1例PCI术后支架内血栓形成患者的药学监护

1例40岁男性患者，因发作性胸痛3年，加重6h入院。入院诊断为：冠心病，急性前壁心肌梗死，陈旧性下壁心肌梗死，PCI＋支架置入术后。入院后急行冠状动脉造影＋PCI术，并给予抗血小板、抗凝、调脂、稳定斑块、改善心肌缺血等治疗。考虑到辛伐他汀可能与氯吡格雷存在代谢酶竞争，从而导致氯吡格雷抗栓效果不充分，临床药师建议将辛伐他汀调整为经CYP2C9代谢的氟伐他汀，或极少经CYP2C19代谢的瑞舒伐他汀；同时，对患者服用的双联抗血小板药物可能引起的胃肠道不适或出血症状，以及他汀类药物相关不良反应进行监测。并分析患者PCI术后支架内血栓形成的原因是抗血小板药物治疗不充分及不健康的生活方式，并据此对患者进行用药教育，督促患者遵循健康的生活方式，保障患者用药安全、有效。

Pharmaceutical care on one patient with stent thrombosis after PCI

One 40-year-old male patient was hospitalized with paroxysmal chest pain for three years and aggravation for six hours. Admitting diagnosis were coronary heart disease, acute anterior myocardial infarction, old inferior myocardial infarction and after operation of PCI and stenting.After admission, symptomatic treatments were given such as urgent coronary artery angiography and PCI operation, antiplatelet, anticoagnlation, regulating blood lipid, stabilizing plaque, improving myocardial ischemia, etc. Pharmaceutical cares were given to the patient by clinical pharmacists. Considering the competition of metabolic enzyme CYP3A4 between simvastatin and clopidogrel which may lead to inadequate antithrombotic effect of clopidogrel, clinical pharmacists suggested that simvastatin should be replaced by fluvastatin metabolized through CYP2C9, or by rosuvastatin metabolized through CYP2C19 rarely. Meanwhile, the potential gastrointestinal discomfort or bleeding symptoms caused by dual antiplatelet drug, as well as the statin drug related adverse reactions were monitored. Clinical pharmacists analyzed that the causes of stent thrombosis after PCI were inadequate antiplatelet drug therapy and unhealthy lifestyle, and provided medication education for the patient and suggested him to follow a healthy lifestyle. Clinical pharmacists played an important role in the safety and effectiveness of drug use.