临床药师参与老年非瓣膜性房颤患者规范化抗凝的实践探索

Clinical pharmacists' involvement in standardized anticoagulant therapy practice for elderly patients with non-valvular atrial fibrillation

关键词:  临床药师  老年  非瓣膜性房颤  新型口服抗凝药物

Key words:  clinical pharmacist  elderly  non-valvular atrial fibrillation  non-vitamin K antagonist oral anticoagulants

摘要:

目的? 探索老年非瓣膜性房颤患者在规范抗凝治疗中的实践难点及干预方向,促进该人群抗凝治疗的规范化。方法? 回顾性抽取本院一年内心血管内科年龄≥60岁的心房颤动病例,对纳入病例进行抗凝治疗规范化的综合评价；采用二元logistic回归分析,探所患者出院时未抗凝治疗的障碍因素,并针对这些障碍因素实施干预；采用逆概率加权的COX回归分析不同NOACs剂量对主要结局事件的影响。 结果? 共纳入489名老年非瓣膜性房颤病例,其中规范病例254例,不规范病例235例,不规范原因包括:有抗凝适应症而未抗凝治疗129例,给药剂量偏低62例,超说明书剂量40例,违背禁忌症4例。二元logistic分析发现诊断为阵发性房颤(OR=0.16,95%CI=0.09 ~ 0.27),住院行起搏器植入术(OR=0.15,95%CI=0.06 ~ 0.40),住院行经皮冠状动脉介入治疗(OR=0.37,95%CI=0.15 ~ 0.90),肌酐≥200 μmol?L-1(OR=0.15,95%CI=0.04 ~ 0.60)是患者出院治疗方案中未抗凝治疗的障碍因素；针对不规范病例中降低NOACs剂量的人群与规范NOACs剂量的两组人群随访4.8年,血栓事件(HR=0.92,95%CI=0.55-1.55)和大出血事件(HR=0.85,95%CI=0.41-1.77)无显著差异(P＞0.05)。结论? 临床药师干预后,我院60岁以上非瓣膜性房颤患者抗凝药物使用率显著提升,但NOACs剂量不足的现象仍普遍存在。

Abstract:

ABSTRACT: OBJECTIVE To explore the practical difficulties and intervention directions in standardized anticoagulant therapy for elderly patients with non-valvular atrial fibrillation, and to promote the standardization of anticoagulant therapy in this population. METHODS Cases of atrial fibrillation (age ≥60 years) from the Department of Cardiology over one year were retrospectively extracted. Anticoagulant therapy appropriateness in elderly NVAF patients were assessed; Binary logistic regression analysis was conducted to identify determinants of anticoagulant therapy omission in discharge treatment plans. Interventions were implemented for these obstacles; The effect of different NOAC doses on major outcome events was analyzed using Cox regression with Inverse Probability of Treatment Weighting (IPTW). RESULTS Among 489 elderly patients with NVAF, 254 patients received appropriate oral anticoagulant therapy, while 235 cases were inappropriate: 129 patients were not treated with oral anticoagulant with indications, 62 cases received reduced-dosage, 40 cases were prescribed off-label dosage, and 4 cases had contraindications. Binary logistic regression analysis indicated paroxysmal AF (OR=0.16, 95%CI=0.09–0.27), pacemaker implantation (OR=0.15, 95%CI=0.06–0.40), percutaneous coronary intervention (OR=0.37, 95%CI=0.15–0.90), and serum creatinine ≥200 μmol?L-1 (OR=0.15, 95%CI=0.04–0.60) as factors associated with obstacles of anticoagulant therapy. Among patients with reduced NOACs dosage and those with standard NOACs dosage, a 4.8-year follow-up showed no significant differences in thrombotic events (HR=0.92, 95%CI=0.55–1.55) and major bleeding events (HR=0.85, 95%CI=0.41–1.77) (P>0.05). CONCLUSION After clinical pharmacist intervention, the use of anticoagulants in non-valvular atrial fibrillation patients over 60 years of age in our hospital has significantly increased, but the phenomenon of reduced NOAC dosage is still common.