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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 黃瑞仁(Juey-Jen Hwang),何藴芳(Yunn-Fang Ho) | |
dc.contributor.author | Yu-Tzu Tung | en |
dc.contributor.author | 童宥慈 | zh_TW |
dc.date.accessioned | 2021-06-13T03:28:47Z | - |
dc.date.available | 2007-08-03 | |
dc.date.copyright | 2006-08-03 | |
dc.date.issued | 2006 | |
dc.date.submitted | 2006-07-27 | |
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dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/32032 | - |
dc.description.abstract | 雖然自1980年開始,國際間陸續有慢性心臟衰竭(chronic heart failure)治療準則公布,但許多研究發現,臨床上對於在治療準則中所建議的藥品有使用不足的情況。因此,本研究採病歷檢閱的方式,以臺大醫院左心室收縮性心臟衰竭(left ventricular systolic dysfunction)病患為研究群體,收錄自民國92年8月1日至93年7月31日間其心臟超音波檢查左心室射出率≦40%的715名病患,進行病因及處方型態分析,以了解心臟衰竭病患的治療現況。 本研究結果顯示,冠狀動脈心臟病和高血壓是最常見的可能病因(59.4%、57.3%)。利尿劑是最多病患使用的藥品(74.7%),ACEIs/ARBs的處方率為59.1%,但β-blockers的處方率只有36%;在藥品劑量方面,則不論是ACEIs/ARBs或是β-blockers,使用的劑量約只有治療準則中所建議最大劑量的六分之ㄧ到二分之ㄧ。 有許多因子會影響這些藥品的處方率,包括病患的年齡、可能病因、所併有之其他疾病、腎臟功能等,以及影響最大的是病患的診治專科別。也就是說,當病患接受心臟外科或其他科別醫師的照護時,其處方ACEIs/ARBs、β-blockers或是spironolactone的校正勝算比,比心臟內科醫師來的低許多,為0.199-0.638 (p<0.05)。 為了要詳細找出病患無法使用這些藥品的原因,本研究將收入的病患與四個大型心臟衰竭藥品臨床試驗,包括SOLVD(enalapril)、MERIT-HF(metoprolol)、RALES(spironolactone)以及Val-HeFT(valsartan)的納入/排除條件做比較。其中,有34.3%的病患符合SOLVD,這些病患使用ACEIs/ARBs的比例為71.1%;15.9%病患符合MERIT-HF,有使用β-blockers的佔41.9%;10.1%病患符合RALES,使用spironolactone的比例為74.6%;以及23.2%符合Val-HeFT,其中使用ACEIs/ARBs有65.4%。 以上數據顯示,即使病患已符合臨床試驗的條件了,原則上應無任何理由不使用這些藥品,但僅ACEIs/ARBs(SOLVD)和spironolactone(RALES)與不符合之病患相比,處方率有明顯增加;另兩個臨床試驗則無顯著差異。因此,確實有藥品使用不足的情形。另外,本研究也試著將病歷上有記載或病患有實驗室檢驗值異常(如Scr)之未用藥原因加以分析,但仍無法得到處方率偏低之滿意的解釋。 本研究提供了目前臺大醫院對於心臟衰竭病患的處方情形,對於ACEIs/ARBs以及β-blockers的處方比例,仍有許多改善的空間,尤其是β-blockers。因此,仍然需要持續的促進醫療人員對於治療準則的認識及了解這些藥品的風險與利益平衡,對於每名病患才能做出最適合的判斷與處置,達到對於病患最佳之醫療照護。 | zh_TW |
dc.description.abstract | Since 1980, a number of guidelines and expert consensus documents for the management of chronic heart failure have been issued by different organizations and other related societies, however, many western studies suggested that the heart failure treatment in daily practice, showing a tendency toward underuse of recommended medications, has not been fully complied with these guidelines. In order to understand the local practice pattern, the aim of this study was to assess how patients with heart failure were managed at a medical center in Taiwan. With an attempt to analyze the etiologies and prescribing patterns of chronic heart failure in Taiwan, we retrospectively reviewed charts of 715 patients whose echocardiograms, acquired between Auguset 2003 and July 2004, showed left ventricular systolic dysfunction (LVEF≦40%). We found that coronary artery disease (59.4%) and