Introduction
Atrial fibrillation is the most common clinical arrhythmia. Prevention of thromboembolic events caused by atrial fibrillation is a very important part of the treatment strategy for atrial fibrillation, but it is worth noting that in anticoagulation During the use of the drug, if it is used unreasonably, the effect of preventing thromboembolic events will not be achieved, and even a series of adverse reactions such as bleeding may be caused. At present, patients with atrial fibrillation generally have irregular use of anticoagulant drugs, and the standardized management of atrial fibrillation anticoagulation has a long way to go.
In order to better focus on patients, gather the common strength of clinical and pharmacy, and optimize and improve the quality of anticoagulation in atrial fibrillation, this time, we are honored to invite Mr. Zhao Shujuan from the clinical pharmacy of Henan Provincial People’s Hospital as the host guest. , Professor Sang Haiqiang from the Department of Cardiology of the First Affiliated Hospital of Zhengzhou University, and Qi Yuedong, deputy director of the Supply Department of the Department of Pharmacy of the First Affiliated Hospital of Zhengzhou University, were interview guests, and they talked about the anticoagulation of atrial fibrillation.
Professor Sang Haiqiang and Director Qi Yuedong made a wonderful summary of standardized anticoagulation in patients with atrial fibrillation
01
The harm of atrial fibrillation and the necessity of anticoagulation
The incidence of atrial fibrillation is increasing year by year. From 2001 to 2012, the prevalence of atrial fibrillation in China increased by 20 times. The prevalence of atrial fibrillation-related stroke increased 13-fold. Atrial fibrillation can lead to a series of adverse events such as death, stroke, heart failure, depression, dementia, hospitalization, and decreased quality of life.
Stroke is the most serious complication of atrial fibrillation. Ischemic stroke patients with atrial fibrillation have higher disability, recurrence and mortality rates than non-atrial fibrillation ischemic stroke patients. The 2020 ESC guidelines for atrial fibrillation propose an ABC comprehensive management pathway for patients with atrial fibrillation, where A is anticoagulation, which highlights the importance of anticoagulation in stroke prevention in patients with atrial fibrillation.
02 Development of anticoagulant drugs and rational anticoagulation
From the advent of heparin to warfarin, and low molecular weight heparin, to the advent of new oral anticoagulants, anticoagulation With the continuous expansion of the types of drugs, there are more options for anticoagulation in patients with atrial fibrillation. The efficacy and safety of new oral anticoagulants have been confirmed, and the patient compliance is better, and the current clinical use has increased significantly.
In clinical practice, three principles should be followed for individualized selection of anticoagulant drugs according to the specific conditions of patients: efficacy, safety, and economy. NOACs are the first-line choice for the management of patients with atrial fibrillation. Taking rivaroxaban as an example, its curative effect is definite and its safety is better than that of warfarin. At present, with the development of centralized VBP, the economic burden of patients using NOACs is further reduced. The economy of condensation is also guaranteed.
03 Precautions for clinical application of NOACs
Multiple factors should be considered in anticoagulation of atrial fibrillation, especially liver and kidney function. Anticoagulant therapy for patients with hepatic insufficiency can be adjusted according to the Child-Pugh score to adjust the dose and type of drugs. Child-Pugh score parameters included: encephalopathy, ascites, bilirubin, albumin, and INR.
NOACs need to adjust their medication according to renal function. In renal insufficiency, dabigatran is prohibited when CrCI is less than 30 mL/min; Doxaban, Apixaban. When CrCI is between 30 mL/min and 50 mL/min, NOACs need to adjust the dose.
The application of NOACs should pay attention to the concomitant medication of the patient. Combined use of antacids: the plasma concentration of dabigatran is reduced by 12%-30%, and rivaroxaban and edoxaban are not affected; Concomitant use of amiodarone: Rivaroxaban had a minor effect but increased plasma concentrations of dabigatran and edoxaban.
04 Original research VS imitation? Drug selection
Bioequivalence means that the geometric mean 90% CI of the main pharmacokinetic parameters of the generic drug is in the range of 80%-125% compared with the reference preparation (original drug), and the biological Equivalence is a study done in healthy people. The original drug has undergone large-scale evidence-based research and extensive patient population research, and its efficacy and safety have been well verified.
Should I choose a brand-name drug or a generic drug? Risk stratification of patients with atrial fibrillation should be performed clinically. For patients with high-risk CHA2DS2-VASc score and HAS-BLED score, it is recommended to use the original brand drug treatment to ensure the efficacy and safety of the treatment of patients with atrial fibrillation.
Completing VBP tasks with high quality, ensuring clinical demands, and meeting the needs of patients are crucial. When choosing anticoagulant drugs individually, it is necessary to take into account some special groups of drugs: such as the elderly, high-risk groups, For the perioperative group and the group with renal insufficiency, the patient should be truly centered, instead of “one size fits all”, drug withdrawal or discontinuation.
Conclusion In the context of VBP, we should be patient-centered, pay attention to the efficacy, safety and rational use of anticoagulant drugs, from the completion of the VBP task to the high-quality completion of the VBP task, so that the majority of atrial fibrillation patients can truly benefit from anticoagulation therapy.