Clinical Tricks (Pearls) with Anticoagulants

B. The 2nd believed justification: NOT give Ivabradine with A. Fib patients that:

Ivabradine works as sinus rhythm control while A. Fib. pathology initiated mainly from ectopic focci in the atrium.

كأن يعنى الافابرادين بيجى على ال SA node

ويقولها اهدى علينا يا ست الحاجة وهدى الريت شوية

طب ما هو أساسا مريض ال A. Fib.

could be initiated by بؤر كهربية فى حتة تانية

فكأن الدواء شغال فى حتة والمرض سبب ظهوره حاجات تانية

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2- High dose levothyroxine (especially preoperative): could be a reason for postoperative A. Fib. (POAF)

– So if A. Fib induced by thyrotoxicosis: IV beta blocker like IV propranolol or esmolol will be preferred over verapamil/diltiazem.

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3- For patients who develop intraoperative AF, the immediate concern is hemodynamic stability. Anticoagulation is not urgently required and can be considered after surgery depend on CHADS score. يبقي ربما مريض يجيله كام دقيقة كدا بعد العملية ويرد معاك بسرعة

يتعامل نفس معاملة المرض ككل طبقا للاسكور لاحقا

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4- Amiodarone is considered last choice in many situations in acute termination of A. Fib (unless with critical care patients): As Amiodarone can induce/exacerbate A. Fib. by hyperthyroidism (mechanism)

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5- Patients with hypertrophic cardiomyopathy (HOCM) and AF should be anticoagulated, regardless of CHA2DS2-VASc score.

يبقي اى مريض عنده المرض دا ما نحسبش ليه الاسكور أصلا

So, oral anticoagulant recommended to A. Fib regardless CHADS score if the patient has hypertrophic cardiomyopathy or Rheumatic mitral valve. فيه مواقف أخرى ولكن يكفيك بس تعرف الاستثنئاين دول

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6- If patient admitted with ACS (MI) like STEMI: IV beta blocker is not routinely used at the time of loading patient with Aspirin + P2Y12 unless the patient with acute case like A. Fib or Aortic dissection and IV ventricular rate is required.

كنا زمان بنقول MONA + B blocker

لكن حاليا ومستقبلا فى موديول الكارديولوجى هتعرف ان للأسف منى اتغيرت ومابقتش تحب بالعادة البيتابلوكر قبل تركيب الدعامة الا اذا وجد سبب لاستخدامها

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7- General warnings regarding DOACs and special populations ?

* It is recommended to avoid DOACs in pregnancy.

* DOACs are not recommended with breastfeeding.

* Avoid DOACs in patients with moderate to severe hepatic dysfunction (Child-Pugh class B or C)

* Avoid DOACs in patients with antiphospholipid syndrome.

* Use with caution: DOACs with AF and class 3 (severe) obesity (BMI 40 kg/m2 or greater) because of concern for potential underdosing of the anticoagulant

* All DOACs with patients undergoing bariatric surgery have unpredictable pharmacokinetics and should be avoided.