhibitors include inhibitors of?

Back 55

3A4 and P-glycoprotein

Front 56

3 ways in treatment in acute V or A TE?

Back 56

1. UFH, LMWH, or Fonda for full course - expensive

2. UFH, LMWH, or Fonda WITH warfarin. injectable is stopped after 5 days and INR over 2 for 2 days

3. Rivaroxaban 15 mg BID 20 days then 20 mg qd

Front 57

when is thrombolytic therapy used?

Back 57

not standard of care

used if life or limb-threatening bleeding

Front 58

these products are favored in pregnancy and cancer

Back 58

LMWH

Front 59

considerations for prevention of cardioembolic stroke in those with atrial fibrillation:

Back 59

*ASA
*warfarin
*dabigatran
*rivaroxaban
*apixaban
Based on CHADS2

Front 60

prophylaxis of cardioembolic stroke with Afib:
CHADS: 0
CHADS: 1
CHADS: 2-6

Back 60

CHADS: 0 - ASA

CHADS: 1 - dabigatran 150 mg BID; warfarin; or ASA

CHADS: 2-6 - dabigatran is preferred

Front 61

prophylaxis of cardioembolic stroke with a bioprosthetic valve:
Mitral

Aortic:

Back 61

Mitral: warfarin 3 months, then ASA

Aortic: ASA

Front 62

prophylaxis of cardioembolic stroke mechanical valve:

Mitral:

Aortic:

Back 62

Mitral mechanical - warfarin

Aortic mechanical - warfarin

Front 63

these do not have FDA indications for prevention of cardioembolic stroke due to prosthetic heart valves and should not be used!

Back 63

Dabigatran
Rivaroxaban
Apixaban

Front 64

protects against an embolus reaching the lungs
increases risk of DVT around filter

Back 64

IVC filter

Front 65

agents used in primary prevention of VTE

Back 65

SC IFH, LMWH, fonda, rivaroxaban

Front 66

risk factors for a major hemorrhagic event

Back 66

HAS BLED risk score
*HTN
*Abn renal or liver
*Stroke
*Bleeding
*Labile INR
*Elderly
*Drugs