ANTICOAGULATION NEWLY UPDATED COLLECTION OF EXAM QUESTIONS
AND VERIFIED ANSWERS DESIGNED TO GUARANTEE YOUR SUCCESS ON
THE LATEST TEST VERSION
Name the components of the CHADSVASC score, what score each component
means and what the final score means - ANSWER CHF (HFrEF)= 1
HTN =1
Age 75 or greater= 2
DM= 1
Stroke/TIA=2
Vascular disease (prior MI, PAD, aortic plaque)=1
Age 65-74=1
Sex category Female=1
Do not add the 2 ages together
As an example a 80 y/o M w/ no PMH has a CHADSVASC of 2
To prevent risk of stroke in patients with Afib and CHADSVASC score of:
0 in men, 1 in women- reasonable to omit anticoagulation, consider ASA
1 in men, 2 in women- consider no anti-coagulation, oral anticoagulation, or
ASA
2 in men, 3 in women- oral anticoagulation is indicated
Which of the guideline recommendations for patients with HF are true?
1. Recommend using anti-platelet therapy (monotherapy, or ASA w/
clopidogrel) for stroke prevention alone, regardless of stroke risk
2. Recommend the use of HAS-BLED score. Those at high risk of bleeding
(HAS-BLED 3 or more) warrant more frequent and regular reviews and follow
up
3. For patients eligible for oral anticoagulation, recommend VKAs over DOACs
- ANSWER 2 is true
Recommend the use of HAS-BLED score. Those at high risk of bleeding (HAS-
BLED 3 or more) warrant more frequent and regular reviews and follow up
1. Do not recommend antiplatelet therapy alone- stroke risk should be
calculated and anticoagulation should be considered
,3. DOACs>VKAs (except in mechanical valves)
For patients with AFib >48 h (or unknown duration) who are undergoing
elective cardioversion, how long should they receive warfarin or DOACs before
the procedure? How long should they receive anticoagulation after the
procedure? - ANSWER VKA (INR 2.0-3.0) or DOAC for at least 3 weeks
before elective cardioversion. May consider an abbreviated course if TEE
approach
VKA or DOAC for at least 4 weeks after, regardless of stroke risk
Name the components of the HASBLED score, what score each component
means and what the final score means - ANSWER HTN (SBP >160)- 1
Abnormal renal (1 pt)/liver function (1 pt)- 1 if 1, 2 if 2
Stroke- 1
Bleed hx or predisposition to bleed (anemia)- 1
Labile INRs- 1
Old- >65
Drugs/Alcohol (drugs include antiplatelets and NSAIDs (1 pt), alcohol is 8 or
more drinks a week (1 pt)- 1 if 1, 2 if 2
9 pt score to assess the risk of bleed with warfarin in Afib pts (inconsistent with
DOACs)
Should not be used to determine who does not receive therapy, but more to
balance the risk of stroke with the risk of bleeding
Score of >4 means greater than 8% risk of major bleed/yr
Warfarin MOA - ANSWER vitamin K antagonist- inhibits vitamin K recycling
by inhibiting vitamin K epoxide reductase conversion and preventing gamma
carboxylation of clotting factors II, VII, IX, and X, leaving these factors unable
to bind to phosholipid membranes and therefore unable to take part in
coagulation
- also inhibits carboxylation/activation of natural anticoagulants proteins c and s
1/2 lives of the clotting factors affected by warfarin - ANSWER II- 72 h
VII- 6 h
IX-24 h
X- 36 h
Dabigatran stability - ANSWER once the bottle is opened, medication should be
used within 4 months, capsules cannot be places in a pillbox
,Converting from dabigatran to warfarin - ANSWER CrCl >50- start warfarin 3
days before d/c dabigatran
CrCl 31-50- start warfarin 2 days before d/c
CrCl 15-30- start warfarin 1 day before d/c
CrCl <15- no recs
Dabigatran can falsely elevate INR
Converting from IV anticoagulants to dabigatran - ANSWER Start dabigatran
