临床药师在导管接触性溶栓联合抗凝治疗急性下肢深静脉血栓的用药分析与药学监护中的作用

目的 探讨临床药师在急性下肢深静脉血栓患者个体化治疗中的作用。 方法 对南京鼓楼医院血管外科2018年8月收治的8例急性下肢深静脉血栓患者的治疗过程进行分析，结合临床药学知识制定导管接触性溶栓及抗凝用药方案，对患者实施全程药学监护。 结果 溶栓治疗期间，患者血浆纤维蛋白原水平呈明显下降趋势，血浆D-二聚体水平呈先升高后降低的趋势，血小板未见明显下降趋势；8例患者在溶栓治疗过程中，2例出现轻微牙龈出血后自行止血，1例出现血尿，停止溶栓治疗后改为口服抗凝药，血尿现象消失。患者预后改善明显，血栓完全溶解，静脉恢复畅通，用药安全得到有效保障。 结论 临床药师在导管接触性溶栓联合抗凝治疗急性下肢深静脉血栓患者的个体化用药监护方面发挥了积极作用。     

Long-term anticoagulant therapy in patients with coronary artery disease.

Secondary prevention of coronary events in coronary artery disease (CAD) patients with aspirin is generally accepted because of ease of administration, predictable safety, and proven efficacy. The use of long-term anticoagulant therapy with heparins, vitamin-K antagonists (VKAs), or thrombin inhibitors is, however, more controversial. During the last 40 years, several trials have been conducted in order to evaluate the role of anticoagulant therapy in patients with CAD as a protection against subsequent death and thrombo-embolic complications. The conducted trials are heterogeneous in many ways, concerning comparative medications, patient populations, endpoints and follow-up, which makes a standardized recommendation on the basis of these studies difficult. This review is an overview of the largest and best studies on this topic and discusses the scientific background for a possible use of VKA or an alternative anticoagulant treatment in CAD patients, looking at both the beneficial effects and the risk of bleeding.     

血栓前体蛋白与心脏瓣膜置换术后的抗凝监测

目的：探讨血栓前体蛋白(TPP)在心脏机械瓣膜置换术后抗凝治疗监测中的意义，及制定术后抗凝治疗的合理方案。方法：比较抗凝组(60例)和对照组(20例)的国际标准化比率(INR)、TPP，并比较抗凝组中有、无房颤的病人华法林用量、INR和TPP，对抗凝组病人TPP和INR的关系作一元线性回归分析，比较各组的INR和血浆TPP浓度。结果：抗凝组与对照组相比，TPP低、INR高。抗凝组有房颤者的血浆TPP浓度高于窦性心律者。线性回归分析结果表明，TPP和INR无明显相关性。出血病人的血浆TPP浓度明显低于正常高限(6μg／ml)。结论：TPP是心脏机械瓣置换术后抗凝治疗理想的辅助监测指标。术后有房颤心律者的血栓栓塞危险性增加。抗凝治疗应同时检测INR和TPP。     

血浆抗凝物质及花生四烯酸代谢产物在高脂血症患者的临床意义

目的:研究血浆抗凝物质及花生四烯酸代谢产物在高脂血症患者的临床意义。方法:临床诊断的高脂血症患者与正常对照组进行比较,其中抗凝血酶 Ⅲ抗原(AT- Ⅲ:Ag)、α1 抗胰蛋白酶(α1 - AT)和α2 巨球蛋白(α2 - MG)采用免疫浊度法;抗凝血酶Ⅲ活性(AT -Ⅲ:A)用发色底物法;血栓烷B2 (TXB2 )和6 - 酮前列腺素F1α(6 - K PGF1α)用放射免疫法。结果:患者组AT Ⅲ:Ag与正常对照组比较无差异(P >0 .0 5 ) ,但AT Ⅲ:A与正常组比较降低,α1 - AT无差异,α2 - MG有显著意义增高(P <0 .0 5 ) ,患者组TXB2 与正常组比较明显增高而6- K PGF1α明显降低(P <0 .0 1 )。结论:抗凝指标降低(AT- Ⅲ:A)示高凝状态,TXB2 和6 - K PGF1α的改变是高脂血症患者的危险因素,对于患者病理意义的研究是有帮助的,也显示患者极易发生动脉硬化的原因。     

