神經內外科加護訓練課程班 part iii 謝鎮陽醫師 台南新樓醫院神經內科...
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神經內外科加護訓練課程班Part III
謝鎮陽醫師台南新樓醫院神經內科
成功大學藥學生物科技研究所2011/04/24
課程大綱 part III
• 心房顫動 vs. 中風• 如何提昇抗凝血劑的使用率 ?
• 使用個案實例• 淺談品質指標的建立、維持、及表現
Atrial fibrillation (AF)
http://heartstrong.files.wordpress.com/2009/06/atrial-fibrillation-lg.jpg
• AF是最臨床上常見的一種心率不整 1
• In 2007, 6.3 million people in the US, Japan, Germany, Italy, Spain, France and UK were living with diagnosed AF2
• Due to the aging population, this number is expected to double within 30 years3
1. Lloyd-Jones DM, et al. Circulation 2004;110:1042-1046. 2. Decision Resources. Atrial Fibrillation Report. Dec 2008. 3. Go AS, et al. JAMA 2001;285:2370-2375.
AF vs. ischemic stroke
http://www.nhlbi.nih.gov/health/dci/images/atrial_fib_stroke.jpg
AF會增加 ischemic stroke的機率
• AF is associated with a pro-thrombotic state
– ~5 fold increase in stroke risk1
• Risk of stroke is the same in AF patients regardless of whether they have paroxysmal or sustained AF2,3
• Cardioembolic stroke has a 30-day mortality of 25%4
• AF-related stroke has a 1-year mortality of ~50%5
1. Wolf PA, et al. Stroke 1991;22:983-988; 2. Rosamond W et al. Circulation. 2008;117:e25–146; 3.Hart RG, et al. J Am Coll Cardiol 2000;35:183-187; 4. Lin H-J, et al. Stroke 1996; 27:1760-1764; 5. Marini C, et al. Stroke 2005;36:1115-1119.
Stroke
• Up to 3 million people worldwide suffer strokes related to AF each year1-3
• AF-related strokes tend to be especially severe and disabling with half of patients dying within 1 year3
1. Atlas of Heart Disease and Stroke, World Health Organization, September 2004. Viewed at http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf
2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 2. 1991:22(8);983-8
3. Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996;27:1760-4
AF相關的 stroke是可以預防的• 2/3 of strokes due to AF are
preventable with appropriate anticoagulant therapy with a vitamin-K-antagonist (INR 2-3)1
• Anticoagulation with a vitamin-K-antagonist (VKA) is recommended for patients with ≥ 1 moderate risk factor2
• A meta-analysis of 29 trials in 28,044 patients showed that adjusted-dose warfarin results in a reduction in ischaemic stroke and in all-cause mortality1
Stroke Death
67% 26%
1. Hart RG et al. Ann Intern Med. 2007;146:857-867 2. Fuster V, et al. JACC. 2006; 48: 854-906
Effect of VKA compared to placebo
Secondary prevention: dosing
• Ischemic stroke, non-valvular AF
• Immediately with aspirin 300 mg/day
• Begin coumadin 5 mg/day, 3-14 days after stroke onset– Aim: INR=2.0 (about 4-5 days later)– Measured INR qod in 1st week
• Mostly: well controlled 4-6 weeks later
Case (1)
• A 73-year-old woman– Old ischemic stroke– Hypertension– Chronic atrial fibrillation
• Acute onset of aphasia– Found at 17:00, 2010-02-25
• NIHSS=19 at discharge (2010-03-05)– Coumadin (5) 1# qd since 2010-03-03– Aprovel (150) 1# qd
Case (1) (cont.)
• 2010-03-11:– BP=120/90 mmHg– INR=1.49– Keep coumadin (5) 1# qd
• 2010-04-08:– INR=1.75– Adjust coumadin (5) to 1#-1.5# qod (≈1.25# qd)
Case (1) (cont.)
• 2010-05-06:– INR=3.50– Adjust coumadin to 1.5# qd on W2,4 and 1# qd
on W1,3,5,6,7 (≈1.1# qd)
• 2010-06-03:– INR=2.34– Keep coumadin to 1.5# qd on W2,4 and 1# qd
on W1,3,5,6,7 (≈1.1# qd)
Case (2)
• A 81-year-old man– Hypertension– Hypercholesterolemia– Chronic atrial fibrillation
• Tanatril (10) 1# qd• Adalat OROS (30) 1# qn• Coumadin 0.5# qd
– Acute aphasia, 2010-05-21• NIHSS=8 at admission• INR=1.12• Add back coumadin (5) 0.5# qd since 2010-05-24 (discharge)
Case (2) (cont.)
• 2010-06-03:– Falling down from a bicycle on 2010-06-01– Lt frontal hematoma, racoon eye– BP=150/110 mmHg– INR=1.17– F/u brain CT: no new ICH nor skull fracture– Coumadin (5) 1# qd
• 2010-06-17:– INR=4.14– Change dose of coumadin ?
Case (3)
• A 61-year-old man– Hypertension with hypertensive cardiovascular disease– Hypercholesterolemia
• 2010-01-28– 09:10: acute left side weakness– 09:27: arrived ER (by EMS)– 09:30: examined by ER doctor– 10:01: brain CT– 10:30: neurologist (NIHSS=25)– 11:08: t-PA– 14:00: NIHSS=10, after t-PA
Case (3) (cont.)
• 2010-01-29:– 09:00, NIHSS=16– Brain CT (2nd)– EKG: atrial fibrillation, persistent
• 2010-02-23:– Add coumadin 1# qd after BP<140/90 mmHg
• 2010-02-26:– INR=2.02
Case (3) (cont.)
• 2010-03-06:– INR=3.48– NIHSS=13 at discharge– Hold coumadin and change coumadin to plavix
• Past history of peptic ulcer and gouty arthritis
• 2010-03-10– INR=1.03– Coumadin 0.5# qd
• 2010-04-28– Home BP around 148-200/90-129 mmHg– INR=1.04– Why?
• He took some herbal medicine (“通血路” -> induce high BP)• He DC coumadin by himself for acupuncture
Contraindication for coumadin
• Allergy– History of coumadin-related skin necrosis
• Bleeding tendency– ICH, active bleeding of GI, GU, respiratory tract
• Non-compliance• Unsupervised senile ( 老年人，無 family)• Psychotic condition ( 精神疾患 )• History or risk of fall ( 易跌倒 )• Uncontrolled hypertension• Endocarditis, pericarditis ( 心內膜或心包膜炎 )
Taiwan Stroke Registry
• 時間： 99.01.01~99.06.30• 急性缺血性中風病人且併心房顫動者之病人人次：
n=21– 有禁忌症者： n=9*
• 急性缺血性中風病人併心房顫動並使用抗凝血藥物之病人人次： n=11 (52.4%)– 比較：
• 馬偕醫院： 36%+
– 急性缺血性中風併心房顫動且無抗凝血藥物禁忌者之使用抗凝血藥物比率： 91.7%
+Acta Neurol Taiwan 2009
*病患之抗凝血劑禁忌明細• 住院中因腦中風死亡： n=3
• 長期臥床不易監測 PT(INR) ： n=3
• 上消化道出血： n=2
• 易出血腫瘤： n=1 (A huge left retro-peritoneal tumor)
9. AF抗擬血
91.7
66.7
100.0
0
20
40
60
80
100
1-6月 8-10月 11-12月
百分比
目標值99年
人都需要「比較」，才知好不好
品質指標的「眉角」• 分母要記得拿掉有 contraindication 的• 要有對照組• 要選比你差的當對照組• 用簡明的圖形來表現• 記得曲線總是要往好的方向發展
