RxPrep Anticoagulation Part 1 (Background/VTE/AF/Pregnancy)

anticoagulant

prevents blood clots from forming and keeps existing clots from becoming larger

true

True or False: Anticoagulants don't break down clots.

venous thromboembolism

What does VTE stand for?

deep vein thrombosis

What does DVT stand for?

pulmonary embolism

What does PE stand for?

VTE; DVT, PE

Anticoagulants are used in the prevention and treatment of ________, which refers to ________ and/or ________.

acute coronary syndrome

What does ACS stand for?

ACS; cardioembolic stroke

Anticoagulants are used in the immediate treatment of ________ and for the prevention of ________.

bleeding

What is the most common side effect of anticoagulants?

blood stasis,

blood vessel injury,

prothrombotic conditions (coagulopathies)

What are 3 factors that can lead to activation of the coagulation process?

blood stasis

stopping or slowing of blood flow

coagulation

________ involves activation of platelets and the clotting cascade.

embolus

If a clot travels to another location in the body, it's called a(n) ________.

clotting factors

All ________ in the coagulation cascade have an active and inactive form.

fibrin

Once activated, a clotting factor will activate the next clotting factor in the sequence until ________ is formed.

II, VII, IX, X

What clotting factor(s) does warfarin inhibit?

Xa

What clotting factor(s) do rivaroxaban, apixaban, and edoxaban inhibit?

direct

Rivaroxaban, apixaban, and edoxaban are (direct/indirect) inhibitors of factor Xa.

Xa

What clotting factor(s) does fondaparinux inhibit?

indirect

Fondaparinux is a(n) (direct/indirect) inhibitor of factor Xa.

low molecular weight heparin

What does LMWH stand for?

LMWHs

Enoxaparin and dalteparin are examples of ________.

unfractionated heparin

What does UFH stand for?

IIa, Xa

What clotting factor(s) does UFH inhibit?

IIa, Xa

What clotting factor(s) do LMWHs inhibit?

c

Which of the following is true about UFH activity?

a) anti-IIa > anti-Xa

b) anti-IIa < anti-Xa

c) anti-IIa = anti-Xa

b

Which of the following is true about LMWH activity?

a) anti-IIa > anti-Xa

b) anti-IIa < anti-Xa

c) anti-IIa = anti-Xa

direct thrombin inhibitors

Argatroban, bivalirudin, and dabigatran are examples of ________.

c

Which of the following direct thrombin inhibitors is an oral formulation?

a) argatroban

b) bivalirudin

c) dabigatran

thrombin

What enzyme converts fibrinogen to fibrin?

IIa

What clotting factor is thrombin?

II

What clotting factor is prothrombin?

Xa

What clotting factor converts prothrombin to thrombin?

direct-acting oral anticoagulant

What does DOAC stand for?

factor Xa inhibitors, thrombin inhibitors

The oral ________ and ________ are further classified as DOACs.

CHEST

What guideline is used for anticoagulant?

less

DOACs have (less/more) drug-drug interactions than warfarin.

shorter

DOACs have a (longer/shorter) duration of action than warfarin.

indication,

kidney/liver function

What 2 things is DOAC dosing based on?

DOAC

Which is preferred for stroke prevention in AF,

DOAC or warfarin?

mechanical heart valve,

moderate-to-severe mitral stenosis

antiphospholipid syndrome

In what 2 situations would warfarin be preferred over a DOAC for stroke prevention in AF?

DOAC

Which is preferred for VTE treatment, DOAC or warfarin?

antiphospholipid syndrome, mechanical heart valve

In what 2 situations would warfarin be preferred over a DOAC for VTE treatment?

warfarin

What anticoagulant is a vitamin K antagonist?

II, VII, IX, X

Vitamin K is required for the carboxylation (activation) of what clotting factor(s)?

international normalized ratio

What does INR stand for?

INR

Warfarin has a narrow therapeutic range and requires careful monitoring of ________.

dietary vitamin K changes,

drugs

What 2 things can affect the INR?

antithrombin

an endogenous anticoagulant that inactivates thrombin and other proteases involved in blood clotting

fondaparinux, LMWH, UFH

What 3 drugs/classes work by binding to antithrombin and causing a conformational change which increases antithrombin activity 1,000-fold?

intravenous direct thrombin inhibitors

________ are important clinically since they don't cross-react with heparin-induced thrombocytopenia antibodies.

oral anticoagulants

________ are used mainly in AF (for stroke prevention) and for DVT/PE (treatment and prevention).

oral anticoagulants

________ are not indicated for the acute management of an ACS when platelet aggregation is the main target of drug therapy.

fibrinolytics

________ break down existing clots but are associated with a very high risk of bleeding.

fibrinolytics

________ are used to immediately treat an acute ischemic stroke or STEMI when the patient could die without rapid restoration of blood flow.

