Nishtala P S, Castelino R L, Peterson G M, Hannan P J, Salahudeen M S
School of Pharmacy, University of Otago, Dunedin, New Zealand.
Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia.
J Clin Pharm Ther. 2016 Jun;41(3):279-84. doi: 10.1111/jcpt.12385. Epub 2016 Apr 7.
Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy.
This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy.
The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments.
Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.
抗栓药物可降低心房颤动（AF）患者的中风风险。然而，老年人抗栓药物的最佳处方仍具挑战性。本研究的目的是评估老年护理院房颤患者的中风风险，并探讨药剂师主导的药物评估对抗血栓治疗使用情况的影响。
本回顾性研究纳入了2011年8月至2012年12月间澳大利亚悉尼老年护理院经认证的药剂师进行的匿名住宅药物管理评估（RMMRs）随机样本。研究参与者为146名65岁及以上居住在低级别和高级别住宅护理机构的房颤患者。在药物评估前后，对患者的抗血栓治疗进行检查。使用CHADS2、CHA2DS2-VASc和HEMORR2HAGES评分工具评估中风和出血风险，并确定抗血栓治疗的适宜性。
研究对象的平均年龄（±标准差）为88.4（7.5）岁，女性占63.7%（n = 93）。大多数居民（n = 99，67.8%）年龄在85至99岁之间。CHADS2评分的平均值（±标准差）为3.1（1.1），CHA2DS2-VASc为4.6（1.5），HEMORR2HAGES为2.3（1.0）。所有居民均被归类为中风高风险人群。146名房颤患者中，共有115名（78.8%）接受了抗栓药物治疗。抗凝药物的使用相对较少（28.1%），药物评估药剂师很少建议改变房颤的血栓预防治疗方案。应用CHA2DS2-VASc风险工具显示，146名居民符合抗血栓治疗条件；其中，74名（50.7%）接受了抗血小板药物治疗，41名（28.1%）接受了抗凝药物治疗。在31名（21.2%）未接受抗栓药物治疗的房颤患者中，21名（67.7%）有抗凝治疗的相对禁忌症。
尽管抗血栓药物的总体使用率较高，但研究发现，符合条件的老年房颤患者不愿意开具或推荐使用抗凝药物，这可能是由于相关禁忌症和多种疾病并存所致。使用指南推荐的中风风险工具可帮助药物评估药剂师优化老年房颤患者的抗血栓治疗。