0-2 h before next dose of IV drug was to be administered or when the IV gtt is
d/c'd
Converting from dabigatran to IV anticoagulants - ANSWER Wait 12 h (CrCl
>30) or 24 h (CrCl <30) after last dose before beginning IV anticoagulation
Converting from warfarin to dabigatran - ANSWER Start dabigatran and d/c
warfarin when INR <2.0
Rivaroxaban drug interactions - ANSWER CYP3A4 and Pgp inhibitors
amiodarone
verapamil
diltiazem
erythromycin
cimetidine
Converting rivaroxaban to warfarin - ANSWER DC rivaroxaban and begin IV
anticoagulant and warfarin when next dose of rivaroxaban would have been
due. DC IV anticoagulant when INR is in acceptable range
Converting from rivaroxaban to another DOAC or IV anticoagulant - ANSWER
DC rivaroxaban and start anticoagulant (not warfarin) when next dose of
rivaroxaban would have been due
Converting from warfarin to rivaroxaban - ANSWER DC warfarin and initiate
rivaroxaban when INR <3.0
Converting from another DOAC or IV anticoagulation to rivaroxaban -
ANSWER Begin rivaroxaban 0-2 h before the next administration of the drug
and dc the other anticoagulant. For continuous infusions, stop the heparin drip
and start rivaroxaban at the same time
Converting from warfarin to apixaban - ANSWER DC warfarin and start
apixaban when INR is <2.0
, Converting from edoxaban to warfarin - ANSWER if pt taking 60 mg
edoxaban, reduce the dose to 30 mg and begin warfarin concomitantly
if pt taking 30 mg edoxaban, reduce the dose to 15 mg and begin warfarin
concomitantly
INR measurements should be taken before edoxaban dose to minimize it's
effects on the INR
Once INR >2.0, d/c edoxaban
Other option: D/C edoxaban and start an IV anticoagulant and warfarin at the
time of the next edoxaban dose. Once INR >2.0, IV anticoagulant can be d/c'd
Converting from edoxaban to another DOAC or IV anticoagulant - ANSWER
D/C edoxaban and begin the new rapid onset anticoagulant at the same time as
the next dose of edoxaban would have been
Converting from warfarin to edoxaban - ANSWER DC warfarin, start edoxaban
when INR <2.5
MOA of dabigatran - ANSWER direct thrombin inhibitor (factor IIa)
MOA of rivaroxaban - ANSWER direct factor Xa inhibitor
Dosing of dabigatran in AFib
When to avoid use - ANSWER 150 mg BID
CrCl 15-30--75 mg BID
CrCl 30-50 and taking ketoconazole or dronedarone- 75 mg BID
Avoid use:
-CrCl <15 or HD
Taking with rifampin
CrCl 15-30 and taking with amiodarone, verapamil, ketoconazole, dronedarone,
diltiazem, clarithromycin
Dosing of rivaroxaban for AFib
When to avoid use - ANSWER 20 mg daily with meals
CrCl <50 or HD- 15 mg daily with meals
Avoid use:
Strong CYP3A4 or Pgp inducers- rifampin, phenytoin, carbamazepine, St.
John's Wort
Strong CYP3A4 or Pgp inhibitors- protease inhibitors, intraconazole,
ketoconazole, conivaptan
apixaban dosing for Afib
AND VERIFIED ANSWERS DESIGNED TO GUARANTEE YOUR SUCCESS ON
THE LATEST TEST VERSION
Name the components of the CHADSVASC score, what score each component
means and what the final score means - ANSWER CHF (HFrEF)= 1
HTN =1
Age 75 or greater= 2
DM= 1
Stroke/TIA=2
Vascular disease (prior MI, PAD, aortic plaque)=1
Age 65-74=1
Sex category Female=1
Do not add the 2 ages together
As an example a 80 y/o M w/ no PMH has a CHADSVASC of 2
To prevent risk of stroke in patients with Afib and CHADSVASC score of:
0 in men, 1 in women- reasonable to omit anticoagulation, consider ASA
1 in men, 2 in women- consider no anti-coagulation, oral anticoagulation, or
ASA
2 in men, 3 in women- oral anticoagulation is indicated
Which of the guideline recommendations for patients with HF are true?
