李舒悦 回翔 金远香 王娟 张欢 王宝彦 徐航

摘 要 目的：評价抗凝门诊临床药师管理的抗凝效果。方法：回顾性分析2019 年8月-2020年1月南京鼓楼医院（以下简称“我院”）抗凝门诊就诊的481例患者的病历资料，记录其基本信息（性别、年龄、患者分级）、使用的抗凝药物、抗凝原因、抗凝相关检查结果[凝血酶原时间、国际标准化比值（INR）等]、华法林剂量、新型口服抗凝药物（NOACs）使用情况及不良反应发生情况等。结果：481例患者于我院抗凝门诊就诊共1 587例次。患者分级分别为一级401例次、二级547例次、三级639例次。470例患者服用华法林，11例服用NOACs（包括6例利伐沙班、5例达比加群酯）。瓣膜置换术为抗凝的主要原因（65.28%），其次为心房颤动（14.97%）、瓣环修复术（12.47%）。凝血酶原时间检测方法以即时检测设备检测为主（83.44%）。三级患者华法林日平均剂量为（3.03±1.28）mg。使用华法林患者的平均INR为1.99±0.56，INR在目标范围内的时间百分比（TTR）为72.79%，其中一级患者平均INR为2.12±0.84、TTR为44.33%，二级患者平均INR为1.95±0.52、TTR为72.34%，三级患者平均INR为1.94±0.33、TTR为90.42%。患者发生小出血102例次（6.43%），发生临床相关非大出血2例次（0.13%），未见大出血和血栓栓塞事件发生。结论：我院抗凝门诊临床药师通过实行分级管理，为患者制定科学的管理措施并进行个体化问诊;患者不良反应症状较轻且发生率较低，服用华法林患者的TTR较高，临床药师管理的抗凝效果明显。

关键词 抗凝门诊;临床药师;抗凝效果;分级管理;华法林;新型口服抗凝药

中图分类号 R973+.2 文献标志码 A 文章编号 1001-0408（2020）18-2289-05

DOI 10.6039/j.issn.1001-0408.2020.18.20

ABSTRACT   OBJECTIVE： To evaluate the anticoagulant effect of clinical pharmacist management in clinic. METHODS： Retrospective analysis was performed on medical records of 481 patients in anticoagulant clinic of Nanjing Drum Tower Hospital （hereinafter referred as “our hospital”） from Aug. 2019 to Jan. 2020. The general information （gender， age， patient grading） of patients， anticoagulant drug， anticoagulant causes， anticoagulant examination [prothrombin time， international standardized ratio results （INR）]， warfarin dose， NOACs usage and ADR were recorded. RESULTS： Totally 481 patients visited anticoagulant clinic of our hospital for 1 587 times in total. The case number of primary， secondary and tertiary patients were 401， 547 and 639， respectively. 470 patients received warfarin， and 11 patients received NOACs （including 6 cases of rivaroxaban， 5 cases of dabigatran etexilate）. The valve replacement was the main cause of anticoagulation （65.28%） ， followed by atrial fibrillation （14.97%）， valve ring repairment （12.47%）. The main detection method of prothrombin time was POCT （83.44%）. Their average dose of warfarin was （3.03±1.28） mg. The average INR of outpatients receiving warfarin was 1.99±0.56， and time within treatment range （TTR） was 72.79%. The average INR of the first grade was 2.12±0.84 and the TTR was 44.33%; the average INR of the second grade was 1.95±0.52 and the TTR was 72.34%; the average INR of the third grade was 1.94±0.33 and the TTR was 90.42%. There were 102 cases （6.43%） of small bleeding， and 2 cases （0.13%） of clinical related non major bleeding; no major bleeding and thromboembolism was observed. CONCLUSIONS： Clinical pharmacists of anticoagulant clinic in our hospital formulate scientific management and provide individualized consultation for patients through implementing hierarchical management of patients. Patients show mild symptoms and low incidence of adverse reactions; the patients taking warfarin have higher TTR; clinical pharmacist management has significant anticoagulant effect.

KEYWORDS   Anticoagulation clinic; Clinical pharmacist; Anticoagulants; Grading management; Warfarin; NOACs

抗凝治疗在深静脉血栓、心房颤动、瓣膜置换术后等血栓性疾病的预防和治疗中具有重要的作用，常见的口服抗凝药物包括华法林和新型口服抗凝药（NOACs）。……