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Volume 41 Issue 12
Dec.  2023
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LIU Yulan, LIU Mei, LU Yi, BI Hui, XU Guili. Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(12): 760-762. doi: 10.12206/j.issn.2097-2024.202204122
Citation: LIU Yulan, LIU Mei, LU Yi, BI Hui, XU Guili. Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(12): 760-762. doi: 10.12206/j.issn.2097-2024.202204122

Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair

doi: 10.12206/j.issn.2097-2024.202204122
  • Received Date: 2022-04-29
  • Rev Recd Date: 2023-04-24
  • Available Online: 2023-12-22
  • Publish Date: 2023-12-25
  •   Objective  To investigate the antithrombotic therapy for acute myocardial infarction patients after PCI stenting combined with tricuspid valve repair.   Methods  The risk of bleeding and embolization was evaluated, relevant data were reviewed, professional knowledges of pharmacy were utilized through the whole treatment process, individualized medication plan for patients was designed and used.   Results  A better therapeutic effect was achieved through the implementation of pharmaceutical care and medication education to the patients.   Conclusion  Clinical pharmacists carry out pharmaceutical care in antithrombotic drugs utilities, which could improve the safety level of drug use and provide basis for clinical rational drug use.
  • [1] 中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 急性ST段抬高型心肌梗死诊断和治疗指南(2019)[J]. 中华心血管病杂志, 2019, 47(10):766-783.
    [2] 国家卫生计生委合理用药专家委员会, 中国药师协会. 冠心病合理用药指南[J]. 中国医学前沿杂志(电子版), 2016, 8(6):19-108.
    [3] GUYATT G H, AKL E A, CROWTHER M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines[J]. Chest, 2012, 141(2 Suppl): 7S-47S.
    [4] 《中国血栓性疾病防治指南》专家委员会. 中国血栓性疾病防治指南[J]. 中华医学杂志, 2018, 98(36):2861-2888.
    [5] VALGIMIGLI M, BUENO H, BYRNE R A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS[J]. Eur J Cardiothorac Surg, 2018, 53(1):34-78. doi:  10.1093/ejcts/ezx334
    [6] Husted S, James S, Becker RC, et al. Ticagrelor versus clopidogrel in elderly patients with acute coronary syndromes:a substudy from the prospective randomized PLATelet inhibition and patient Outcomes (PLATO) trial[J]. Cardiovasc Qual Outcomes, 2012, 5(5):680-688. doi:  10.1161/CIRCOUTCOMES.111.964395
    [7] WALLENTIN L, BECKERR C, BUDAJ A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes[J]. N Engl J Med, 2009, 361(11):1045-1057. doi:  10.1056/NEJMoa0904327
    [8] ZUR B, STOFFEL-WAGNER B. Misleading high-sensitivity troponin algorithm for NSTEMI in the ESC guidelines[J]. Clin Chem Lab Med, 2015, 53(12):e323.
    [9] HEINTJES E M, PENNING-VAN BEEST F J A, JOHANSSON S, et al. Comparison of incidences of cardiovascular events among new users of different statins: a retrospective observational cohort study[J]. Curr Med Res Opin, 2009, 25(11):2621-2629. doi:  10.1185/03007990903269112
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Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair

doi: 10.12206/j.issn.2097-2024.202204122

Abstract:   Objective  To investigate the antithrombotic therapy for acute myocardial infarction patients after PCI stenting combined with tricuspid valve repair.   Methods  The risk of bleeding and embolization was evaluated, relevant data were reviewed, professional knowledges of pharmacy were utilized through the whole treatment process, individualized medication plan for patients was designed and used.   Results  A better therapeutic effect was achieved through the implementation of pharmaceutical care and medication education to the patients.   Conclusion  Clinical pharmacists carry out pharmaceutical care in antithrombotic drugs utilities, which could improve the safety level of drug use and provide basis for clinical rational drug use.

