房颤患者华法林治疗服药依从性的研究进展

脑卒中是房颤的最主要危害,可导致患者致残率和致死率增加,严重影响患者的生活质量。使用华法林抗凝可明显减少脑卒中并发症。然而同治疗一般慢性病的药物相比,由于华法林具有可能导致出血的副作用,加之需定期采血检测INR值来调整药物剂量,使得其服药依从性上较一般的慢性病药物更差。而如果不能保证合适的药物剂量,不能达到标准的INR值,则患者发生栓塞和出血的可能性会大大增加。本文综合探讨如何提高房颤患者使用华法林治疗的服药依从性。     

延续性护理对房颤患者华法林服药依从性的效果观察

目的探讨延续性护理对房颤患者华法林服药依从性的效果。方法将100例房颤患者随机分为两组各50例,对照组予常规出院指导,观察组予延续护理。在两组患者出院6个月时评估其服药依从性。结果观察组依从性好为29例(58.0%),依从性一般为16例(32.0%),依从性差为5例(10.0%),平均依从性得分为(7.19±0.64)分;对照组依从性好为16例(32.0%),依从性一般为18例(36.0%),依从性差为16例(32.0%),平均依从性得分为(6.28±0.50)分;观察组出院6个月内服药依从性明显优于对照组(P <0.05)。结论对房颤患者进行延续护理能够强化其华法林服药依从性。     

房颤患者华法林抗栓治疗的护理

总结了115例心房颤动（房颤）患者行华法林抗栓治疗的护理管理方法。针对华法林治疗中过量易导致出血,不足易引发栓塞,且影响药物效果因素多,监测INR的不便致使临床应用受限的现状,采用全面细致的用药护理管理,可以降低华法林治疗过程中的不良事件的发生,提高治疗的安全性和依从性。确保抗栓治疗的效果,减少房颤患者栓塞事件的发生。     

华法林治疗房颤的护理观察

目的观察分析华法林治疗房颤的护理效果。方法给予医院收治的84例房颤患者采用华法林治疗,同时实施系统护理干预,评价临床疗效。结果治疗以及护理后,84例患者病情均得到有效控制,INR达标时间为7~12 d,稳定在1.5~2.5,可维持12~26 d,治疗过程中,有1例患者牙龈出血,调整华法林剂量后出血停止。结论房颤患者接受华法林治疗安全有效,结合护理干预,可有效改善患者的生活质量水平,应用效果显著。     

华法林治疗房颤中的护理体会

目的探讨华法林治疗房颤中的护理要点。方法回顾分析120例患者的临床资料及护理经验。结果华法林起始剂量为2.5mg,根据INR调整华法林用量,维持剂量为1.25～3.25mg,INR达到1.6～2.5水平需时间为5～12d,INR稳定于1.6～2.5水平需10～28d。在华法林剂量调整过程中INR最高达6.93,患者无出血并发症;随访2～4年,其中4例有并发出血;所有患者随访期间无缺血脑卒中及其他部位的血栓。结论华法林的应用是安全可靠的,但其出血的不良反应也不能忽视,应严密观察,定期复查凝血酶原,随时调整剂量,精心护理,以充分发挥其治疗作用,减少其不良反应。     

房颤患者服用华法林的健康教育体会

目的：使房颤患者及家属了解和掌握华法林抗凝治疗的重要性、注意事项及不良反应等。方法：通过对房颤患者及家属在应用华法林抗凝治疗前,强化健康教育。结果：病人及家属对华法林的抗凝治疗有了正确的认识和一定程度的掌握,提高了患者的用药依从性,实施健康教育的患者能够按时随访凝血酶原时间（PT）及国际标准化比值（INR）。有效减少了抗凝治疗的并发症,未出现血栓栓塞事件,无严重出血发生。     

1例房颤患者服用华法林抗凝治疗的药学监护

1例86岁男性房颤患者,入院后给予华法林抗凝治疗,期间发现患者国际标准化比值(INR)波动较大。临床药师从疾病及药物相互作用等多方面因素进行分析,同时结合药物代谢动力学和药效学特点,向临床提供合理建议,对患者进行用药指导,保障患者用药安全。     

