王玉珠 李静 吕迁洲 潘雯

摘 要 年轻女性突发脑梗死入院。既往行心脏机械瓣膜置换术后长期口服华法林4.5 mg/d抗凝治疗。因失语、右侧肢体无力入院，入院第2天INR高达5.48。患者由于失语无法提供发病前华法林用药情况和INR监测资料，使此次脑梗死诱因不甚明确。药师仔细询问家属病史，利用华法林剂量计算工具和基因型测定结果，仍认为脑梗死与抗凝不足有关，并大胆建议提高华法林剂量。出院后随访10个月，华法林剂量4.5～6.0 mg/d，INR在2.5～3.5。随访中患者回忆起发病前一个月自行把华法林剂量减低为3 mg/d，曾测定INR 2.04，并未达标，的确有抗凝不足；由于急诊回家后担心脑梗死加重自行增加华法林剂量，可解释INR一过性升高。

关键词 心脏机械瓣膜置换术后 脑梗死 华法林 抗凝不足

中图分类号：R743.34 文献标志码：C 文章编号：1006-1533（2018）19-0073-04

Analysis of the medication in a young woman with cerebral infarction after mechanical heart valve replacement

WANG Yuzhu*， LI Jing， LYU Qianzhou， PAN Wen**

（Department of Pharmacy， Zhongshan Hospital， Fudan University， Shanghai 200032， China）

ABSTRACT A young woman was admitted to the hospital for sudden cerebral infarction. Oral warfarin 4.5 mg/d was taken for long-term anticoagulation after mechanical heart valve replacement. Because of aphasia and weakness of the right limb， she was then admitted into the neurology ward in our hospital for further diagnose and treatment. On the second day of admission， the monitoring INR was up to 5.48. The patient could not tell the warfarin medication status and INR monitoring data due to aphasia， making the cause of cerebral infarction unclear. The pharmacist carefully asked her family member about her medical history， and still believed that her cerebral infarction was associated with insufficient anticoagulation by calculation of the warfarin dose and genotyping and boldly suggested increasing the warfarin dose. INR was at 2.5-3.5 after 10 months followup when the dose of oral warfarin was maintained at 4.5-6.0 mg/d. Meanwhile， the patient recalled during the follow-up that the warfarin dose was ever reduced to 3 mg/d and the monitoring INR was at 2.04 one month before the onset of cerebral infarction， which indicated that the anticoagulant dose was insufficient， and furthermore the warfarin dose was increase by herself after she came back home from emergency room because she worried that the risk of cerebral infarction would be aggravated， all of these might explained why the transient increase of INR occurred.

KEy WORDS postoperative cardiac valve replacement； cerebral infarction； warfarin； insufficient anticoagulant

1 病史摘要

一患者，女，25歲，身高158 cm，体重45 kg，体表面积1.41 m2。因骑车途中突发意识丧失摔倒在地被送入我院急诊。体格检查：血压120/75 mmHg，心率 75次/min，体温36.5 ℃，呼吸20次/min。呼之无应答，压眶反应存在，逃避反射存在。双侧瞳孔等大等圆，对光反应灵敏。两肺呼吸音清晰，未闻啰音。腹平软，无压痛。查头颅CT未见明显异常。心电图：①窦性心动过缓；②V2-V5导联ST段抬高﹤1 mm，以J点抬高为主。肌酸激酶304 U/L，肌酸激酶MM亚型283 U/L，凝血酶原时间（PT）23.7 s，国际正常化比值（INR）1.7。急诊室留观6 h后，患者清醒，有自主活动，未搭理医生，自动离院。

2 d后，患者再次入急诊，家属诉患者右侧肢体无力伴言语不能3 d。体格检查：神清，失语，查体不能合作，双瞳孔等大正圆，直径3 mm，光敏，双眼可疑右侧凝视，未引出眼震。……