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pharm
antiplatelets and anticoagulants
| Question | Answer |
|---|---|
| thrombus formation | clot formation |
| thrombin | the link between tissue injury, coagulation, and platelet response critical mediator in coagulation elicits multiple responses in platelets and other cells |
| thrombin aka | factor 2 activated others |
| platelet aggregation | clots clumped together |
| fibrin | the backbone of a clot |
| plug | helps to stop bleeding |
| resting platelet | adheres to site of tissue damage |
| coagulation cascade | activation of proteins in the liver, produces things that help us clot |
| thrombus | immobile clot |
| embolus | drifting blood clot |
| embolism | blockage due to embolus |
| thrombosis can occur... | in any artery, vein, heart chamber, heart valve |
| thrombosis leads to... | DVT, PE, MI, cerebrovascular accident (CVA) |
| oral antiplatelets | aspirin , ASA(blood thinner) P2Y12 inhibitor phosphodiesterase type-3 (PDE-3) inhibitors |
| oral antiplatelets: P2Y12 inhibitor | clopidogrel prasugrel ticagrelor |
| oral antiplatelets: phosphodiesterase type-3 (PDE-3) inhibitors | cilostazol dipyridamole (may be used in combo with low dose ASA) |
| parenteral antiplatelets | IV P2Y12 inhibitor Glycoprotein IIb/IIIa inhibitors |
| parenteral antiplatelets: IV P2Y12 inhibitors | cangrelor |
| Glycoprotein IIb/IIIa inhibitors | eptifibatide tirofiban |
| indication for antiplatelets | ASCVD (secondary and primary prevention) acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) acute ischemic stroke |
| aspirin mechanism | inhibits COX-1 enzyme leading to less thromboxane A2 (TXA2)-mediated platelet activation |
| aspirin indications to treat | CAD PAD ACS percutaneous coronary intervention (PCI) acute ischemic stroke |
| aspirin adverse effects | bleeding rash GI effects |
| P2Y12 inhibitors mechanism | inhibits ADP from binding to P2Y12 receptor leading to anti-platelet effect |
| P2Y12 inhibitors indications for treatment | cardiovascular (ACS, PCI), neurovascular (acute ischemic stroke), and peripheral vascular used in addition to ASA as "duel therapy" |
| P2Y12 inhibitors adverse effects | -bleeding (prasugrel and ticagrelor are more potent than clopidogrel)... inc risk of bad outcomes -dyspnea, bradycardia (ticagrelor) |
| oral anticoagulants | warfarin direct thrombin inhibitors: dabigatran selective factor Xa inhibitors |
| selective factor Xa inhibitors | rivaroxaban apixaban edoxaban |
| direct oral anticoagulants (DOACs) | direct thrombin inhibitors selective factor Xa inhibitors -they don't require a cofactor to bind first |
| parenteral anticoagulants | heparin selective factor Xa inhibitors (injectables) direct thrombin inhibitors |
| parenteral anticoagulants heparin | unfractionated heparin (UFH) low-molecular weight heparins (LMWHs): -enoxaparin -dalteparin |
| parenteral anticoagulants selective factor Xa inhibitors (injectables) examples | fondaparinux |
| parenteral anticoagulants direct thrombin inhibitors | argatroban bivaliruden used often if cannot take heparin (allergy) |
| indication for anticoagulation prevention and treatment of thromboembolism | venous thrombolism (VTE) ->DVT or PE pulmonary embolism ACS severe LV systolic dysfunction heart valve replacement atrial arrhythmia (Afib, atrial flutter) thrombophilia ("hyper-coagulable state") malignancy |
| indication for anticoagulation heart valve replacement | mechanical valve? = metal foreign body triggers clotting cascade |
| indication for anticoagulation thrombophilia | predisposed, genetic (ex factor X) |
| indication for anticoagulation malignancy | cancer will cause clotting |
| warfarin mechanism | vitamin K antagonist (VKA) inhibits VKORC1 (protein in liver) which is responsible for activation of vitamin K-dependent clotting factors (III, VII, IX, X) and protein C and S |
| warfarin adverse effects/ monitoring | bleeding (PT/INR) skin necrosis (many small clots) purple toe syndrome |
| PT lab | prothrombin time |
| INR lab | international normalized ratio norm = 1 second want to prolong INR to 2-3 seconds |