hypertension (57.3%) were the most common possible etiologies. Diuretics (74.7%) were most frequently prescribed for patients. Prescription rate of ACEIs/ARBs was 59.1%, yet β-blockers were used only in 36% of patients. Daily dosages of ACEIs/ARBs and, particularly, β-blockers were below their respective recommended target doses on average. Multiple logistic regression analysis of these heart failure prescriptions indicated that the possible etiologies, age, co-morbid factors, renal function, and especially, the physicians’ subspecialties influenced the rate of prescription for recommended medications. That is, non-cardiologists were less likely to prescribe ACEIs/ARBs, β-blockers, and spironolactone (OR=0.199-0.638, p < 0.05) for patients with left ventricular systolic dysfunction. Four internationally renowned large placebo-controlled chronic-heart-failure trials including SOLVD, Val-HeFT, MERIT-HF, and RALES have proved ACEIs, ARBs, β-blockers, and spironolactone to be safe and effective, respectively. To further elucidate possible reasons for deviating from evidence-based life-saving pharmacotherapy, we have selected appropriate patients who also fulfilled the enrolment criteria of those randomized trials for analysis. We would like to identify, in real world, the proportion of patients eligible for evidenced-based treatment and the rate of appropriate prescription. Our data demonstrated that patients who fulfilled enrolment criteria of the four identified trials mentioned above were more likely to be treated with ACEIs/ARBs (71.1% of SOLVD-eligible patients vs. 52.7% in SOLVD-ineligible patients, p<.0001 and 65.4% of Val-HeFT-eligible patients vs. 57.1%, p=0.0834), β-blockers (41.9% of MERIT-HF-eligible patients vs. 34.9%, p=0.1941), and spironolactone (74.6% of RALES-eligible patients vs. 31.3%, p<.0001) than trial-ineligible patients. In addition, an attempt to search for reasonable explanations of the unsatisfactory prescription rate was made by analyzing chart records and laboratory data with disappointing results. In summary, the study offered the prescription patterns of patients with chronic heart failure at a medical center in Taiwan. However, the prescription of recommended medications including ACEIs/ARBs and, particularly, β-blockers remains low. Continued medical education of chronic heart failure treatment guidelines is still warranted to improve the dissemination and implementation current knowledge in daily practice for a better care of individual patients. | en |
dc.description.provenance | Made available in DSpace on 2021-06-13T03:28:47Z (GMT). No. of bitstreams: 1 ntu-95-R93451004-1.pdf: 708890 bytes, checksum: d6ab53c6263bba8c93e8bfdd81503b77 (MD5) Previous issue date: 2006 | en |
