Фибрилляция предсердий и приверженность к пероральной антикоагулянтной терапии: разбор клинических случаев

М.С. Дешко, С.Л. Бойко, Н.В. Шпак, В.А. Снежицкий

УО «Гродненский государственный медицинский университет»

Распространенность фибрилляции предсердий (ФП) продолжает увеличиваться. Инсульт у пациентов с ФП является наиболее неблагоприятным осложнением аритмии и отличается тяжелым течением, выраженностью неврологического дефицита и высокой вероятностью летального исхода по сравнению с другими причинами инсульта. Пероральная антикоагулянтная терапия (ОАК) позволяет значимо снизить риск инсульта и других системных эмболий, но одновременно несет риск геморрагических осложнений. Высокая приверженность к лечению является главным условием эффективности и безопасности ОАК. Проблема приверженности в лечении хронических заболеваний, требующих постоянного приема лекарственных средств, остается нерешенной. Социальные, экономические и демографические факторы, психологические особенности личности пациента, инерционность системы здравоохранения, формализм в реализации рекомендаций в условиях рутинной клинической практики, нарушение преемственности между стационарным и амбулаторно-поликлиническим звеном, ограничения ресурсной базы и другие факторы формируют низкую приверженность среди пациентов с ФП. Отказ, прерывистый прием, несвоевременное назначение ОАК, невыполнение рекомендаций по контролю модифицируемых факторов риска, сопутствующих антикоагулянтной терапии, трансформируются в высокий уровень сердечно-сосудистых и церебрососудистых событий у пациентов с ФП. В настоящей статье представлен разбор трех клинических случаев пациентов с осложненным течением ФП, обсуждается лечение с позиций доказательной медицины, роль низкой приверженности в развитии осложнений, препятствия на пути повышения приверженности.

ключевые слова: фибрилляция предсердий, пероральная антикоагулянтная терапия, приверженность, инсульт, инфаркт миокарда, внутричерепное кровоизлияние

для цитирования: М.С. Дешко, С.Л. Бойко, Н.В. Шпак, В.А. Снежицкий. Фибрилляция предсердий и приверженность к пероральной антикоагулянтной терапии: разбор клинических случаев. Неотложная кардиология и кардиооваскулярные риски, 2020, Т. 4, № 2, С. 1019–1028

Atrial fibrillation and adherence to oral anticoagulation: review of clinical cases

M.S. Dzeshka, S.L. Boyko, N.V. Shpak, V.A. Snezhitskiy

Prevalence of atrial fibrillation (AF) is continuously increasing. Stroke in AF patients is the most unfavorable complication of arrhythmia, clinical course being severer, neurological deficit pronounced, and mortality higher compared to stroke patients without AF. Oral anticoagulation (OAC) results in significant reduction of stroke and systemic embolism but at the same time is compromised by haemorrhagic complications. High adherence to treatment is essential for effectiveness and safety of OAC. Nonetheless, poor adherence to treatment in case of chronic diseases requiring drug regimen remains unresolved. Social, economic and demographic factors, patient’s psychological markers, inertia of the healthcare system, formalism in the implementation of recommendations in routine clinical practice, violation of the continuity between inpatient and outpatient care, limited resources and other factors lead to low adherence among patients with AF. Refusal of OAC, intermittent treatment, delayed medication with OAC, failure to follow recommendations for the control of modifiable risk factors associated with anticoagulant therapy, are transformed into a high level of cardiovascular and cerebrovascular events in patients with AF. This article presents an analysis of three clinical cases of patients with complicated AF, discusses treatment from the standpoint of evidence-based medicine, the role of low adherence in the development of complications, and obstacles to increasing adherence.

keywords: atrial fibrillation, oral anticoagulation, adherence, stroke, myocardial infarction, intracranial bleeding

for references: M.S. Dzeshka, S.L. Boyko, N.V. Shpak, V.A. Snezhitskiy. Atrial fibrillation and adherence to oral anticoagulation: review of clinical cases. Neotlozhnaya kardiologiya i kardioovaskulyarnye riski [Emergency cardiology and cardiovascular risks], 2020, vol. 4, no. 2, pp. 1019–1028

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