| warfarin drug-drug interactions | Abx, NSAIDs (inc bleeding), vitamin K (the antidote of warfarin, makes it less effective), steroids, alcohol, Vit E, anticonvulsants, immunosuppressants, proton pump inhibitors, statins |
| warfarin monitoring- indications | DVT, PE, prevention of systemic embolism 2-3 |
| mechanical prosthetic valves (mitral ) | 2.5-3.5 INR lest side between L atrium and L ventricle |
| mechanical prosthetic valves (atrial ) | 2-3 |
| warfarin patient counseling | adverse effects - bleeding/bruising s/s of clotting - weekness one side, FAST INR monitoring diet: consistent intake of vitamin K (moderation) common drug interactions tablet ID |
| warfarin nursing implications | slow onset of effect (4-5 days until goal INR) may require parenteral anticoag. for "bridging" monitor INR for >2 days, then 2-3 times/week, then less most common med associated with bleeding often help for procedures or line placements |
| warfarin general administration time | administer in the evening |
| warfarin reversal | discontinued/ hold warfarin vitamin K (phytonadione) fresh frozen plasma (FFP) prothrombin complex concentrates PCC -3 factor or 4 factor (tries to give back factors III, VII, IX, X) recombinate factor VIIa, very rapid reversal |
| direct oral anticoagulants (DOACs) | direct thrombin inhibitors -dabigatran selective factor Xa inhibitors -rivaroxaban -apixaban -edoxaban |
| DOACs vs warfarin | DOACs are prefered to warfarin for most pts because their superior safety profile and at lease equivalent efficacy DOACs shouldnt be used for certain pts DOACs dont require Lab monitoring DOACs are expensive |
| pts that should not get DOACs | mechanical heart valve, severe mitral stenosis, advanced kidney disease, hyper-coagulant states |
| unfractionated heparin (UFH) | derived from pig intestines |
| heparin nursing implications | prophylaxis (low dose SQ injection ) Tx: IV bolus and continuous IV infusion, starting dose is indication-based, titrated to aPTT or anti-factor Xa concentrations. short half life, reversible (protamine) monitor for bleeding and thrombocytopenia |
| Heparin induced Thrombocytopenia (HIT) | type 1 and type 2 1: meh, dont really talk about 2: most consequential |
| type 2 HIT | immune mediated, 50,000 platelet count (decrease), delayed onset (day 5); rapid if recent exposure, incidence 1-3%, thromboembolic sequelae 30-50% (clot may develop), Tx: D/C heparin by all routes and select non-heparin anticoagulant and document |
| low molecular weight heparins (LMWH) | length of molecule is shorter |
| LMWH nursing implications | heparin derived (heparin allergy) injectable (SQ), once or twice daily not monitored not fully reversible caution w procedures (long half life) cleared by kidneys; adjust dose or avoid if renal failure bleeding |
| LMWH used for what | VTE prophylaxis or tx (weight based) |
| fondaparinux | synthetic analog of the pentasaccharide binding sequence of heparin selective factor Xa inhibition |
| fondaparinux nursing implication | non-heparin anticoagulant injectable (SQ), given once daily non monitored long half life and not reversible caution with procedures (long half life) cleared by kidneys; adjust dose or avoid if renal failure bleeding |
| fondaparinux used for | VTE prophylaxis or tx |
| direct thrombin inhibitors- nursing implications | non-heparin anticoagulant used for pt w documented or suspected HIT use institutional nomograms, titrated to goal aPTT |
| Argatroban DTI: | metabolized by enzymes in the blood and causes a falsey high INR |
| bivalirudin DTI: | metabolized by enzymes in the blood and partial clearance through kidneys |
| fibrinolytics | recombinate tPA, alteplase (tPA: tissue plasminogen activator) rPA, reteplase TNK-tPA, tenecteplase |
| fibrinolytics indications | ST-segment elevation myocardial infarction (MI) acute ischemic stroke pulmonary embolism peripheral arterial occlusion clotted catheter |
| fibrinolytics indications: ST-segment elevation myocardial infarction (MI) | delay in door-to-balloon time (PCI) |
| fibrinolytics indications: acute ischemic stroke | symptoms onset <3 hours (or <4.5 hours) |
| fibrinolytics indications: pulmonary embolism | hemodynamically unstable |
Created by:
ago24