非瓣膜性房颤患者华法林用药依从性及其影响因素的调查分析

目的:为改善非瓣膜性房颤患者用药依从性,更好地保证治疗安全性和有效性提供参考。方法:选取部分在我院住院接受华法林抗凝治疗的非瓣膜性房颤患者进行问卷调查,分别采用8条目Morisky用药依从性量表(MMAS-8)和华法林用药知识量表(WRKS)评估患者华法林用药依从性及抗凝治疗相关知识知晓情况,并应用χ2检验、t检验及Logistic多元回归分析方法探讨影响患者华法林用药依从性的相关因素。结果:共发放问卷129份,回收有效问卷112份,有效回收率为86.82%。受访患者MMAS-8平均得分为(6.54±1.61)分,用药依从性好者占42.86%。受访患者WRKS平均得分为(7.95±1.65)分,用药依从性好者平均得分为(9.31±0.83)分,用药依从性差者平均得分为(6.92±1.34)分。单因素分析发现,用药依从性好者与用药依从性差者在性别、年龄、职业、文化程度、合并症种数、WRKS得分等方面比较,差异均有统计学意义(P<0.05)。Logistic多元回归分析结果显示,WRKS得分、性别、文化程度、合并症种数与受访患者用药依从性均显著相关(P<0.05)。结论:非瓣膜性房颤患者华法林用药依从性较差,与多种影响因素相关,其中华法林抗凝治疗相关知识知晓情况是一个重要因素。     

华法林在房颤病人中的应用及护理对策

目的探讨华法林在房颤病人治疗过程中的副作用及护理对策。方法抽调我科2001年1月～2004年1月期间收治的房颤病例，回顾性分析使用华法林治疗期间所出现的不良反应及副作用。结果病人不良反应及副作用的发生与医生的处方剂量、病人的年龄、其他药物影响及因各种原因未进行相关监测有关。结论在房颤病人使用华法林治疗期间，适宜的健康教育，恰当的监测和护理观察、病人和家属良好的遵医行为是预防的关键。     

华法林治疗房颤的疗效观察

目的 探讨华法林治疗房颤的疗效.方法 回顾分析本院于2011年12月～2013年1月收治的58例房颤患者的临床资料.对出院后患者进行12个月的电话跟踪、随访和复查.结果 跟踪调查期间,58例患者在长期服用华法林情况下,出现3例皮下出血,4例黑便,1例牙龈出血,2例血尿,根据患者病症,合理调整华法林剂量,症状消失.结论 在房颤治疗中采用华法林,对血栓和栓塞有着显著的治疗效果,有效降低和避免血栓和栓塞的发生,无严重不良反应,只发生轻微的出血副作用,可以作为首选药物治疗房颤,有着良好的治疗效果.     

Direct costs of warfarin treatment among patients with atrial fibrillation in a Finnish health care setting

ABSTRACT

Objective: The main objective was to estimate the mean direct costs of warfarin treatment for atrial fibrillation (AF) patients. Secondly, the costs of initiating warfarin treatment during a 60-day period and the impact of International Normalized Ratio (INR) and co-morbidities on costs were estimated.

Design and data: The study was performed as a retrospective cohort study over a 12‐month period in a Finnish communal health care setting. All AF patients aged 65 years or older (n = 250) with warfarin treatment were identified from the database of the health service district of an urban area. Patient specific information related to co-morbidities, INR-control, complications and health care resource use were collected. Cost information was obtained from the Finnish national health care unit cost list.

Methods: The effect of treatment balance and other background variables on treatment costs were evaluated using ordinary least squares regression (OLS), log-transformed OLS and generalized linear model (GLM). The mean costs were calculated on the basis of the different models and bias corrected and accelerated (BCa) bootstrap confidence intervals (CIs) were calculated for the mean costs.