dc.description.tableofcontents | 目錄
摘要 I Abstract IV 表目錄 IX 圖目錄 XII 第一章 前言 1 第二章 文獻探討 3 第一節 心臟衰竭疾病簡介 3 第二節 心臟衰竭治療藥品簡介 16 第三節 國外心臟衰竭處方型態分析 30 第四節 大型心臟衰竭藥品臨床試驗與EuroHeart Failure Survey病患特性及其藥品使用情形比較 34 第三章 研究目的 37 第四章 研究方法 38 第一節 研究設計 38 第二節 研究對象 39 第三節 資料收集 40 第四節 研究流程 46 第五節 統計方法 47 第五章 研究結果 49 第一節 病患特性 49 第二節 心臟衰竭病患處方型態分析 58 第三節 開方時藥品選用之預測因子分析 73 第四節 本研究病患與大型臨床試驗病患特性比較及其處方型態分析 80 第六章 討論 92 第一節 病患基本資料 92 第二節 處方型態 95 第三節 使用藥品之預測因子 102 第四節 臨床上病患與大型藥品臨床試驗收入病患之比較 106 第五節 研究限制 110 第六節 未來研究建議 112 第七章 結論 114 參考文獻 117 附錄一 病患紀錄表 129 表目錄 表2-1 心臟衰竭的原因 6 表2-2 ACC/AHA慢性心臟衰竭分級 8 表2-3 NYHA分級 8 表2-4 ACEIs使用在心臟衰竭病患的建議劑量 19 表2-5 β-Blockers治療心臟衰竭的起始劑量與目標劑量 22 表2-6 Candesartan使用在心臟衰竭病患的臨床試驗 28 表2-7 文獻中各類藥品的處方比例 31 表2-8 比較EuroHeart Failure Survey中,符合大型藥品臨床試驗之納入/排除條件和不符合之病患其藥品使用比例 36 表2-9 符合個別臨床試驗條件之病患藥品使用比例 36 表4-1 四個大型藥品臨床試驗之病患納入/排除條件 44 表5-1 納入病患人數 50 表5-2 病患基本資料 52 表5-3 病患心臟衰竭之可能病因 56 表5-4 病患依性別之可能病因差異 57 表5-5 病患出院藥或最近一次門診處方 60 表5-6 依病患診治專科別之病患特性及處方型態 61 表5-7 病患追蹤一年後處方型態 66 表5-8 ACEIs/ARBs之處方型態 67 表5-9 β-Blockers之處方情形 68 表5-10 ACEIs/ARBs處方劑量 70 表5-11 β-Blockers處方劑量 71 表5-12 使用至少50%目標劑量之人數百分比 72 表5-13 ACEIs/ARBs單變項分析 74 表5-14 ACEIs/ARBs多變項分析 75 表5-15 β-Blockers單變項分析 76 表5-16 β-Blockers多變項分析 77 表5-17 Spironolactone單變項分析 78 表5-18 Spironolactone多變項分析 79 表5-19 本研究與大型臨床試驗研究對象收錄條件之比較 82 表5-20 本研究中符合四個臨床試驗條件之病患特性 83 表 5-21 符合臨床試驗納入條件之病患排除原因 90 表6-1 本研究與EuroHeart Failure Survey病患族群比較 93 表6-2 本研究與EuroHeart Failure Survey之病因比較 94 表6-3 本研究與EuroHeart Failure Survey各藥品使用比例 99 表6-4 本研究與Patel等人之研究結果比較 99 表6-5 與Lenzen等人之研究比較符合臨床試驗條件病患之藥品使用情形 109 圖目錄 圖2-1 心臟衰竭stage A的治療 10 圖2-2 心臟衰竭stage B的治療 12 圖2-3 心臟衰竭stage C的治療 14 圖5-1 病患年齡層分布 53 圖5-2 病患腎臟功能(Scr)分布 53 圖5-3 病患左心室射出率(LVEF)分布 54 圖5-4 依病患診治專科別之處方型態 62 圖5-5 依病患Scr分布之處方型態 63 圖5-6 依病患住院或門診分布之處方型態 64 圖5-7 病患追蹤一年後處方型態 66 圖5-8 SOLVD之納入過程 86 圖5-9 MERIT-HF之納入過程 87 圖5-10 Val-HeFT之納入過程 88 圖5-11 RALES之納入過程 89 | |
dc.language.iso | zh-TW | |
dc.title | 左心室收縮性心臟衰竭病患病因及處方型態之回溯性研究 | zh_TW |
dc.title | The Retrospective Study of Etiologies and Prescribing Patterns of Patients with Left Ventricular Dysfunction | en |
dc.type | Thesis | |
dc.date.schoolyear | 94-2 | |
dc.description.degree | 碩士 | |
dc.contributor.advisor-orcid | ,何藴芳(yfho@ntu.edu.tw) | |
dc.contributor.oralexamcommittee | 林俊立,何奕倫 | |
dc.subject.keyword | 心臟衰竭,病因,處方型態,處方率, | zh_TW |
dc.subject.keyword | heart failure,etiology,prescribing pattern,prescription rate,ACEI,ARB,beta-blocker,spironolactone, | en |
dc.relation.page | 147 | |
dc.rights.note | 有償授權 | |
dc.date.accepted | 2006-07-28 | |
dc.contributor.author-college | 醫學院 | zh_TW |
dc.contributor.author-dept | 臨床藥學研究所 | zh_TW |
顯示於系所單位: | 臨床藥學研究所 |
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