Lackner T E, Battis G N
Pharmacy Corporation of America, Minneapolis, USA.
Arch Fam Med. 1995 Dec;4(12):1017-26. doi: 10.1001/archfami.4.12.1017.
To assess warfarin sodium use and anticoagulant monitoring in nursing home patients with nonvalvular atrial fibrillation (NVAF), according to American College of Chest Physicians Consensus Conference guidelines.
Retrospective, multicenter, point-prevalence study.
Nursing homes in Minneapolis-St Paul, Minn.
Nine-hundred two patients 60 years and older, from whom 69 with a diagnosis of NVAF and 16 with valvular atrial fibrillation (VAF) (control group) were identified.
Patient demographics and diseases, diagnostic tests for atrial fibrillation (AF), antithrombotic drugs and dosage, anticoagulant activity test results, other drugs, and drug allergies were determined by chart review and attending physician response to written communication from the nursing home's medical director and consultant pharmacist.
Prevalence of NVAF, VAF, and risk factors for thromboembolism and major bleeding, use of warfarin and other antithrombotic drugs for AF, anticoagulation control, and the relationship of warfarin dose with the recommended international normalized ratio (INR) and prothrombin time (PT).
Nonvalvular AF was documented in 7.6% of the patients. Most patients with NVAF were at an increased risk for stroke, yet only 20% without a conventional contraindication to warfarin use experienced anticoagulation; a greater proportion of patients with VAF experienced anticoagulation. The INR was within the recommended range for NVAF over a 6-month period 37% of the time and recommended PT, 52% of the time. An equal percentage of warfarin dose changes occurred in response to a PT ratio outside the recommended range as occurred with an INR outside the recommended range.
Many nursing home patients have NVAF with comorbid conditions that subject them to a greater than average risk for thromboembolic stroke. Warfarin is underused for stroke prophylaxis and often is not used according to the American College of Chest Physician guidelines. Physicians, nurses, and consultant pharmacists must be better informed about (1) known risk factors for thromboembolism and major bleeding to identify patients with AF who will most likely benefit from warfarin therapy, (2) maintaining an INR of 2 to 3, and (3) the need for small warfarin dose adjustments in elderly patients.
根据美国胸科医师学会共识会议指南，评估疗养院中非瓣膜性心房颤动（NVAF）患者华法林钠的使用情况及抗凝监测情况。
回顾性、多中心、现患率研究。
明尼苏达州明尼阿波利斯 - 圣保罗的疗养院。
902名60岁及以上患者，其中确诊为NVAF的患者69例，瓣膜性心房颤动（VAF）患者16例（对照组）。
通过病历审查以及主治医生对疗养院医疗主任和顾问药剂师书面函件的回复，确定患者的人口统计学和疾病信息、心房颤动（AF）的诊断检查、抗血栓药物及剂量、抗凝活性测试结果、其他药物以及药物过敏情况。
NVAF、VAF的患病率以及血栓栓塞和大出血的危险因素，用于AF的华法林和其他抗血栓药物的使用情况、抗凝控制情况，以及华法林剂量与推荐的国际标准化比值（INR）和凝血酶原时间（PT）的关系。
7.6%的患者记录有非瓣膜性AF。大多数NVAF患者发生中风的风险增加，但在无华法林使用常规禁忌证的患者中，只有20%接受了抗凝治疗；VAF患者接受抗凝治疗的比例更高。在6个月期间，INR有37%的时间处于NVAF推荐范围内，推荐的PT有52%的时间处于该范围内。因PT比值超出推荐范围而发生的华法林剂量变化百分比与因INR超出推荐范围而发生的变化百分比相同。
许多疗养院患者患有NVAF并伴有合并症，这使他们发生血栓栓塞性中风的风险高于平均水平。华法林在预防中风方面使用不足，且常常未按照美国胸科医师学会指南使用。医生、护士和顾问药剂师必须更好地了解以下内容：（1）已知的血栓栓塞和大出血危险因素，以识别最可能从华法林治疗中获益的AF患者；（2）将INR维持在2至3；（3）老年患者需要小幅调整华法林剂量。