Results: The best fitting cost model was log-transformed OLS. The costs of warfarin treatment on the basis of the log-transformed model were 589.82 euros (BCa 95% CI: 586.68–591.99) per patient compared to 616.00 euros (BCa 95% CI: 579.98–652.96) obtained with the OLS-model. For the treatment initiation period, the mean costs were 263 euros (BCa 95% CI: 218.90–314.71). Depending on the way that INR-control was defined, the mean costs were 95.27 euros or 166.92 euros higher for patients who were not in the defined INR-balance.

Conclusions: The INR-control has a significant impact on the warfarin treatment costs. The choice of model influences the estimated mean costs. In addition, different models identify statistically significant effects between different background variables and costs.     

住院心房颤动患者华法林的使用分析

目的分析比较瓣膜性心房颤动和非瓣膜性心房颤动住院患者华法林使用情况及国际标准化比值（INR）达标状况。方法收集969例住院心房颤动患者的病历资料进行回顾性分析。将患者分为瓣膜性心房颤动和非瓣膜性整体的心房颤动2组,分析2组华法林使用率和达标率的差异及应用华法林患者的INR达标水平。结果瓣膜性心房颤动患者161例中使用华法林者93例,占57.8%;非瓣膜性心房颤动患者808例中使用华法林者214例,占26.5%。93例使用华法林的瓣膜性心房颤动患者中,INR值在2.0～3.0者21例,占22.6%;214例使用华法林的非瓣膜性心房颤动患者中,INR值在2～3者38例,占17.8%。2组患者华法林的使用率比较差异有统计学意义（P＜0.05）,INR达标率比较差异无统计学意义（P＞0.05）。使用华法林的307例心房颤动患者的达标率INR在2.0～3.0者59例,占19.2%;INR＜2.0者230例,占74.9%;INR＞3.0者为18例,占5.9%。结论华法林在心房颤动患者中的使用率低且使用华法林后INR的达标率低。     

Factors associated with warfarin discontinuation,including bleeding patterns,in atrial fibrillation patients

Abstract

Objective:

To determine risk factors for both warfarin discontinuation and bleeding in patients with atrial fibrillation (AF).     

某三甲医院心房颤动患者华法林规范化抗凝治疗现状调查分析

目的：了解心房颤动患者抗凝治疗现状,为心房颤动规范化抗凝治疗提供参考。方法：选取皖南医学院弋矶山医院2013年1月~2014年12月非瓣膜性心房颤动患者200例,采用CHA2DS2-VASc和HAS-BLED评分系统对纳入人群进行血栓危险分层和出血风险评估,并依据《2010年欧洲心脏病学会（ESC）心房颤动治疗指南》评价其规范化抗凝情况。结果：CHA2DS2-VASc和HAS-BLED评分分别为（2.73±2.10）分和（1.57±1.13）分。183例（91.5%）患者接受抗血栓治疗,使用华法林抗凝治疗的有74例（37%）,而血栓高危组125例患者中,接受华法林抗凝治疗50例（40%）。华法林抗凝治疗时间（5.78±4.73） d,累积给药剂量为（19.46±18.19） mg,55例（74.32%）患者出院前监测国际标准化比值（INR）,INR达标率为30.9%。结论：心房颤动以华法林抗凝治疗现状不容乐观,应采取有效的干预措施,提高心房颤动患者抗凝治疗规范化程度。     

1例房颤患者服用华法林期间INR值异常波动的药学监护

1例78岁房颤患者长期服用华法林,1NR值控制在1．6～2．5。入院当日测PT41．6S,INR3．53,遂停用华法林。4d后测INR1．25,低于正常水平,患者重新口服华法林。因关节疼痛加用塞来昔布,监测凝血四项显示PT、INR值分别由14．4S、1．25上升至36．7S、3．12。临床药师分析患者所用药物中,氯雷他定、塞来昔布均可加强华法林的抗凝作用,建议停用华法林、静脉注射维生素K1,医师采纳。此后,继续监测患者的凝血指标,至INR值回落后恢复使用华法林。患者住院期间未发生出血及栓塞事件。     

