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Cardio IPC Exam 2

Total questions: 117

Worksheet time: 1hrs 7mins

Name
Class
Date
1.

Which of the following is an intrinsic pathway of blood coagulation?

a)

Coagulation pathway upon contact activation or trauma within a vessel

b)

Coagulation pathway upon trauma to vessel surface that activates TF

2.

Which of the following factors are common in both intrinsic and extrinsic pathways?

a)

X

b)

V

c)

II

d)

VIII

e)

VII

3.

Which proteins interact in the Extrinsic pathway?

a)

TF

b)

VII

c)

VIII

d)

IX

4.

Why is Factor V important to thrombin activation

a)

It directly cleaves IIa thrombin to activate fibrinogen

b)

It allows Xa to activate and cleave prothrombin in the presence of Ca2+ into thrombin via y-carboxy glutamate

c)

It allows Y-carboxyglutamate to bind Ca2+ and cleave X into Xa

5.

Order in the correct steps of Hemostasis from Extrinsic pathway: 1) Circulating VIIa binds TF and forms complex. 2) Factor Xa cleaves prothrombin into thrombin. 3) Vessel injury exposes free TF. 4) TF-VIIa complex activates X. 5) Platelet releases active thrombin to cleave fibrinogen into fibrin. 6) Fibrin activates platelets and ties aggregates together

a)

1-2-3-4-5-6

b)

3-1-4-2-5-6

c)

6-2-1-4-3-5

d)

6-5-4-3-2-1

6.

What does Antithrombin do as a natural anticoagulant?

a)

Inhibits Factors, or proteases, from cleaving and activating the rest of the cascade factors

b)

Degrade factor Va and VIIIa to decrease activation of II and X to decrease IIa

c)

Bind Heparin sulfate proteoglycan chains to increase activity of inactivating thrombin and Xa

7.

Heparin has a long monosaccharide chain which can have high MW, a specific pentasaccharide region binds to _______ that inhibits serine proteases by cleaving an ____-_____ peptide to form an inactive covalent complex.

a)

Thrombin; Arg-Ser

b)

Antithrombin; Glu-Asp

c)

Antithrombin; Arg-Ser

d)

Prothrombin; Lys-Cys

8.

True or False: Heparin can bind antithrombin and bring AT and thrombin together but also can conformationally change AT to bind to coagulation factors

a)

True

b)

False

9.

If you have a long heparin pentasaccharide bound to Antithrombin will it inhibit Thrombin, Factor Xa, or both

a)

Thrombin

b)

Factor Xa

c)

Both

10.

True or False: LMWH binds antithrombin and inhibits thrombin

a)

True

b)

False

11.

Unfractionated heparin comes as a long chain from a natural source of what animal?

(a)  

12.

LMWH is prepared by depolymerization of UFH and varies in short to intermediate length but still do not effectively inhibit _________

a)

Thrombin

b)

Prothrombin

c)

Xa

13.

LMWH will (increase/decrease) bioavailability and make for (more/less) predictable variability in patient response

a)

Increase; less

b)

Increase; more

c)

Decrease; less

d)

Decrease; more

14.

Is fondaparinux a specific synthetic UFH or a LMWH

a)

UFH

b)

LMWH

15.

HIT is an immunological reaction to PF4, Heparin, or PF4-Heparin complex that can also cause ______ on top of thrombocytopenia

a)

Coagulation

b)

Anticoagulation

16.

Protamine is the reversal agent that forms ionic bonds with polysacc groups on heparin. Pick the correct order of greatest to least reversal effect on heparin, fondaparinux, and LMWH

a)

Heparin > LMWH > Fondaparinux

b)

Fondaparinux > heparin > LMWH

c)

LMWH > Fondaparinux > heparin

17.

Which heparin anticoagulant product would you most likely use in a patient on dialysis or with severe renal failure?

a)

Heparin

b)

LMWH

c)

Fondaparinux

18.

True or False: Lovenox and generic enoxaparin are approved bioequivalents with the same PK/PD profiles

a)

True

b)

False

19.

Vitamin K helps aid the biosynthesis of Prothrombin by carboxylating Glutamate which goes on to bind Ca2+ to cleave prothrombin into active Thrombin. Vitamin K antagonists do what effect on this?

a)

Blocks the reductases needed to recycle Vit-K epoxide back into useable Vitamin K

b)

Blocks the Vit-K depended carboxylase needed for glutamate to make active prothrombin

c)

Blocks Vitamin K entry into vasculature to stop biosynthesis of Prothrombin

d)

Blocks the oxidases needed to recycle Vit-K epoxide back into useable Vit K

20.

