鍾國彪Chung, Kuo-Piao臺灣大學:醫療機構管理研究所紀俊麟Chi, Chun-LinChun-LinChi2010-05-052018-06-292010-05-052018-06-292009U0001-1708200915122100http://ntur.lib.ntu.edu.tw//handle/246246/180890背景: Clopidogrel藥物已經是急性心肌梗塞的標準治療之一，但初始劑量的最佳給藥時間為何，仍然沒有定論。的: 研究Clopidogrel藥物給藥時間與急性心肌梗塞病患預後的相關性。料與方法: 本研究為回溯性、觀察性研究，針對2004年9月至2006年8月期間，三間醫院共254名急性心肌梗塞病患進行資料收集。排除不適用此藥物之病患後，研究人員收集病患基本資料、給藥時間、以及病患是否發生併發症之情況。病患進一步被分為早期治療組(到院時間至給藥時間間距小於四小時)以及晚期治療組(到院時間至給藥時間間距大於四小時)。果: 早期治療組之併發症機率明顯較晚期治療組低 (早期治療組併發症機率2.8%、晚期治療組12.6%，P=0.003)。早期治療的益處，在邏輯式迴歸分析以及分層分析之後，仍然相當顯著。晚期治療明顯與併發症有相關性，其勝算比為5.105，95%信賴區間為1.596 – 16.333，P=0.006。若將晚期治療組進一步分為兩個次群組(「4至24小時」，以及「大於24小時」)，則可觀察到「預後」與「給藥時間」的漸層相關性(Chi-square for trend, P=0.002)。超過24小時才接受到藥物的病患，其併發症發生率最高。論: 得到Clopidogrel藥物早期治療(小於四小時)之急性心肌梗塞病患，其併發症發生率較接受晚期治療之病患明顯降低。鍵字: clopidogrel, 急性心肌梗塞, 給藥時間Background: Although clopidogrel treatment has become a standard therapy in the management of acute myocardial infarction, the optimal timing for initial clopidogrel administration is yet to be determined.bjective: To explore the association of time of initial clopidogrel administration in the emergency department (ED) and patient outcomes.ethods: This retrospective, observational study was conducted at two university tertiary hospitals and one community hospital. Consecutive patients with acute myocardial infarction (n=254) were enrolled from September 2004 to August 2006. Patients with contraindications for clopidogrel treatment were excluded. Patient characteristics, initial treatment time, and adverse outcomes were recorded. Subjects were classified as early group (treatment initiated within 4 hours of ED arrival) and late group (treatment initiated later than 4 hours).esults: The early group demonstrated a much lower rate of adverse outcomes (2.8% vs. 12.6% in late group, P=0.003). The benefits of early administration of clopidogrel persisted after stratification and adjustment for patient and clinical factors. Late clopidogrel administration was associated with significantly increased adverse outcomes (adjusted odds ratio, 5.105, 95% confidence interval, 1.596 to 16.333, P=0.006). When the late group was further divided into two subgroups (4-24 hrs vs. > 24 hrs), a graded association was noted between time to initial clopidogrel administration and adverse outcomes (Chi-square for trend, P=0.002). Patients receiving clopidogrel >24 hours of ED presentation had the highest incidence of adverse outcomes.onclusions: Patients who receive early clopidogrel treatment in the ED have significantly reduced adverse outcomes after acute myocardial infarction.ey words: clopidogrel, myocardial infarction, timing of administrationContents試委員會審定書謝文摘要文摘要hapter 1 Introduction 1tudy Purpose 1hapter 2 Literature Review 2lopidogrel in Patients at Risk of Ischemic Events 2uidelines Regarding Clopidogrel Administration in Acute Coronary Syndromes 3on-ST-Segment Elevation Myocardial Infarction and Unstable Angina 3T-Segment Elevation Myocardial Infarction 6lopidogrel in Patients Undergoing Coronary Artery Bypass Grafting 6uality of Care in Acute Coronary Syndromes 8ummary of Literature Review 11hapter 3 Material and Method 12tudy design 12atient population 12ata abstraction 13tudy groups 13dverse events 14tatistical analysis 15hapter 4 Results 16iming of administration 16actors associated with timing of clopidogrel administration 17utcome differences between early group and late group 17ifference in STEMI and NSTEMI 18IMI risk scores 18hapter 5 Discussion 19ompliance rate of clopidogrel administration 19imeliness of clopidogrel administration and the impact on outcomes 20ifference in treatment patterns between NSTEMI and STEMI 22IMI Risk Scores 22imitations 23onclusion 23eferences 39ppendix 44ppendix 1: Recording Sheet for Acute Coronary Syndromes 44ppendix 2: ROC curve 45ppendix 3: IRB documentation 46ist of Tablesables 26able 1. Factors associated with clinical outcomes in patients with acute myocardial infarction 26able 2. Patient Baseline Characteristics According to Time to Clopidogrel Administration 28able 3. Factors Associated with Late Clopidogrel Administration 29able 4. Adverse Outcomes in Clopidogrel Early vs. Late Groups Stratified by Patient and Clinical Factors 30able 5. Characteristics and Adverse Outcomes of Clopidogrel Administration 31able 6. Adjusted and Unadjusted Odds Ratios of Adverse Outcomes According to Time-to-Clopidogrel Administration 32ist of Figuresigures 33igure 1. The Goal of Clopidogrel Treatment 33igure 2. Distribution of Timing of Clopidogrel Administration 34igure 3. Rate of Adverse Outcomes According to Time-to-Clopidogrel Administration 35igure 4. Age vs. Rate of Adverse Outcomes 36igure 5. Distribution of TIMI Risk Scores 37igure 6. Rate of Adverse Outcomes in Various TIMI Risk Groups 38application/pdf571510 bytesapplication/pdfen-USclopidogrel急性心肌梗塞給藥時間myocardial infarctiontiming of administrationthesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/180890/1/ntu-98-R95843003-1.pdf