1. Recommend using anti-platelet therapy (monotherapy, or ASA w/
clopidogrel) for stroke prevention alone, regardless of stroke risk
2. Recommend the use of HAS-BLED score. Those at high risk of bleeding
(HAS-BLED 3 or more) warrant more frequent and regular reviews and follow
up
3. For patients eligible for oral anticoagulation, recommend VKAs over DOACs
- ANSWER 2 is true
Recommend the use of HAS-BLED score. Those at high risk of bleeding (HAS-
BLED 3 or more) warrant more frequent and regular reviews and follow up
1. Do not recommend antiplatelet therapy alone- stroke risk should be
calculated and anticoagulation should be considered
,3. DOACs>VKAs (except in mechanical valves)
For patients with AFib >48 h (or unknown duration) who are undergoing
elective cardioversion, how long should they receive warfarin or DOACs before
the procedure? How long should they receive anticoagulation after the
procedure? - ANSWER VKA (INR 2.0-3.0) or DOAC for at least 3 weeks
before elective cardioversion. May consider an abbreviated course if TEE
approach
VKA or DOAC for at least 4 weeks after, regardless of stroke risk
Name the components of the HASBLED score, what score each component
means and what the final score means - ANSWER HTN (SBP >160)- 1
Abnormal renal (1 pt)/liver function (1 pt)- 1 if 1, 2 if 2
Stroke- 1
Bleed hx or predisposition to bleed (anemia)- 1
Labile INRs- 1
Old- >65
Drugs/Alcohol (drugs include antiplatelets and NSAIDs (1 pt), alcohol is 8 or
more drinks a week (1 pt)- 1 if 1, 2 if 2
9 pt score to assess the risk of bleed with warfarin in Afib pts (inconsistent with
DOACs)
Should not be used to determine who does not receive therapy, but more to
balance the risk of stroke with the risk of bleeding
Score of >4 means greater than 8% risk of major bleed/yr
Warfarin MOA - ANSWER vitamin K antagonist- inhibits vitamin K recycling
by inhibiting vitamin K epoxide reductase conversion and preventing gamma
carboxylation of clotting factors II, VII, IX, and X, leaving these factors unable
to bind to phosholipid membranes and therefore unable to take part in
coagulation
- also inhibits carboxylation/activation of natural anticoagulants proteins c and s
1/2 lives of the clotting factors affected by warfarin - ANSWER II- 72 h
VII- 6 h
IX-24 h
X- 36 h
Dabigatran stability - ANSWER once the bottle is opened, medication should be
used within 4 months, capsules cannot be places in a pillbox
,Converting from dabigatran to warfarin - ANSWER CrCl >50- start warfarin 3
days before d/c dabigatran
CrCl 31-50- start warfarin 2 days before d/c
CrCl 15-30- start warfarin 1 day before d/c
CrCl <15- no recs
Dabigatran can falsely elevate INR
Converting from IV anticoagulants to dabigatran - ANSWER Start dabigatran
0-2 h before next dose of IV drug was to be administered or when the IV gtt is
d/c'd
Converting from dabigatran to IV anticoagulants - ANSWER Wait 12 h (CrCl
>30) or 24 h (CrCl <30) after last dose before beginning IV anticoagulation
Converting from warfarin to dabigatran - ANSWER Start dabigatran and d/c
warfarin when INR <2.0
Rivaroxaban drug interactions - ANSWER CYP3A4 and Pgp inhibitors
amiodarone
verapamil
diltiazem
erythromycin
cimetidine
Converting rivaroxaban to warfarin - ANSWER DC rivaroxaban and begin IV
anticoagulant and warfarin when next dose of rivaroxaban would have been
due. DC IV anticoagulant when INR is in acceptable range
Converting from rivaroxaban to another DOAC or IV anticoagulant - ANSWER
DC rivaroxaban and start anticoagulant (not warfarin) when next dose of
rivaroxaban would have been due
Converting from warfarin to rivaroxaban - ANSWER DC warfarin and initiate
rivaroxaban when INR <3.0
Converting from another DOAC or IV anticoagulation to rivaroxaban -
ANSWER Begin rivaroxaban 0-2 h before the next administration of the drug
and dc the other anticoagulant. For continuous infusions, stop the heparin drip
and start rivaroxaban at the same time
Converting from warfarin to apixaban - ANSWER DC warfarin and start
apixaban when INR is <2.0
, Converting from edoxaban to warfarin - ANSWER if pt taking 60 mg
edoxaban, reduce the dose to 30 mg and begin warfarin concomitantly
if pt taking 30 mg edoxaban, reduce the dose to 15 mg and begin warfarin
concomitantly
INR measurements should be taken before edoxaban dose to minimize it's
effects on the INR
Once INR >2.0, d/c edoxaban
Other option: D/C edoxaban and start an IV anticoagulant and warfarin at the
time of the next edoxaban dose. Once INR >2.0, IV anticoagulant can be d/c'd
Converting from edoxaban to another DOAC or IV anticoagulant - ANSWER
D/C edoxaban and begin the new rapid onset anticoagulant at the same time as
the next dose of edoxaban would have been
Converting from warfarin to edoxaban - ANSWER DC warfarin, start edoxaban
when INR <2.5
MOA of dabigatran - ANSWER direct thrombin inhibitor (factor IIa)
MOA of rivaroxaban - ANSWER direct factor Xa inhibitor
Dosing of dabigatran in AFib
When to avoid use - ANSWER 150 mg BID
CrCl 15-30--75 mg BID
CrCl 30-50 and taking ketoconazole or dronedarone- 75 mg BID
Avoid use:
-CrCl <15 or HD
Taking with rifampin
CrCl 15-30 and taking with amiodarone, verapamil, ketoconazole, dronedarone,
diltiazem, clarithromycin
Dosing of rivaroxaban for AFib
When to avoid use - ANSWER 20 mg daily with meals
CrCl <50 or HD- 15 mg daily with meals
Avoid use:
Strong CYP3A4 or Pgp inducers- rifampin, phenytoin, carbamazepine, St.
John's Wort
Strong CYP3A4 or Pgp inhibitors- protease inhibitors, intraconazole,
ketoconazole, conivaptan
apixaban dosing for Afib