Which of the following are Factors that Warfarin (a VKA) blocks carboxylation of glutamate in?

a)

Xa

b)

X

c)

VII

d)

IX

e)

IIa

21.

Why does warfarin's anticoagulation effect have such a long onset of action?

a)

The warfarin target Factors have extremely long T1/2 and are already gamma-carboxylated, they have to turnover production

b)

Warfarin has poor bioavailability and is slow to produce effect

c)

It does not have as high affinity for targets as heparin does

22.

VKORC1 is the Vit-K epoxide reductase resides in the liver which works to synthesize Warfarin sensitive coagulation Factors. This can create a variable patient response due to pharmacogenomics. What else in the liver causes patient variability with warfarin?

a)

CYP3A4

b)

CYP2C9

c)

CYP2D6

d)

CYP2C19

23.

True or False: The R enantiomer of warfarin is the more potent anticoagulant

a)

True

b)

False

24.

What is the elimination of Warfarin?

a)

Hepatic

b)

Renal

25.

Would a CYP inducer increase or decrease warfarin effects?

a)

Increase

b)

Decrease

26.

What is the primary reversal agent of Warfarin?

a)

Protamine

b)

Vitamin K1

c)

Phytonadione

d)

Praxbind

27.

Bivalirudin/AngioMax is a hirudin like thrombin inhibitor peptide that binds the catalytic site and the anion binding exosite of clot-bound thrombin. What is the MOA of this drug?

a)

Reversibly inhibits thrombin from cleaving fibrinogen to fibrin

b)

Irreversibly inhibits thrombin from cleaving fibrinogen to fibrin

c)

Remains partially bound to thrombin exosite after hydrolysis to continue inhibiting thrombin activity

d)

Is a peptide mimetic of Phe-Pro-Arg sequence in fibrinogen

28.

Argatroban is a peptide mimetic of Phe-Pro-Arg sequence of fibrinogen that thrombin cleaves and inhibits thrombin directly similarly to Bivalirudin, are Argatroban and Bivalirudin orally or intravenously dosed?

a)

Orally

b)

Intravenously

29.

Can you use Argatroban in someone with hepatic failure?

a)

Yes; it is renally cleared

b)

No; it is hepatically cleared

30.

Dabigatran/Pradaxa is an oral direct thrombin inhibitor, what is a major effect of Pradaxa that is not shared with Xarelto or Eliquis DOACs?

a)

It inhibits Thrombin, Eliquis and Xarelto inhibit Xa

b)

It is less safe as it inhibits all Thrombin, not just thrombin bound to antithrombin, and Eliquis/Xarelto only effect cascade

c)

It is safer than Eliquis/Xarelto as it is a pro-drug

d)

It does not have inter-patient variability to response due to esterase cleavage of prodrug and not metabolism

31.

What are unique aspects of Dabigatran's reversal agent Praxbind?

a)

It is an IV monoclonal antibody

b)

It is both a coagulant and anticoagulant depending on use similar to Vit-K and Warfarin

c)

It is only an anticoagulant, unlike Vit-K and warfarin

d)

It is an oral reversal agent that activates Thrombin and has higher affinity

32.

If a drug inhibits PgP will this increase or decrease a DOAC effect of anticoagulation?

a)

Increase

b)

Decrease

33.

Do DOACs that inhibit factor Xa have an effect on platelets?

a)

No; it does not directly inhibit thrombin and will have no platelet effect

b)

Yes; it also inhibits thrombin which has a platelet effect

34.

What is the MOA of the DOAC Factor Xa inhibitor reversal agent Andexanet Alfa?

a)

Acts as a decoy Xa that has high affinity for the DOACs

b)

It occupies Xa binding sites and inhibits DOACs from binding

c)

It is a monoclonal antibody that directly inhibits the DOACs but does not cause coagulation

35.

Which Factor Xa inhibitor DOAC requires doses to be taken with food?

a)

Rivaroxaban

b)

Eliquis

c)

Edoxaban

d)

Dabigatran

36.

What Factors does Warfarin effect in the clotting cascade?

a)

2

b)

7

c)

9

d)

10

e)

3

37.

True or False: Warfarin inhibits Protein C and S which are the natural anticoagulants of the body

a)

True

b)

False

38.

What are some initial dosing considerations when starting warfarin?

a)

Age

b)

Diet

c)

Alcohol

d)

Weight

e)

Financial

39.

What's the standard starting dose of warfarin in a normal patient?

a)

5mg

b)

2.5mg

c)

10mg

d)

20mg

40.