antiplatelets

________ are used mainly for CAD (including ACS) and to prevent recurrent ischemic stroke/TIA.

antiplatelets

________ are not sufficient for treating DVT/PE.

Joint Commission's National Patient Safety Goals

The ________ require policies and protocols to properly initiate and manage anticoagulant therapy.

dispensing,

administration,

monitoring,

patient/caregiver education,

ordering

Patients receiving anticoagulants should receive individualized care through a defined process that includes what 5 standardized processes?

decrease; hemoglobin

An acute (decrease/increase) in ________ could signify that bleeding is occurring.

epistaxis

bleeding from the nose

pain in affected limb, unilateral lower extremity swelling

What are 2 symptoms of DVT?

ultrasound

What is used to diagnose DVT?

acute medical illness, immobility, medications, obesity, pregnancy/postpartum, recent surgery/major trauma

What are 6 modifiable risk factors for VTE?

erythropoiesis-stimulating agents, estrogen, SERMs

What 3 drugs/classes are risk factors for VTE?

cancer/chemotherapy, HF, increasing age, nephrotic syndrome, previous VTE, respiratory failure, thrombophilia

What are 7 non-modifiable risk factors for VTE?

antiphospholipid syndrome,

antithrombin deficiency,

factor V Leiden,

protein C deficiency,

protein S deficiency

What are 5 examples of thrombophilias?

graduated compression stockings,

intermittent pneumatic compression device

What are 2 non-drug alternatives for VTE prevention?

calf muscle exercises,

frequent ambulation,

graduated compression stockings

What are 3 recommendations for reducing VTE risk in long-distance travelers?

3 months

How long should any VTE that's caused by surgery or a reversible risk factor be treated?

selective estrogen receptor modulator

What does SERM stand for?

estrogen, SERMs

What 2 drugs/classes are contraindicated in patients with history of, or current, VTE?

dabigatran, oral factor Xa inhibitor (DOAC);

warfarin

________ and ________ are preferred over ________ for the first 3 months of treatment for a DVT in the leg or a PE in patients without cancer.

oral factor Xa inhibitors (DOAC);

LMWH, other oral anticoagulants

________ are preferred over ________ and other ________ for the first 3 months of treatment for a DVT in the leg or a PE in patients with cancer.

cardioembolic stroke

Patients with AF or atrial flutter can form clots in the heart that can travel to the brain and cause a(n) ________.

3 weeks; 4 weeks after

For patients with AF >48 hours or unknown duration, anticoagulation is recommended for at least ________ prior to and ________ after cardioversion.

4 weeks

For patients with AF ≤48 hours undergoing elective cardioversion, start full therapeutic anticoagulation at presentation, perform cardioversion, and continue full anticoagulation for at least ________ while patient is in normal sinus rhythm.

stroke risk

For patients who remain in AF, the need for chronic anticoagulation therapy is based on ________.

mechanical heart valves; warfarin

Patients with AF and ________ have the highest risk for clotting/strokes and are treated with ________ only.

direct thrombin inhibitors,

factor Xa inhibitors (DOAC)

What 2 anticoagulant classes are not approved for patients with AF and mechanical heart valves?

CHA2DS2-VASc

What scoring system is used to estimate stroke risk and guide therapy for anticoagulant use in AF?

CHF

What does the "C" in CHA2DS2-VASc stand for?

HTN

What does the "H" in CHA2DS2-VASc stand for?

age ≥75 YO; 2 points

What does the "A2" in CHA2DS2-VASc stand for?

diabetes

What does the "D" in CHA2DS2-VASc stand for?

prior stroke/TIA; 2 points

What does the "S2" in CHA2DS2-VASc stand for?

vascular disease (prior MI, PAD, aortic plaque)

What does the "V" in CHA2DS2-VASc stand for?

age 65-74

What does the "A" in CHA2DS2-VASc stand for?

sex category - female

What does the "Sc" in CHA2DS2-VASc stand for?

1

All the components of the CHA2DS2-VASc scoring system, except for "A2" and "S2" account for ________ point(s) per risk factor.

0

What CHA2DS2-VASc score in males is considered low risk of stroke?

1

What CHA2DS2-VASc score in females is considered low risk of stroke?

no anticoagulation recommended

What is the recommended course of action for a CHA2DS2-VASc score that's considered low risk?

≥1

What CHA2DS2-VASc score in males is considered moderate risk of stroke?

≥2

What CHA2DS2-VASc score in females is considered moderate risk of stroke?

≥2

What CHA2DS2-VASc score in males is considered high risk of stroke?

≥3

What CHA2DS2-VASc score in females is considered high risk of stroke?

oral anticoagulation w/ DOAC recommended

What is the recommended course of action for a CHA2DS2-VASc score that's considered high risk?

apixaban, dabigatran, edoxaban, rivaroxaban

What are 4 DOACs recommended for a high risk CHA2DS2-VASc score?

HAS-BLED

What scoring system is used to estimate bleeding risk and guide therapy for anticoagulant use in AF?