LIU Yulan, LIU Mei, LU Yi, BI Hui, XU Guili. Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(12): 760-762. doi: 10.12206/j.issn.2097-2024.202204122
Citation: LIU Yulan, LIU Mei, LU Yi, BI Hui, XU Guili. Pharmaceutical care in a case of myocardial infarction complicated with antithrombotic therapy after tricuspid valve repair[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(12): 760-762. doi: 10.12206/j.issn.2097-2024.202204122
  • 急性心肌梗死经皮冠状动脉介入治疗(PCI)支架术后基本药物治疗包括抗栓、抗心肌缺血治疗、改善患者预后等,其中PCI术后抗栓方案的选择尤其重要[1-2]。对于心脏瓣膜病,特别是瓣膜修补术后的抗栓方案的选择,各国指南推荐不尽相同,国内该领域尚缺乏充足的临床证据[3-4]。对于急性心梗后PCI支架术后合并三尖瓣修补术(瓣环)抗栓方案的选择更是缺乏临床指南或专家共识以指导医师用药。本文就1例心梗合并器质性心脏病行手术治疗患者的抗栓方案进行用药指导,旨在为该类患者抗栓方案的选择提供合适的用药依据。

    • 患者,女性,72岁,2019年9月13日无明显诱因突发胸痛,遂于次日入院就诊。既往史:有高血压病史1年,无其他慢性病史,无吸烟、饮酒史。急诊心电图示急性前壁心肌梗死,予阿司匹林肠溶片300 mg嚼服+替格瑞洛片180 mg口服,行急诊PCI术。冠脉造影结果:LAD近段于第一间隔支发出前完全闭塞,TIMI血流0级,植入1枚药物支架至LAD近段。术后收治心血管内科进一步诊治。入院诊断:①急性前壁心肌梗死;②室间隔穿孔;③心功能Ⅳ级(Killip分级);④心源性休克;⑤冠心病;⑥高脂血症。

      9月14日考虑患者室间隔穿孔,心梗后机械并发症,立即至导管室行主动脉球囊反搏术+深静脉置管术,后心超检查提示室间隔穿孔(0.75 cm、0.46 cm),左室心尖部附壁血栓形成待排。9月15日患者转入心胸外科监护室。9月17日行室间隔穿孔修补+室壁瘤切除+三尖瓣成形术(爱德华30 mm三尖瓣成形环),术后常规给予阿司匹林联合氯吡格雷抗血小板治疗,依诺肝素钠注射液抗凝治疗,患者恢复良好。9月23日抗栓药物调整为阿司匹林+氯吡格雷+华法林。10月12日患者出现胸闷,伴大汗淋漓,再次收治心胸外科,胸部CT示右侧胸腔积液,行胸腔闭式引流术,常规给予强心、利尿、抗感染、抗栓(阿司匹林肠溶片+氯吡格雷+华法林)等对症支持治疗。10月23日复查CT示积液减少,转老年科继续治疗,抗栓方案为阿司匹林+替格瑞洛片+华法林,另进行调脂稳斑、控制心室率、强心、利尿等治疗。10月25日临床药师查房建议,抗栓药物调整为阿司匹林+氯吡格雷+华法林。11月1日患者无不适主诉,遂带药出院。此后,临床医师和药师电话随访,该患者自诉无不适症状。

    • 该患者首次入院后行PCI术支架植入术,根据《冠心病合理用药指南(第2版)》[2],行PCI的急性冠状动脉综合征患者,应双联抗血小板治疗,疗程12~36个月。2017年ESCDAPT指南[5]推荐,对于行PCI的稳定性冠心病患者,在考虑了缺血风险和出血风险后,可考虑替格瑞洛替代氯吡格雷联合阿司匹林治疗,目前新版指南对于替格瑞洛已为ⅠA类推荐。心血管内科给予阿司匹林联合替格瑞洛抗血小板治疗,同时给予依诺肝素钠抗凝,抗栓方案选择合理。