When is the best time to bring a patient in after initiating warfarin to check INR?

a)

2 weeks

b)

2-3 days

c)

10 days

d)

1 month

41.

If a patient's INR goes from 1.8 on day 6 to 2.8 on day 9 is this an ideal change/too fast/too slow

a)

Ideal

b)

Fast

c)

Slow

42.

Which 2 of the following green vegetables has the most Vitamin K content?

a)

Kale

b)

Cucumbers

c)

Iceberg lettuce

d)

Brussel sprouts

43.

A patient comes in and their INR has increased since last time where they were stable. Which factors can increase INR

a)

Alcohol binge

b)

Acute Illness

c)

Increased VitK in diet

d)

Weight gain

44.

A patient comes in with an INR at 3.5 (no bleeding) when their goal range is 2-3. Which of the following would be best for their warfarin dosing?

a)

Decrease the dose 5-15%

b)

Hold 1 dose

c)

Hold 2 doses

d)

Administer Vitamin K

45.

If a patient's INR is at 1.8 and their goal is 2-3 due to them consistently eating more kale salad at lunchtime, what would be an appropriate change?

a)

Increase dose 5-15%

b)

Give 2 doses in one day

c)

Give bridging parenteral therapy Enoxaparin x 5 days

d)

Decrease dose 5-15%

46.

If a patient has an INR of 8.0, would you need to give them vitamin K?

a)

Yes

b)

No

47.

Which of the following are CYP inducers that can decrease INR and increase risk of clotting?

a)

Phenytoin

b)

Rifampin

c)

Bactrim

d)

Amiodarone

48.

Which of the following are CYP inhibitors which increase warfarin levels and increase INR?

a)

Carbamazepine

b)

Dicloxacillin

c)

Metronidazole

d)

Ketoconazole

e)

Penicillin

49.

Which CYP effect has a faster onset effect Inducer or Inhibitor?

a)

Inhibition

b)

Induction

50.

Which thyroid disorder will increase catabolism of clotting factors and increase INR?

a)

Hypothyroidism

b)

Hyperthyroidism

51.

If a person is taking ASA 325mg QD, will this increase their INR or their bleeding risk?

a)

INR

b)

Bleeding Risk

52.

A patient comes in to have their INR checked and it is slightly increased from last time. Which one of these supplements could impact this?

a)

CBD

b)

St. John's Wort

c)

CoQ10

d)

Green Tea leaf

53.

Which lab measurement can aid in diagnosing VTE?

a)

BNP

b)

D-Dimer

c)

Troponin

d)

ACTH

54.

Who has higher risk of recurrent VTE?

a)

Men

b)

Women

55.

When is anticoagulation indicated in AFib according to CHADSVASC score?

a)

>1 Men

b)

>2 Women

c)

>1 Women

d)

>2 Men

56.

True or False: Mechanical valve replacement patients only need 3-6 months of anticoagulation therapy post surgery

a)

True

b)

False

57.

True or False: DOACs are not to be given in mechanical valve replacement patients

a)

True

b)

False

58.

What's the difference in INR goals for Aortic valve replacements with no risk factors and Mitral valve replacements?

a)

Mitral valve 2-3, Aortic 2.5-3.5

b)

Aortic 2-3, Mitral 2.5-3.5

59.

Which DOACs are not metabolized by CYP enzymes?

a)

Dabigatran

b)

Apixaban

c)

Edoxaban

d)

Rivaroxaban

60.

Which DOAC has the best bioavailability?

a)

Dabigatran

b)

Apixaban

c)

Edoxaban

d)

Rivaroxaban

61.

Which 2 DOACs have more renal clearance than the others?

a)

Rivaroxaban

b)

Dabigatran

c)

Edoxaban

d)

Apixaban

62.

True or False: Dabigatran is indicated in both hip and knee replacements and Apixaban is only indicated in hip replacements

a)

True

b)

False

63.

Which DOAC has the most limited use and indications?

a)

Dabigatran

b)

Rivaroxaban

c)

Edoxaban

d)

Apixaban

64.

Which is the only DOAC indicated for PAD/CAD with aspirin?

a)

Dabigatran

b)

Rivaroxaban

c)

Apixaban

d)

Edoxaban

65.

Which 2 DOACs do not require Parenteral LMWH therapy for VTE when starting

a)

Dabigatran

b)

Apixaban

c)

Edoxaban

d)

Rivaroxaban

66.

What's the correct dosing for Apixaban for VTE initiation therapy?

a)

10mg BID x 7 days

b)

5mg QD x 7 days

c)

15mg BID x 21 days

d)

20mg QD x 21 days

67.

