Anticoag A-fib PRE

What causes blood clot formation in patients with A-fib?

Atria beating irregularly, causing blood to swirl within the atria

Rate control is lifelong anticoagulation indicated by the ______

stroke risk (CHA₂DS₂-VASc)

Rhythm control is indicated by what 2 things?

1. stroke risk

2. anticoagulation before/after cardioversion (depends on clinical scenario)

What are the 3 different clinical scenarios for anticoagulation BEFORE cardioversion?

1. AF 48 hours or more or unknown duration

2. AF < 48 hours

3. Hemodynamic instability

What are the options for AF that lasts 48 hours or more or is unknown?

• AC for at least 3 weeks before cardioversion, regardless of stroke risk

• perform TEE

  • if no thrombus: no prior AC needed

  • if thrombus: 3-6 weeks AC then repeat imaging before cardioversion

For patients with AF <48 hrs and a stroke risk of 0 or 1, what is your option?

no AC necessary

For patients with AF <48 hrs and a stroke risk of 2+, what is your option?

consider pre-cardioversion TEE

How do you anticoagulate with hemodynamic instability?

initiate AC ASAP

How do you anticoagulate AFTER cardioversion?

• continue for at least 4 weeks

• long-term: depends on stroke and bleeding risk

What are the options for in-patient anticoagulation?

• heparin drip

• LMWH

• bridge to OAC

heparin drip bolus and infusion is titrated to goal _____ or _____

anti-Xa; aPTT

Dosing for inpatient anticoagulation with enoxaparin

• 1mg/kg q12hr

• 1.5 mg/kg q24hr

You use watchman devices in patients with high ______risks

bleeding

What are the 3 risk scores?

1. atria

2. CHA₂DS₂-VASc

3. Garfield-AF

This risk score is considered the most validated tool compared to others in its assessment of stroke risk in nonvalvular AF

CHA₂DS₂-VASc

What are the 3 bleeding risk scores?

1. HAS-BLED

2. HEMORR₂HAGES

3. ATRIA

With the HAS-BLED, a score of ____ and up means you are at a higher risk for bleeding

3

True or false: there is NO DOAC indicated for treatment of AC in valvular AF

true

In nonvalvular AF, what CHADS score for men and women recommends oral AC?

Men: 2+

Women: 3+

For nonvalvular AF, what oral anticoagulation is recommended?

dabigatran, rivaroxaban, apixaban, edoxaban OVER warfarin

What does CHA₂DS₂-VASc stand for?

C: heart failure

H: HTN

A₂: age, additional risk

D: diabetes

S₂: thromboembolism

V: vascular disease

A: age standard risk/weight

Sc: sex category

What does the ATRIA risk score focus on?

anticoagulation and risk factors in A-fib

What does the CHA₂DS₂-VASc score focus on?

A-fib risk

What does the GARFIELD-AF score focus on?

global anticoagulant registry in the field-atrial fibrillation

Describe the bleeding risk in dabigatran

• lower risk of major bleeding with 110mg compared to warfarin

• no significant difference in major bleeding with 150mg dose (superior) compared to warfarin (increased risk of GI bleeding)

Describe the bleeding risk with rivaroxaban

• major bleeding compared to warfarin

• increased risk of GI bleeding compared to warfarin

Describe the bleeding risk with apixaban

Major bleeding is significantly lower

Describe the bleeding risk with edoxaban

• Major bleeding was significantly lower with both edoxaban doses compared to warfarin

• Higher rate of GI bleeding with edoxaban 60mg

What is the reversal agent for pradaxa?

idarucizumab

What is PCC?

prothrombin complex concentrate (reversible agent)

For CCD, monotherapy with _____ is preferred over combo with antiplatelet

OAC

For PAD, monotherapy with OAC is ______ over dual therapy

reasonable

Recommendation for anticoagulation in CKD3

warfarin or evidence-based doses of direct thrombin or factor Xa inhibitors

Recommendations for anticoagulation therapy in CKD4

warfarin or labeled doses of DOACs

Recommendations for anticoagulation in end stage CKD/dialysis

warfarin or evidence-based dose of apixaban

With valvular heart disease, in what scenario is warfarin recommended over DOACs ?

In rheumatic mitral stenosis or mitral stenosis of moderate or greater severity

How long do you anticoagulate for after successful cardioversion?

at least 4 weeks

True or false: cardiac catheterization is considered a low bleed risk

true