华法林和阿司匹林对永久性房颤患者抗凝治疗的有效性及安全性观察

目的比较华法林和阿司匹林用于永久性房颤患者抗凝治疗的有效性及安全性。方法入选符合本研究标准的141例永久性房颤患者,随机分为两组,华法林组（治疗组）70例,以华法林2.5mg/d作为起始剂量,阿司匹林组（对照组）71例,阿司匹林100mg/d,早饭后即刻服用。结果治疗组发生出血3例（4.29%）,脑梗死2例（2.82%）,上腹不适1例（1.43%）。对照组发生出血2例（2.82%）,脑梗死13例（18.31%）,上腹不适15例（21.13%）。治疗组脑梗死、上腹不适的发生率低于对照组（P〈0.05）,两组间出血发生率无统计学差异（P〉0.05）。结论华法林抗凝治疗可明显减少栓塞事件及上腹部不适的发生率,INR维持在2.0～3.0之间,用药既有效又安全。     

阿司匹林联合华法林对冠心病合并心房纤颤患者的安全性和有效性分析

目的观察阿司匹林联合华法林对冠心病合并心房纤颤的有效性和安全性。方法回顾性分析2012年8月至2013年8月46例来我科住院治疗的冠心病合并心房纤颤患者,分为观察组(阿司匹林和华法林联合治疗)和对照组(华法林单药治疗),每组23例。随访1年,比较两组血栓栓塞发生率、出血发生率及患者的肾功能。结果观察组患者血栓栓塞发生率、出血发生率及肾功能各项指标与对照组比较,差异无统计学意义(P>0.05)。结论阿司匹林联合华法林治疗冠心病合并房颤的脑血栓发生率较低,出血风险较小,对肾功能也没有严重损害,但与华法林单药治疗比较,差异无统计学意义。     

Treatment patterns and real-world effectiveness of warfarin in nonvalvular atrial fibrillation within a managed care system

ABSTRACT

Objective: To examine warfarin utilization and clinical effectiveness among patients with nonvalvular atrial fibrillation within usual clinical care in a managed care system.

Research design and methods: A retrospective analysis of health care claims for an approximately four million member managed care organization was performed. Health plan members with a diagnosis of nonvalvular atrial fibrillation in calendar year 2000 were identified and stratified into two cohorts: Warfarin Therapy (newly initiating warfarin) or Warfarin Candidates (eligible for warfarin therapy according to the ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation, but did not receive warfarin).

Measurements: The occurrence of thromboembolism, ischemic stroke, and hemorrhage during a maximum 720‐day follow-up were compared between cohorts, adjusting for age, gender, and other risk factors, using Cox regression.

Results: Among 12?539 subjects (mean age 78.0 ± 8.8 years) with nonvalvular atrial fibrillation, 4895 (39.0%) initiated Warfarin Therapy and 7644 (61.0%) were Warfarin Candidates. Event occurrences among Warfarin Therapy vs. Warfarin Candidates were: ischemic stroke, 3.7% vs. 4.5%; any thromboembolism, 7.8% vs. 10.8%; and hemorrhage, 4.4% vs. 4.9%, respectively. Warfarin therapy was not associated with an increased risk for hemorrhage (hazard ratio [HR] = 0.97, 95% confidence interval [CI] = 0.82–1.15), while risks for ischemic stroke and any thromboembolism were significantly reduced, by 22% (HR = 0.78, 95% CI = 0.65–0.93) and 34% (HR = 0.66, 95% CI = 0.59–0.75), respectively.

Conclusions: Within usual clinical care for the managed care population examined, warfarin remains underused despite current guidelines recommending its use in nearly all patients with nonvalvular atrial fibrillation. Although utilization of anticoagulation clinics and INR values attained were unknown in this study, the observed risk reductions for ischemic stroke and thromboembolism were lower than those achieved in clinical trials, while no increased risk for hemorrhage was observed. These findings suggest that warfarin is used conservatively, and dosed cautiously, diminishing the full potential benefit of anticoagulant therapy in patients with nonvalvular atrial fibrillation.