What's the correct dosing for Rivaroxaban initiation in VTE?

a)

15mg BID x 7 days

b)

15mg BID x 21 days

c)

20mg BID x 21 days

d)

20mg BID x 7 days

68.

Which DOAC should be completely avoided in severe hepatic impairment?

a)

Rivaroxaban

b)

Apixaban

c)

Dabigatran

d)

Edoxaban

69.

Dabigatran is usually dosed 150mg BID in AFib unless CrCL is _____ then it moves to 75mg BID

a)

<15

b)

15-30

c)

>95

d)

45

70.

Which DOACs have the most avoidance in CrCL <30

a)

Rivaroxaban

b)

Dabigatran

c)

Apixaban

d)

Edoxaban

71.

Which DOACs can be used in obese patients effectively?

a)

Rivaroxaban

b)

Edoxaban

c)

Dabigatran

d)

Apixaban

72.

At what INR can warfarin be stopped and Rivaroxaban started?

a)

3

b)

2.5

c)

2

d)

3.5

73.

When switching from Rivaroxaban or Apixaban TO warfarin, is a parenteral anticoagulant needed?

a)

Yes

b)

No

74.

Which of the following is a decoy Factor Xa for anticoagulant reversal?

a)

Praxxbind

b)

Andexxa

c)

FEIBA

d)

KCENTRA

75.

Which DOAC can take the longest to clear when stopping prior to a major surgery?

a)

Dabigatran

b)

Rivaroxaban

c)

Apixaban

d)

Edoxaban

76.

LMWH is 100% bioavailable when administered SQ, it is cleared (renally/hepatic)

a)

Renal

b)

Hepatic

77.

You are using anticoagulants on a patient with AFib also trying to prevent a stroke from occurring. Would this be prophylactic dosing or therapeutic dosing

a)

Prophylactic

b)

Therapeutic

78.

What are some reasons BID dosing may be better in LMWH for PK parameters

a)

Once daily dosing may have subtherapeutic clearance

b)

BID dosing has higher peak Cmax

c)

BID dosing can reach steady state

d)

QD dosing can reach steady state but not therapeutic levels

79.

You are prescribing a patient LMWH Enoxaparin, they weigh 100kg - what would their BID and QD dosing be?

a)

100mg BID

b)

150mg BID

c)

150mg QD

d)

100mg QD

80.

When would you not use LMWH for anticoagulation?

a)

A patient just received an epidural anesthesia for a procedure

b)

A patient needs therapeutic VTE treatment

c)

A patient who needs to start Warfarin therapy

d)

A patient starting Dabigatran therapy

81.

True or False: Enoxaparin can be used safely in pregnancy as it does not cross the placenta

a)

True

b)

False

82.

What would be appropriate usage of LMWH for a patient with CrCL 30-50ml/min

a)

Rounding down to next lowest dose

b)

Rounding up to next highest dose

c)

Using once daily dosing

d)

Using twice daily dosing

83.

True or False: UFH elimination is cleared renally and shouldn't be used in patients with CKD

a)

True

b)

False

84.

What's the therapeutic goal using UFH?

a)

INR 2-3

b)

INR 2.5-3.5

c)

1.5-2.5x normal control of 30s

d)

10x normal control of 30s

85.

aPTT should be monitored every (a)   hours on UFH therapy in order to adjust

86.

What is standard dosing for bolus UFH in normal patients __ U/kg

a)

16

b)

18

c)

80

d)

60

87.

What is normal IV infusion dosing for UFH in normal patients in __ U/kg/hr?

a)

60

b)

80

c)

18

d)

20

88.

What is prophylactic dosing of Enoxaparin?

a)

30-40mg BID

b)

1mg/kg BID

c)

1.5mg/kg QD

d)

30-40mg QD

89.

What is prophylactic dosing of UFH?

a)

5000U BID

b)

5000U QD

c)

80U/kg

d)

18U/kg/hr

90.

You are giving an inpatient Heparin for diagnosed VTE, suddenly their SBP drops to 82mmhg. What would be the correct treatment to use to stabilize hemodynamics?

a)

tPA Alteplase 100mg

b)

Hold Heparin

c)

Increase Heparin +2U/kg/hr

d)

Start Andexxa anticoagulation reversal

91.

Which of the following would Heparin be better used for?

a)

High Risk PE

b)

Renal Failure

c)

High Bleed Risk

d)

HIT

92.

True or False: DOACs are non-inferior to warfarin in VTE/PE treatment efficacy but were superior in all-cause bleed outcomes

a)

True

b)

False

93.

