【摘要】：目的:了解心臟機(jī)械瓣膜置換術(shù)后患者抗凝現(xiàn)狀并評(píng)價(jià)其抗凝治療質(zhì)量,初步探討心臟瓣膜置換術(shù)后患者抗凝隨訪依從性的影響因素。方法:隨機(jī)抽取2013年1月至2014年12月間在貴州省人民醫(yī)院(以下簡(jiǎn)稱我院)心臟外科行心臟機(jī)械瓣膜置換術(shù)后半年以上,需終身使用華法林抗凝治療的140例患者進(jìn)行回訪,回顧性研究其相關(guān)臨床資料,分析與抗凝治療相關(guān)的血栓栓塞及出血事件發(fā)生率,通過計(jì)算患者TTR初步評(píng)價(jià)隨訪患者抗凝質(zhì)量。將堅(jiān)持在我院復(fù)查、隨診期間兩次復(fù)查的時(shí)間間隔未超過90天并且復(fù)查次數(shù)不少于3次的使用傳統(tǒng)抗凝管理模式(患者定期到醫(yī)院門診復(fù)查隨診、醫(yī)生給出抗凝建議的抗凝管理模式)的患者分為A組,復(fù)查隨診期間兩次復(fù)查的時(shí)間間隔超過90天或復(fù)查次數(shù)少于3次的使用傳統(tǒng)抗凝管理模式的患者分為B組,對(duì)A、B兩組患者的年齡、性別、每次復(fù)查所耗費(fèi)時(shí)間與經(jīng)濟(jì)代價(jià)、每次復(fù)查是否需要親友陪同等可能影響患者抗凝隨訪依從性的相關(guān)因素進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:共隨機(jī)抽取機(jī)械瓣置換手術(shù)患者140例,失訪21例,完成隨訪119例,其中死亡3例(2.52%)�；卦L患者中發(fā)生腦梗塞患者2例(2.1%),嚴(yán)重出血并發(fā)癥1例(1.1%)。隨訪患者中,有7例采用自我管理的模式(患者通過獲得的復(fù)查結(jié)果,并沒有找醫(yī)生咨詢結(jié)果,而是通過自己的理解及自己掌握的相關(guān)知識(shí)自己調(diào)整華法林,自己決定下次復(fù)查時(shí)間)進(jìn)行抗凝管理,其他患者均使用的是傳統(tǒng)抗凝管理模式,未發(fā)現(xiàn)使用其他新型抗凝管理模式的患者。A組60例患者INR檢測(cè)值共692次,其中INR最低值為0.84,最高值為6.75,患者INR值處于極端低抗凝水平占26.16%,相對(duì)安全范圍占70.63%,極端高抗凝水平占3.61%。B組患者有27例,其患者INR值處于極端低抗凝水平占31.79%,相對(duì)安全范圍占61.59%,極端高抗凝水平INR占6.62%。通過線性內(nèi)插法計(jì)算A組患者TTR,TTR最小為0,最大為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組患者不符合TTR計(jì)算標(biāo)準(zhǔn)未計(jì)算TTR。比較A、B兩組患者的性別、年齡及患者每次復(fù)查所需時(shí)間的差異,差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),比較A、B兩組患者每次復(fù)查是否需要親友陪同、每次復(fù)查耗費(fèi)金錢多少的差異性,有顯著差異(P0.05)。結(jié)論:傳統(tǒng)抗凝管理模式下患者抗凝治療質(zhì)量欠理想,加強(qiáng)隨訪是保證抗凝安全的一種有效方法,需要進(jìn)一步探索時(shí)間-經(jīng)濟(jì)效益更好的管理模式為患者提供更多的便利。有患者自發(fā)采用了自我管理模式,其抗凝質(zhì)量需進(jìn)一步研究論證�；颊呙看螐�(fù)查需要人陪同、單次復(fù)查耗費(fèi)財(cái)力相對(duì)較大等因素降低了患者復(fù)查隨訪的依從性,抗凝管理人員應(yīng)加強(qiáng)對(duì)這類患者的宣教與隨訪。
[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 鹵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.
【學(xué)位授予單位】：遵義醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2

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