1例风湿性二尖瓣置换术后房颤患者的药学监护

Pharmaceutical care on a patient with atrial fibrillation after rheumatic mitral valve replacement

1例78岁女性患者,因"阵发性心悸,喘憋40余年,加重半月余"入院,入院后临床诊断:风湿性心脏病、二尖瓣置换术后;心力衰竭、心功能Ⅳ级;心律失常、心房颤动、室性早搏;高血压3级、很高危。风湿性心脏病史40余年,15年前行二尖瓣置换术,术后规律口服华法林钠片抗凝治疗至今。入院后检查凝血功能,发现国际标准化比值(INR)为6.07,高于正常值(INR 2.0~3.0),凝血时间延长,出血风险增加,故临床药师建议暂时停用华法林钠片。同时分析了患者INR异常的原因,通过重新调整华法林钠片用量、将厄贝沙坦片调整为替米沙坦片的措施,治疗9 d后患者病情好转出院。

One 78-year-old female patient was hospitalized because of paroxysmal palpitations, wheezing for more than 40 years and aggravation for half a month. The clinical diagnosis were rheumatic heart disease, postoperative mitral valve replacement; heart failure, cardiac function grade Ⅳ; arrhythmia, atrial fibrillation, premature ventricular contraction; high blood pressure, level 3, very high risk. The patient had more than 40 years history of rheumatic heart disease. The patient experienced mitral valve replacement 15 years ago and had been regularly taken warfarin sodium tablets up to now. After admission, the result of the coagulation function indicated that the patient was in high risk of bleeding with an international normalized ratio（INR） 6.07, which was much higher than normal INR（2.0 – 3.0）. Therefore, clinical pharmacist suggested stopping warfarin sodium tablets and analyzed the reasons resulted in the high INR. After resetting the dosage of warfarin sodium and changing irbesartan tablets to telmisartan tablets, the patient was improved and discharged 9 days later.