True or False: Enoxaparin and DOAC first dose have similar onset and PK

a)

True

b)

False

94.

Cancer can increase risk of clots in many patients, DOACs are preferred in VTE of cancer patient except in which type?

a)

GI Cancer

b)

Lung

c)

Osteosarcoma

d)

Leukemia

95.

HIT is more common in UFH use in patients and is an immune-mediated reaction caused by the PF4-Heparin Complex. Which of the following is a diagnostic test that has a good negative predictive value but has higher false positive rates?

a)

ELISA

b)

Optical Density

c)

D-Dimer

d)

Serotonin Release Assay

96.

Which of the following is the gold standard HIT test?

a)

ELISA

b)

Optical Density

c)

Serotonin Release Assay

97.

What should be done for treatment of HIT from UFH?

a)

D/c all heparin product

b)

Give platelet transfusion

c)

Immediately start warfarin while platelets <100K

d)

Start DOAC or Hirudin type anticoagulants

98.

One treatment for anticoagulation while a patient has a HIT reaction is Argatroban. Which of the following is true about argatroban usage?

a)

IV dosing is 2.0mcg/kg/min

b)

aPTT should be monitored every 2 hours

c)

Renal Elimination, do not use in CKD

d)

Hepatic metabolism, safe for use in CKD

e)

INR should be monitored every 2 hours

99.

When Argatroban and warfarin are administered together in patients, what is a therapeutic INR level?

a)

4

b)

2-3

c)

1-2

d)

INR cannot be measured therapeutically with argatroban use

100.

True or False: When using DOACs for HIT patients, the dosing is the same as VTE treatment

a)

True

b)

False

101.

Fondaparinux has off label usage for HIT patients, is it renally eliminated and contraindicated in CKD?

a)

Yes

b)

No

102.

Which of the following anticoagulants requires bridging with parenteral therapy to transition to oral use full time?

a)

Warfarin

b)

Apixaban

c)

Dabigatran

d)

Edoxaban

103.

DOACs like apixaban, edoxaban, and rivaroxaban can be procedurally bridge 24-48 hours prior to surgery, why does Dabigatran have longer bridge time?

a)

It is predominately renally cleared

b)

Must hold 2-3 t1/2 lives

c)

Dabigatran has a t1/2 of 8-12 hrs

d)

Dabigatran can be toxic when used with anesthesia and needs to be entirely cleared

104.

True or False: When transitioning from Enoxaparin to a DOAC like rivaroxaban, you can give the PO dose at the next scheduled dose time (Q12 hours) due to similar PK profiles

a)

True

b)

False

105.

True or False: When transitioning from infusion heparin to DOAC PO, you can do a simultaneous stop of heparin and start of doac

a)

True

b)

False

106.

Match the cell type to its correct life span

a)

RBC: 3months

b)

Platelets: 3 months

c)

Platelets: 7-10 days

d)

WBC: hours to years

107.

What is the hemoglobin concentration cutoff for when RBC transfusion should be initiated?

a)

<7gm/dl

b)

<12gm/dl in women

c)

<13 gm/dl in men

d)

<10gm/dl

108.

True or False: 1U of RBC transfusion will raise hemoglobin by 1gm/dl

a)

True

b)

False

109.

Fresh Frozen plasma is useful in some cases of supertherapeutic warfarin anticoagulation. What will INR never fall below when administering FFP

a)

1.7

b)

2

c)

3

d)

1

110.

True or False: You can use type B+ FFP in patients who have O+ blood

a)

True

b)

False

111.

What is the FFP Units to use for high risk or active bleeding on warfarin?

a)

4-6U

b)

2U

c)

1 U

112.

True or False: Cryoprecipitate (Cryo) contains Vitamin K dependent factors

a)

True

b)

False

113.

True or False: Protamine dosing in heparin reversal is 1mg per 1mg enoxaparin. What should you not exceed in a single dose?

a)

50mg

b)

100mg

c)

500mg

114.

PCC KCentra has a concentrated mixture of coagulation factors, what should be given prior to use?

a)

Vitamin K

b)

FEIBA

c)

FFP

d)

DOACs

115.

True or False: Since Andexxa is very expensive in DOAC reversal, usually KCentra or FEIBA PCC can be given instead

a)

True

b)

False

116.

Which ROA of Vitamin K has the worst absorption

a)

SQ

b)

IV

c)

PO

117.

Which of the following are Antifibrinolytic agents used to prevent degradation of clots by blocking plasmin?

a)

Transexamic Acid

b)

Idarucizumab

c)

Aminocaproic Acid

d)

FEIBA