      9月17日转入心胸外科行室间隔穿孔修补+室壁瘤切除+三尖瓣成形术(爱德华30 mm三尖瓣成形环)。术后给予患者抗栓方案:阿司匹林+氯吡格雷+依诺肝素钠抗栓治疗。临床药师查阅指南文献发现,目前国内外只有二尖瓣以及主动脉瓣修补术后抗栓方案的指南,且抗栓药物的推荐意见有很大差别,未明确三尖瓣修补术后抗栓药物选择方案[4-5]。临床药师结合国内用药情况,针对三尖瓣成形术给予华法林抗凝,但考虑患者72岁高龄,三尖瓣瓣膜修补术内膜化速度慢,因此建议国际标准化比值(INR)控制在1.6~2.0,使用6个月。9月23日,调整抗栓方案为阿司匹林+氯吡格雷+华法林。

      10月23日,患者转老年科继续治疗,医师考虑患者目前PCI术后1月余,且是心脑血管疾病极高危患者,给予阿司匹林及替格瑞洛抗血小板治疗,同时给予华法林抗凝。临床药师查房指出抗栓方案不合理,《冠心病合理用药指南(第2版)》[2]不推荐替格瑞洛或普拉格雷作为抗血小板药物组成三联抗栓治疗,出血风险极大。替格瑞洛是一种新型强效P2Y12受体拮抗剂,Husted等[6]研究表明,替格瑞洛较氯吡格雷进一步改善ACS患者的预后,总出血、大出血、轻微出血事件发生风险相对较高[7-8]。临床医师采纳,及时停用替格瑞洛。10月25日,抗栓方案改为阿司匹林+氯吡格雷+华法林。药师建议INR控制在1.6~2.0,定期复查凝血酶原时间(PT)和INR(表1)。住院期间,患者情况良好,无出血迹象。

      项目10月24日10月29日10月31日
      凝血酶原时间(t/s)16.515.117.5
      国际标准化比值1.471.341.56

      患者出院需制定合理的用药方案,考虑该患者出院后1~3个月患者栓塞风险大,临床药师建议3联抗栓,4~6个月为减低该高龄患者出血风险暂停氯吡格雷,6个月后暂停华法林使用,7~12个月继续双联抗血小板,1年后患者口服阿司匹林进行冠心病二级预防,临床医师采纳。具体方案见表2

      药物 1~3个月 4~6个月 7~12个月 1年后
      阿司匹林肠溶片100 mg,qd
      硫酸氢氯吡格雷片75 mg,qd
      华法林片1.5 mg,qod
    • 首先,氯吡格雷为CYP2C19、CYP3A4、CYP3A5的代谢底物,需要避免与奥美拉唑等CYP2C19酶抑制剂合用,以防疗效降低;他汀类药物经CYP3A4途径代谢与氯吡格雷发生相互作用,患者高血脂,临床药师建议选择相互作用更小的瑞舒伐他汀(CYP3A4弱代谢)[9]。其次,阿司匹林与氯吡格雷合用,可通过多种途径干扰正常凝血过程的发生,出血风险可能增加。60岁及以上老年患者表现出比华法林的抗凝作用更大的INR反应,因此老年人在任何有增加出血风险的情况或身体状况下,使用华法林需要进行更频繁的出血监测。阿司匹林还有可能从血浆结合处置换出华法林,两者合用出血风险增加,不良反应以胃肠道出血最为常见。因此,临床药师告知患者服药期间需要定期复查PT和INR,监测有无出血,包括大小便颜色、皮肤浅表出血点、血肿及其他出血现象,如有异常,及时就诊。另外,劝告患者积极控制好高血压、高血脂等危险因素。患者出院后的1年内,临床药师每3个月随访一次,均未发现任何出血及栓塞风险,依从性良好,按原方案给药。

    • 该患者是1例PCI支架术后合并三尖瓣修补术患者,高龄,既往高血压病史,属于血栓高危人群,针对围手术期抗凝和抗血小板药物的选择十分重要。临床药师关注患者抗栓治疗的全过程用药情况,对于医师的不合理抗栓方案及时干预,结合临床指南与患者病情制定最优抗栓方案,确保患者最低栓塞风险和最小出血风险;对于心脏瓣膜病,特别是瓣膜修补术后的抗栓方案的选择,提供了一定参考。该患者入院后,周转科室多且用药复杂,临床药师从关注药物相互作用、积极进行患者教育等多个方面进行药学监护,保证了患者用药安全、合理、有效,体现了临床药师的价值。

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