冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护

目的 探讨临床药师在急性心肌梗死（AMI）患者经皮冠脉介入术（PCI）后发生肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）抗栓治疗方案制定及药学监护。方法 临床药师利用急性冠脉综合征临床风险评分（GRACE）及抗血小板、抗凝治疗出血风险评分（Crusade）进行死亡风险及缺血、出血风险评估，及时调整抗栓治疗方案。出现HIT后分析血小板减少的原因及凝血功能，确定可能的相关药物因素，选择阿加曲班替代抗凝治疗，并及时监测活化部分凝血活酶时间（APTT）进行剂量调整。从药物的作用机制，不良反应，安全经济性，阐述出院带药选择华法林对患者的用药优势。结果 选择阿加曲班替代抗凝治疗，维持双联抗血小板（阿司匹林+氯吡格雷）方案，患者情况控制平稳，未出现出血及血栓栓塞并发症，顺利出院。结论 临床药师需要充分了解药理学及药动学变化，可协助临床发现药物治疗相关问题。同时需加强监测，以便及时调整用药方案，提高临床用药的安全性和合理性，为患者提供更好的药学服务。

Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention

Objective To explore clinical pharmacists'' role in antithrombotic therapy for acute myocardial infarction (AMI) inpatients with heparin-induced thrombocytopenia (HIT) after percutaneous coronary intervention (PCI).Methods Clinical pharmacists used the acute coronary syndrome clinical risk score (GRACE) and anti-platelet and anticoagulant treatment bleeding risk score (Crusade) to assess the risk of ischemia and bleeding in order to adjust the dose for antiplatelet therapy.The causes of thrombocytopenia and coagulation were evaluated.The possible medication related factors were identified for HIT patient.Argatroban was used to replace anticoagulant therapy and APTT was closely monitored in order to adjust dose in a timely manner.Warfarin was recommended for the discharged patients based on the mechanism of action,adverse reactions,safety and economics.Results No bleeding or thromboembolic complications was observed on the patient with argatroban for anticoagulant therapy and aspirin plus clopidogrel as maintenance therapy.Conclusion With good understanding in pharmacology and pharmacokinetics,clinical pharmacists can help doctors to solve the problems related to drug therapy in time.Therefore,better pharmaceutical care can be provided to patients with improved medication safety and rationality.