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系統識別號 U0026-3007201218361800
論文名稱(中文) 急性心肌梗塞後次級預防藥物之使用型態及成效
論文名稱(英文) Utilization and Impact of Pharmacotherapy for Secondary Prevention after Acute Myocardial Infarction (AMI)
校院名稱 成功大學
系所名稱(中) 臨床藥學與藥物科技研究所
系所名稱(英) Institute of Clinical Pharmacy and Pharmaceutical sciences
學年度 100
學期 2
出版年 101
研究生(中文) 陳儀芳
研究生(英文) I-Fang Chen
學號 s66994019
學位類別 碩士
語文別 中文
論文頁數 113頁
口試委員 指導教授-高雅慧
口試委員-李貽恆
口試委員-李政翰
口試委員-高淑敏
中文關鍵字 心肌梗塞  次級預防  藥品使用 
英文關鍵字 myocardial infarction  secondary prevention  drug utilization 
學科別分類
中文摘要 中文摘要
研究背景
急性心肌梗塞(acute myocardial infarction)在已開發國家中一直是最常見的死因,其發生率及死亡率也是名列第一,在台灣,心臟疾病也是高居前十大死因之第二位。
當病人出現急性冠心症之症狀時,我們必須立即給予藥物治療,必要時可積極進行心導管介入性手術,最後,當病人病情穩定準備出院時,皆必須處方長期使用的次級預防藥品。
根據ACC/AHA國際治療指引,次級預防藥物治療包括主要四大類:抗血小板劑、乙型受體阻斷劑、RAAS抑制劑,以及降血脂劑。次級預防藥品在許多大型臨床試驗中已被證實,能有效地降低急性心肌梗塞後死亡率、心肌梗塞或心血管事件的再發生。
縱使許多研究證實次級預防藥品之效益,過去許多研究卻發現,臨床實際使用次級預防藥品的情形略顯偏低。
研究方法
我們運用2001-2009年全民健康保險資料庫,進行一個回溯性世代研究,納入2006年1月1日至2008年12月31日(含)間,首次診斷為急性心肌梗塞,且住院期間合併使用至少一樣抗血小板劑及肝素類之病人。此外,我們排除:年齡小於18歲、5年前曾有急性心肌梗塞之病人,住院日期前5年(含)內無納保紀錄者,及當次住院期間死亡者。
本研究主要目的有二,包括:追蹤病人發生急性心肌梗塞後,出院後30天內使用四大類次級預防藥品情形,以及可能影響處方藥品之因子,包括:人口學特性、共病症,或接受心導管介入性手術與否。並且,為了評估次級預防藥品使用成效,將病人依照不同使用藥品品項數分4組,追蹤一年後的存活率。



研究結果
主要研究對象共31666人,平均年齡65歲,男性占73%,超過2/3病人在住院期間接受經皮冠狀動脈擴張術。出院後30天內使用次級預防藥品情形: antiplatelets約84.59%,beta-blockers約51.58%,ACEIs/ARBs約60.13%,及statins約42.34%。然而,卻有9.23%病人未接受任何一樣次級預防藥品。
在影響因子部分,我們也觀察到藥品的使用會受到病人的年齡、性別、本身共病症,或住院期間是否接受經皮冠狀動脈擴張術而有所不同。
成效評估方面,本研究發現,隨著病人使用次級預防藥品品項數越多,可顯著降低死亡風險。
結論
心肌梗塞後使用次級預防藥品,可顯著降低病人的死亡風險,然而,在台灣使用藥物治療的情況並不理想。因此,為了提升醫療照護品質及改善病人的預後,在治療病人時,次級預防藥品的使用是有改善的空間。
英文摘要 Abstract
Background
Acute myocardial infarction (AMI) remains a common cause of death worldwide and continues to be the number one cause of morbidity and mortality. In Taiwan, heart disease is also responsible for second leading cause in 2010.
We give drug therapy or coronary revascularization when patients with symptoms of acute coronary syndrome. Finally, when patients are in the late phase of hospital discharge, they need long term medical therapy for secondary prevention.
According to American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend four drug categories for long-term treatment of patients after an acute coronary event, including antiplatelet therapy angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and statins.
Several studies confirmed that all these interventions are highly efficacious in reducing the recurrence of MI, the subsequent use of coronary interventions, or the risk of death. However, despite the effectiveness of preventive drugs, there is several evidences show that secondary prevention is underused after AMI in the real world.
Method
We conducted a retrospective cohort study by using 2001-2009 Taiwan’s National Health Insurance Research Database (NHIRD). We identified each patients’ first hospitalization for AMI (ICD-9: 410) which dated between January 1, 2006 and December 31, 2008. We included only those patients who were prescribed at least one antiplatelet and heparin groups during hospitalization.
Moreover, those who had been hospitalized for an AMI during the previous 5 years were excluded in order to select patient with first-time AMI. Those who were less than 18 years of age, who died during the hospitalization were also excluded.



