1例主动脉瓣生物瓣置换伴冠脉搭桥术抗栓策略制定的药学实践

A Case of Pharmacy Practice of Antithrombotic Strategy for an Surgical Bioprosthetic Aortic Valve Replacement Combined with Coronary Artery Bypass Grafting

目的 探讨抗凝药师参与抗栓策略制定对于促进临床合理用药的作用。方法 抗凝药师通过重整患者入院前的抗栓方案,分析疗效不佳的原因,建议医师检测相关代谢酶的基因多态性,并权衡主动脉瓣生物瓣置换合并冠脉搭桥术后不同抗栓方案利弊以协助临床制定抗栓策略,优化药物治疗方案。结果 患者院前服用常规剂量阿司匹林和氯吡格雷三年,冠状动脉狭窄情况仍较前进展,药师分析了心血管危险因素控制情况并考虑氯吡格雷疗效受CYP2C19基因多态性影响,最终基因检测结果证实存在氯吡格雷抵抗;此外,根据现有临床证据,术后抗凝联合抗血小板治疗与双抗治疗相比,没有降低长期血栓栓塞风险且增加出血风险,降低患者服药依从性,综上建议选用阿司匹林联合替格瑞洛的抗栓方案。结论 抗凝药师运用专业知识参与个体化抗栓策略制定,为患者提供精细化药学服务,必将促进临床合理用药。

OBJECTIVE To explore the effect of anticoagulant pharmacists participating in the formulation of antithrombotic strategy on promoting the rational use of drugs in clinical practice.METHODS Anticoagulant pharmacists analyzed the causes of poor therapeutic effects by reforming the antithrombotic regimen before admission.It was recommended that physicians detect the gene polymorphisms of related metabolic enzymes and weigh the advantages and disadvantages of different antithrombotic regimens after surgical bioprosthetic aortic valve replacement combined with coronary artery bypass grafting to assist in the clinical development of antithrombotic strategies and optimize the drug treatment regimen.RESULTS After taking a regular dose of aspirin and clopidogrel for three years, the coronary artery stenosis still progressed.The pharmacist analyzed the control of cardiovascular risk factors and considered that the efficacy of clopidogrel was affected by CYP2 C19 gene polymorphism.The final genetic test results confirmed the presence of clopidogrel resistance.In addition, based on the available clinical evidence, postoperative anticoagulant therapy combined with antiplatelet therapy did not reduce the risk of long-term thromboembolism and increased the risk of bleeding compared with dual antibody therapy, reducing patient medication compliance, and in summary, an antithrombotic regimen of aspirin combined with ticagrelor was recommended.CONCLUSION Anticoagulant pharmacists use professional knowledge to formulate individualized antithrombotic strategies and provide refined pharmaceutical therapy for patients, which will certainly promote the rational use of drugs in clinical practice.