CAJ | 학술논문

1例40岁男性患者,因发作性胸痛3年,加重6 h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.
1례40세남성환자,인발작성흉통3년,가중6 h입원.입원진단위:관심병,급성전벽심기경사,진구성하벽심기경사,PCI+지가치입술후.입원후급행관상동맥조영+PCI술,병급여항혈소판、항응、조지、은정반괴、개선심기결혈등치료.고필도신벌타정가능여록필격뢰존재대사매경쟁,종이도치록필격뢰항전효과불충분,림상약사건의장신벌타정조정위경CYP2C9대사적불벌타정,혹겁소경CYP2C19대사적서서벌타정;동시,대환자복용적쌍련항혈소판약물가능인기적위장도불괄혹출혈증상,이급타정류약물상관불량반응진행감측.병분석환자PCI술후지가내혈전형성적원인시항혈소판약물치료불충분급불건강적생활방식,병거차대환자진행용약교육,독촉환자준순건강적생활방식,보장환자용약안전、유효.
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, anticoagulation, 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.