网络用药指导对心脏瓣膜置换术后患者华法林抗凝管理效果的影响

Effect of network medication guidance on anticoagulation management of warfarin in patients after cardiac valve replacement

目的探讨网络用药指导对华法林抗凝管理效果的影响。方法研究设计为回顾性队列研究,研究对象选自2018年1月至2019年4月在中南大学湘雅医院心脏大血管外科行心脏瓣膜置换术且术后口服华法林≥3个月的患者。根据国际标准化比值(INR)复查情况将患者分为术后1个月网络组(术后1个月内网络上传INR复查结果≥2次)、术后1个月对照组(术后1个月在湘雅医院复查INR且有INR数据记录)、术后3个月网络组(术后3个月内网络上传INR复查结果≥4次)和术后3个月对照组(术后3个月在湘雅医院复查INR且有INR数据记录)等4组。比较网络组和对照组患者性别、年龄分布以及术后1或3个月INR及INR达标率。结果设定时段内在湘雅医院行心脏瓣膜置换术的患者共420例,术后均口服华法林抗凝。420例患者中,术后1个月有网络或湘雅医院复诊记录者266例(63.3%),纳入术后1个月网络组者71例、术后1个月对照组者178例;术后3个月有网络或湘雅医院复诊记录者132例(31.4%),纳入术后3个月网络组者46例、术后3个月对照组者77例。术后1个月网络组患者年龄小于、INR达标率高于而抗凝不足发生率低于术后1个月对照组,差异均有统计学意义[(49±10)岁比(53±11)岁,P=0.009;64.8%(46/71)比45.5%(81/178),P=0.006;21.1%(15/71)比46.6%(83/178),P<0.001];术后3个月网络组INR和INR达标率明显高于而抗凝不足发生率明显低于术后3个月对照组,差异均有统计学意义[(2.05±0.45)比(1.84±0.62),P=0.044;67.4%(31/46)比30.9%(30/97),P=0.002;30.4%(14/46)比54.5%(42/77),P=0.009]。结论网络用药指导有助于改善心脏瓣膜置换术后患者华法林抗凝管理效果,提高患者INR达标率。抗凝不达标主要表现为抗凝不足,应予重视。

Objective To explore the effect of network medication guidance on anticoagulation management of warfarin.Methods The study was designed as the retrospective cohort study.Study subjects were selected from patients who underwent cardiac valve replacement during January 2018 and April 2019 in the Department of Cardiovascular Surgery of Xiangya Hospital,Central South University,and took oral warfarin for 3 months or more after operation.According to the mode of revisit,the patients were divided into 4 groups:1-month post-operation network group(INR review results were uploaded online for more than 2 times within 1 month after operation),1-month post-operation control group(INR was reviewed in Xiangya Hospital 1 month after the operation and INR data was recorded),3-month post-operation network group(INR review results were uploaded online for more than 4 times within 3 months after operation),and 3-month post-operation control group(INR was reviewed in Xiangya Hospital 3 months after the operation and INR data was recorded).The gender and age distribution of patients in the network group and the control group,as well as INR and INR compliance rate at 1 or 3 months after operation were compared.Results A total of 420 patients underwent cardiac valve replacement in Xiangya Hospital during the study period,and all of them were prescribed warfarin for anticoagulation.Among the 420 patients,266 patients(63.3%)had network or Xiangya Hospital revisit records 1 month after operation,71 of which were included in the 1-month post-operation network group and 178 of which in the 1-month post-operation control group;132(31.4%)patients had network or Xiangya Hospital revisit records 3 month after operation,46 of which were included in the 3-month post-operation network group and 77 of which in the 3-month post-operation control group.Patients in the 1-month post-operation network group had lower age,higher INR compliance rate,and lower incidence of insufficient anticoagulation than those in the 1-month post-operation control group,and the differences were all statistically significant[(49±10)years vs.(53±11)years,P=0.009;64.8%(46/71)vs.45.5%(81/178),P=0.006;21.1%(15/71)vs.46.6%(83/178),P<0.001].Patients in the 3-month post-operation network group had higher INR,higher INR compliance rate,and lower incidence of insufficient anticoagulation than those in the 3-month post-operation control group,and the differences were all statistically significant[(2.05±0.45)vs.(1.84±0.62),P=0.044;67.4%(31/46)vs.30.9%(30/97),P=0.002;30.4%(14/46)vs.54.5%(42/77),P=0.009].Conclusions Network medication guidance is helpful to improve the effect of warfarin anticoagulation management and improve the INR compliance rate of patients after cardiac valve replacement.The main manifestation of substandard anticoagulation is insufficient anticoagulation,which should be paid attention to.