血小板减少的房颤伴动脉粥样硬化患者的抗栓治疗管理策略及文献分析

Management strategy of antithrombotic therapy in thrombocytopenia patients with atrial fibrillation and atherosclerosis and a literature review

目的为血小板减少的房颤伴动脉粥样硬化患者的抗栓治疗管理提供参考。方法临床药师参与1例血小板减少的房颤伴动脉粥样硬化患者的治疗过程,根据患者病史、实验室检查结果等分析血小板减少原因,同时参考相关指南评估患者的血栓-出血风险,协助临床医师为患者制定个体化抗栓治疗方案及药学监护计划;检索中国知网收集血小板减少相关抗栓治疗的文献并进行分析。结果该患者血小板减少考虑为原发性血小板减少症可能性大,其出血风险主要是年龄≥65岁、存在出血倾向以及合并使用抗栓药物。临床药师评估患者的血栓-出血风险后,建议临床医师予以全剂量贝米肝素钠注射液+盐酸决奈达隆片+琥珀酸美托洛尔缓释片;针对血小板减少,临床医师予以复方皂矾丸、咖啡酸片和升血小板胶囊,但用药后患者出现腹泻,临床药师建议停用升血小板胶囊,临床医师采纳建议。患者出院时,临床药师建议出院抗栓治疗方案为单用抗凝或择期抗凝,临床医师考虑该患者目前血小板减低、尿潜血(+)和大便隐血弱阳性,故选择择期抗凝治疗,并嘱出院带药为琥珀酸美托洛尔缓释片+阿托伐他汀钙片。文献分析结果显示,血栓栓塞患者血小板减少的原因主要包括肝素诱导性血小板减少症、免疫性血小板减少症等,经对症治疗后所有患者均好转。结论临床药师通过参与血小板减少的房颤伴动脉粥样硬化患者的抗栓治疗管理,有效控制了患者的病情,确保了患者用药安全、有效。

OBJECTIVE To provide reference for the management of antithrombotic therapy in thrombocytopenia patients with atrial fibrillation and atherosclerosis.METHODS The clinical pharmacist participated in the treatment of a thrombocytopenia patient with atrial fibrillation and atherosclerosis,and analyzed the causes of thrombocytopenia according to the patient’s medical history and laboratory examination results.At the same time,the risk of thrombosis-bleeding was evaluated according to the relevant guidelines,and the clinicians were assisted in formulating individual antithrombotic therapy plan and pharmaceutical care plan for the patient.The literature on antithrombotic therapy related to thrombocytopenia was collected and analyzed by retrieving CNKI.RESULTS Thrombocytopenia was considered as primary thrombocytopenia in this patient,and the main risk of bleeding was age≥65 years old,bleeding tendency,and combined use of antithrombotic drugs.After the clinical pharmacist assessed the risk of thrombosis and bleeding,the clinician was recommended to give full dose of Bemiheparin sodium injection+Dronedarone hydrochloride tablets+Metoprolol succinate sustained-release tablets.In view of thrombocytopenia,the clinician gave Compound zaofan pill,Caffeic acid tablet and Sheng xuexiaoban capsule,but the patient developed diarrhea after the medication.The clinical pharmacist suggested stopping Sheng xuexiaoban capsule,and the clinician adopted the clinical pharmacist’s suggestion.When the patient was discharged from hospital,the clinical pharmacist suggested that the antithrombotic therapy plan for discharge was anticoagulation alone or selective anticoagulation.The clinician chose selective anticoagulation treatment considering that the patient’s current thrombocytopenia,urinary occult blood(+)and fecal occult blood were weakly positive,and ordered the patient to take Metoprolol succinate sustained-release tablets+Atorvastatin calcium tablets at discharge.Literature analysis showed that the causes of thrombocytopenia of patients with thromboembolism mainly included heparin induced-thrombocytopenia,immune thrombocytopenia,etc.All patients were improved after symptomatic treatment.CONCLUSIONS By participating in the management of antithrombotic therapy for the thrombocytopenia patient with atrial fibrillation and atherosclerosis,clinical pharmacists can help effectively control the patient’s condition and ensure the safety and effectiveness of drug use.