The purposes of this study were two-fold. Firstly, we used a nationwide population-based database to determine prescribing pattern and associated factors of the four drug categories for secondary prevention following an AMI in Taiwan. Secondly, we aimed to assess the impact on different combination of secondary prevention medications and 1-year survival.
Results
We identified 31666 patients as our major study cohort. The mean age of the study cohort is 65 years old and nearly 73% of the sample patients are men.
Over two thirds of the patients underwent percutaneous coronary intervention. The use of antiplatelet medications at discharge was 85%, use of beta-blockers was 51.58%, and use of ACE inhibitors was almost 60% and lipid-lowering drugs were prescribed in 42.34%. Suprisingly, still 9.23% of patients didn’t receive any class of preventive drugs.
To identify variables that were predictive of the utilization of various drugs, we found that age, gender, preexisting comorbidity, and cardiac procedure during admission were associated with compliance with guideline.
For the impact of secondary prevention, use more of these agents was independently and strongly associated with lower 12-month mortality in patients with acute myocardial infarction.

Conclusions
Although pharmacotherapy for secondary prevention after AMI was effective, the utilization was suboptimal. Moreover, we also identified several factors affecting prescription of preventive medication. For a good quality care of AMI patients, we need to improve adherence to guidelines of management.
論文目次 目錄
中文摘要 I
Abstract III
誌謝 V
目錄 VII
表目錄 I
圖目錄 III
第一篇、急性心肌梗塞後次級預防藥物之使用型態及成效 1
第一章、研究背景 1
第二章、文獻回顧 2
第一節、急性心肌梗塞 2
第二節、急性心肌梗塞與次級預防藥物 6
第三節、病患接受次級預防藥品的影響因子 19
第四節、目前各國急性心肌梗塞後次級預防藥品治療使用評估的研究 22
第五節、次級預防藥物使用與成效評估 25
第六節、總結 26
第三章、研究目的及重要性 27
一、研究目的 27
二、研究之重要性 27
第四章、研究方法 28
第一節、研究設計 28
第二節、研究變項與操作定義 34
第三節、研究變項校正及排除條件之操作定義 38
第四節、資料處理流程 40
第五節、統計方法 41
第五章、研究結果 42
第一節、研究對象納入與排除 42
第二節、研究對象之人口學特性 44
第三節、觀察期間次級預防藥品使用型態 46
第四節、有/無使用次級預防藥品之基本資料比較 49
第五節、影響接受次級預防藥品的因素 57
第六節、次級預防藥物使用與成效評估 67
第六章、研究討論 73
第一節、研究對象之納入、排除條件之分析 73
第二節、次級預防藥品使用型態 74
第三節、使用次級預防藥品之影響因子 79
第四節、次級預防藥品使用之成效評估 87
第五節、研究限制 88
第七章、結論與建議 89
第八章、未來研究方向 90

第二篇、臨床藥事服務-靜脈輸注藥品電腦化醫囑系統之改善 91
第一章、前言 91
第二章、文獻回顧 93
第一節、注射藥品與給藥疏失 93
第二節、減少注射藥品給藥疏失的方法 93
第三節、電腦化醫令系統與靜脈注射藥物 95
第三章、服務目的 95
第四章、研究方法 96
第一節、建置時程 96
第二節、藥品資料庫整理 97
第三節、靜脈輸注藥品電子醫囑系統介面設計 97
第五章、臨床藥事服務結果 98
第一節、計畫與排程 98
第二節、藥品資料庫整理 98
第三節、靜脈輸注藥品電子化醫囑系統介面設計 101
第六章、心得與建議 105
參考文獻 106
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