心脏机械瓣膜置换术后患者抗凝管理现状研究—单中心抽样调查

发布时间：2018-12-29 19:16

【摘要】：目的:了解心脏机械瓣膜置换术后患者抗凝现状并评价其抗凝治疗质量,初步探讨心脏瓣膜置换术后患者抗凝随访依从性的影响因素。方法:随机抽取2013年1月至2014年12月间在贵州省人民医院(以下简称我院)心脏外科行心脏机械瓣膜置换术后半年以上,需终身使用华法林抗凝治疗的140例患者进行回访,回顾性研究其相关临床资料,分析与抗凝治疗相关的血栓栓塞及出血事件发生率,通过计算患者TTR初步评价随访患者抗凝质量。将坚持在我院复查、随诊期间两次复查的时间间隔未超过90天并且复查次数不少于3次的使用传统抗凝管理模式(患者定期到医院门诊复查随诊、医生给出抗凝建议的抗凝管理模式)的患者分为A组,复查随诊期间两次复查的时间间隔超过90天或复查次数少于3次的使用传统抗凝管理模式的患者分为B组,对A、B两组患者的年龄、性别、每次复查所耗费时间与经济代价、每次复查是否需要亲友陪同等可能影响患者抗凝随访依从性的相关因素进行统计学分析。结果:共随机抽取机械瓣置换手术患者140例,失访21例,完成随访119例,其中死亡3例(2.52%)。回访患者中发生脑梗塞患者2例(2.1%),严重出血并发症1例(1.1%)。随访患者中,有7例采用自我管理的模式(患者通过获得的复查结果,并没有找医生咨询结果,而是通过自己的理解及自己掌握的相关知识自己调整华法林,自己决定下次复查时间)进行抗凝管理,其他患者均使用的是传统抗凝管理模式,未发现使用其他新型抗凝管理模式的患者。A组60例患者INR检测值共692次,其中INR最低值为0.84,最高值为6.75,患者INR值处于极端低抗凝水平占26.16%,相对安全范围占70.63%,极端高抗凝水平占3.61%。B组患者有27例,其患者INR值处于极端低抗凝水平占31.79%,相对安全范围占61.59%,极端高抗凝水平INR占6.62%。通过线性内插法计算A组患者TTR,TTR最小为0,最大为78.8%,平均(26.0±19.1)%,其中抗凝控制良好的患者3例,占5%,控制欠佳的有57例,占95%。B组患者不符合TTR计算标准未计算TTR。比较A、B两组患者的性别、年龄及患者每次复查所需时间的差异,差异无统计学意义(P0.05),比较A、B两组患者每次复查是否需要亲友陪同、每次复查耗费金钱多少的差异性,有显著差异(P0.05)。结论:传统抗凝管理模式下患者抗凝治疗质量欠理想,加强随访是保证抗凝安全的一种有效方法,需要进一步探索时间-经济效益更好的管理模式为患者提供更多的便利。有患者自发采用了自我管理模式,其抗凝质量需进一步研究论证。患者每次复查需要人陪同、单次复查耗费财力相对较大等因素降低了患者复查随访的依从性,抗凝管理人员应加强对这类患者的宣教与随访。
[Abstract]:Objective: to investigate the anticoagulant status and the quality of anticoagulant therapy in patients with cardiac mechanical valve replacement and to explore the influencing factors of anticoagulant compliance. Methods: 140 patients undergoing cardiac mechanical valve replacement in Guizhou Provincial people's Hospital (hereinafter referred to as our hospital) from January 2013 to December 2014 were randomly selected and received warfarin anticoagulant therapy for life. The clinical data and the incidence of thromboembolism and hemorrhage associated with anticoagulant therapy were analyzed retrospectively. The anticoagulant quality of follow-up patients was evaluated by calculating TTR. We will insist on using the traditional anticoagulant management mode in our hospital, the time interval between the two reexaminations during the follow-up period is not more than 90 days and the times of reexamination are not less than 3 times. Patients with anticoagulant management suggested by the doctor were divided into two groups: group A, who had two reexaminations with a time interval of more than 90 days or less than 3 times during the follow-up period, and those who used the traditional anticoagulant management mode, and were divided into two groups: group A, A. The age, sex, time and economic cost of each reexamination, and whether relatives and friends were needed to accompany the patients in group B were statistically analyzed, which might affect the compliance of patients with anticoagulant follow-up. Results: totally 140 cases of mechanical valve replacement were randomly selected, 21 cases were lost, 119 cases were followed-up, 3 cases (2.52%) died. 2 cases (2.1%) had cerebral infarction and 1 case (1.1%) had severe hemorrhage complication. Seven of the patients followed up using a self-management model (the patients did not consult a doctor with the results obtained, but adjusted warfarin through their own understanding and knowledge. Other patients used the traditional anticoagulant management mode, and no other new anticoagulant management mode was found. In group A, the INR detection value of 60 patients was 692 times. The lowest value of INR was 0.84, and the highest value was 6.75.The INR value of patients was in extremely low anticoagulant level (26.16%), the relative safe range was 70.63%, and the extremely high anticoagulant level accounted for 27 cases in group B. The INR value of the patients was in extremely low anticoagulant level (31.79%), the relative safe range was 61.59 and the extremely high anticoagulant level (INR) was 6.62%. The TTR,TTR of group A was calculated by linear interpolation method with the minimum of 0 and the maximum of 78.8%, with an average of (26.0 卤19.1)%. There were 3 patients with good anticoagulant control, accounting for 5 cases, and 57 cases with poor control. Patients in group B did not meet the TTR calculation criteria and did not calculate TTR. There was no significant difference in sex, age and the time required for each reexamination between the two groups (P0.05). There were significant differences in the cost of each review (P0.05). Conclusion: the quality of anticoagulant therapy in the traditional anticoagulant management mode is not ideal. Strengthening follow-up is an effective method to ensure the safety of anticoagulant. It is necessary to further explore the time-economic management model to provide more convenience for patients. Some patients spontaneously adopted self-management model, its anticoagulant quality needs further research and demonstration. Patients need to be accompanied for each reexamination, single reexamination cost relatively large financial resources and other factors reduced the compliance of follow-up, anticoagulant management should strengthen the education and follow-up of these patients.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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