临床药师参与1例长期血液透析合并心房颤动患者经皮冠状动脉介入术后抗栓治疗方案调整的药学实践

Clinical Pharmacists Participated in the Pharmaceutical Practice of Adjusting the Antithrombotic Regimen for A Patient with Atrial Fibrillation and Long-Term Hemodialysis Status After Percutaneous Coronary Intervention

关键词:  临床药师  血液透析  心房颤动  经皮冠状动脉介入治疗  抗栓治疗  药学实践

Key words:  clinical pharmacist  hemodialysis  atrial fibrillation  percutaneous coronary intervention  antithrombotic therapy  pharmaceutical care

摘要:

目的 探讨临床药师在终末期肾病(end-stage kidney disease,ESKD)长期血液透析合并心房颤动患者行经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术后,抗凝与抗血小板药物调整的抗栓治疗思路。方法 临床药师全程参与1例长期血液透析合并房颤患者PCI术后的抗栓治疗管理,基于患者高出血风险(HAS-BLED 4分)和较低抗凝净获益(透析风险评分0分),建议谨慎评估华法林抗凝的必要性；并针对患者氯吡格雷基因型抵抗和PCI术后高缺血风险,协助医师制定个体化的抗栓方案。结果 药师基于透析风险评分和现有证据局限性,考虑患者目前抗凝获益有限,需密切监测华法林出血风险。针对氯吡格雷中间代谢型和PCI术后高缺血风险,药师建议在PCI术后短期内将氯吡格雷剂量增至150 mg·d-1以对抗血小板抵抗,并在PCI术后3个月,根据出血与缺血风险再评估可将剂量降至标准水平。随访期间,患者抗栓治疗方案得到平稳过渡,未发生严重缺血或出血事件。结论 临床药师发挥专业优势,协助医师制定了高危患者的个体化抗栓策略。这对于提升血液透析合并复杂心血管疾病患者的用药安全性和有效性具有重要意义。

Abstract:

OBJECTIVE To explore the adjustment strategies for antithrombotic therapy (Anticoagulation and Antiplatelet Agents) led by clinical pharmacists after percutaneous coronary intervention (PCI) in patients with End-Stage Kidney Disease (ESKD) on long-term hemodialysis and Atrial Fibrillation. METHODS Clinical pharmacists participated in the comprehensive antithrombotic management for a patient with atrial fibrillation and long-term hemodialysis status post PCI. The antithrombotic strategy was analyzed from various aspects, including the assessment of high bleeding risk (HAS-BLED 4 points) and low net benefit from anticoagulation (Dialysis Risk Score 0 point), and the identification of high ischemic risk combined with intermediate metabolizer status. Based on these findings, the pharmacists recommended a cautious evaluation of warfarin necessity and assisted physicians in formulating an individualized antithrombotic regimen. RESULTS Based on the Dialysis Risk Score and the limitations of current evidence, the pharmacist determined the patient""s net anticoagulation benefit to be marginal and advised rigorous monitoring for warfarin-associated bleeding.Addressing the high post PCI ischemic risk and the Clopidogrel intermediate metabolizer phenotype, the pharmacist recommended a strategy of therapeutic dose intensification: increasing the Clopidogrel dose to 150 mg·d-1 temporarily in the immediate post PCI phase to overcome potential platelet resistance. Furthermore, following the principle of balancing ischemic and bleeding risks, a de-escalation of the dose back to the standard level was suggested at the 3-month follow-ups. During the follow-up period, the patient""s antithrombotic regimen achieved a smooth transition, and no major ischemic or hemorrhagic events occurred. CONCLUSION Clinical pharmacists assisted physicians in developing an individualized antithrombotic strategy for this high-risk patient leveraging their professional expertise. This practice is crucial for enhancing medication safety and efficacy in patients with complex cardiovascular disease requiring hemodialysis.