抗凝治疗肺心病血栓前状态的临床研究

目的探讨肺心病患者的血栓前状态，观察并分析低分子肝素抗凝干预的疗效。方法将54倒肺心病患者分为低分子肝素治疗组和常规治疗组各27例。分别检测治疗前后血浆血管性假血友病因子(VWF)、血浆凝血酶片段1 2(F1 2)、纤堆蛋白原(Fg)、血小板颗粒膜蛋白(GMP-140)和D-二聚体(DD)。结果肺心病患者VWF、F1 2、Fg、GMP-140、DD血浆浓度显著高于对照组；肺心病治疗组经LMWH治疗后上述各凝血分子标记物及PaCO2明显降低。而PaO2显著增高。常规组虽血气指标略有改善。但凝血分子标记物未见改善。结论尽早检测肺心病血栓前状态，及时给予低分子肝素抗凝干预，有望从根本上改善肺心病惠性加重期患者的不良预后。     

Loss of Anticoagulant Effect of Heparin During Circulation of Human Blood In Vitro

Device-induced thrombogenesis was studied in an in vitro model using human blood circulated through an artificial ventricle. A new constant pressure filtration technique was used to detect circulating microemboli, the activated partial thromboplastin time (APTT) test was used to monitor the blood for the presence of anticoagulant activity of heparin, and hemolysis was quantified by measuring the plasma free hemoglobin level. Circulation of blood through a 20-ml stroke volume pneumatically driven ventricle for 6-9 h resulted in a significant reduction of APTT, indicating the loss of the anticoagulant effect of heparin. Microemboli concentration was minimal until the APTT decreased below 125 s, at which time the microemboli concentration increased rapidly. This was presumed to be due to the formation of thrombi following a decrease in heparin activity. A significant increase in hemolysis was also noted when blood was pumped. None of these changes was noted in the nonpumped control blood. Spontaneous loss of heparin activity in blood circulated by a pneumatically driven pump may have clinical implications and may help understanding of the problems associated with device-induced thrombogenesis.     

枸橼酸抗凝血液透析

研究解剖高危出血患者血液透析的抗凝方法－局部枸橼酸抗凝的临床应用和疗效。方法：采用１．６ｍｏｌ／Ｌ的枸橼酸钠、空心纤维透析器和普通含钙碳酸氢盐透析，观察ＲＣＡ透析对患者出血、体外循环凝血、血游离钙、总钙、Ｋ＾＋，Ｎａ＾＋，ｐＨ，ＨＣＯ＾－３，Ｓｃｒ，ＢＵＮ及血清枸橼酸浓度的影响。     

The heparin management test: a new device for monitoring anticoagulation during coronary intervention

Whole blood coagulation analysers are widely used during percutaneous coronary interventions. The precise degree of anticoagulation in patients is important in this setting. The aim of this investigation was to compare the results obtained with ACT (Hemochron) and HMT, the Heparin Management Test (TAS) in patients undergoing percutaneous coronary interventions. Patients (n=100) were enrolled prospectively. Each patient received 10,000 units of heparin. At the end of the procedure, the mean ACT was 284±31 seconds and the mean HMT was 292±33 seconds. The correlation between the two methods was highly significant (r=0.64, p<0.001). The HMT correlates well with ACT values in patients undergoing percutaneous coronary interventions. Its use in the management of these patients should be considered.     

单纯抗凝与导管内溶栓加抗凝治疗肺动脉栓塞疗效对比分析

目的评价单纯抗凝与导管内溶栓加抗凝治疗肺动脉栓塞疗效对比。方法经肺动脉造影或增强螺旋CT证实的急性肺动脉栓塞患者63例，随机分两组，一组单纯肝素抗凝32例，另一组导管内尿激酶溶栓加肝素抗凝31例。结果单纯抗凝治疗总有效率96．7％；导管内溶栓加抗凝治疗总有效率100％，但临床症状改善较快。单纯抗凝无效1例，经导管内溶栓后好转。经导管内溶栓出现消化道出血1例。本观察无1例死亡。结论单纯抗凝与导管内溶栓加抗凝治疗总有效率相近，无并发症出现。所以对无血液动力学改变的急性肺动脉栓塞单纯肝素抗凝即可取得确切疗效，可降低风险。