临床药师参与1例亚急性心肌梗死合并腔隙性脑梗及深静脉血栓患者的抗栓治疗体会

Clinical pharmacists participating in antithrombotic treatment in subacute myocardial infarction patient with cerebral lacuna infarction and deep vein thrombosis

目的探讨亚急性心梗合并腔梗及深静脉血栓患者的抗栓策略,协助临床制订个体化的用药方案。方法临床药师通过分析血栓形成的原因,评估缺血及出血风险,查找循证医学证据,提出合理建议,并观察药物疗效、监护用药安全。结果患者存在多个血栓危险因素,同时属于出血很高危人群。药师建议阿司匹林剂量减少为75mg,qd,加用质子泵抑制剂,同时联合低分子肝素抗凝。药师建议被部分采纳。患者病情好转后出院,且住院期间未出现出血及血栓症状。结论临床药师在协助医生积极抗栓的同时,最大程度地保证了用药安全。

Objective To discuss antithrombotic drug treatment in subacute myocardial infarction patient with cerebral lacuna infarction and deep vein thrombosis. Methods Clinical pharmacists analyzed the causes of the blood clot formation,assessed ischemia and hemorrhage risk, consulted evidence-based medicine information, put forward reasonable suggestions and monitored the medication efficacy and safety. Results There were a lot of risk factors of thrombosis in this patient who was also at high risk of bleeding. Clinical pharmacists recommended to reduce aspirin dose to 75 mg daily and add proton pump inhibitors. Anticoagulant therapy should also include low molecular heparin. Some suggestions were accepted by doctors. The patient＇s condition was improved and there was no bleeding during hospitalization. Conclusion Clinical pharmacists assisted doctors in the antithrombotic treatment and maximized medication safety.