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抗血小板疗法预防早期复发性卒中
Antiplatelet Treatment to Prevent Early Recurrent Stroke


Peter M. Rothwell ... 心脑血管疾病 • 2020.07.16
相关阅读
• 替格瑞洛联合阿司匹林用于轻型卒中或短暂性脑缺血发作患者 • 急性缺血性卒中或短暂性脑缺血发作后应用替格瑞洛联合阿司匹林与阿司匹林单药治疗的比较 • 氯吡格雷和阿司匹林治疗急性缺血性卒中和高危短暂性脑缺血发作 • 急性短暂性脑缺血发作或轻型卒中的双重抗血小板治疗:阐明益处 • 卒中和短暂性脑缺血发作的治疗进展 • 氯吡格雷联合阿司匹林治疗对短暂性脑缺血发作或轻度卒中有益

不采取紧急治疗的情况下,短暂性脑缺血发作(TIA)或轻型卒中患者在发病后1周内的重型卒中风险高达10% 1。一些研究表明,立即使用抗血小板药和他汀类药物并控制血压可将上述风险降低70%~80% 1,2,这主要受益于阿司匹林3,但7日期间复发性卒中的残余风险仍达到2%~3% 4。鉴于阿司匹林的效果,采用另一种药物进行更强化的抗血小板治疗或采用双联抗血小板治疗可否降低这一残余风险?

在TIA或轻型卒中后的急性期,迄今并无其他单一抗血小板药表现出明显优于阿司匹林的效果,而双嘧达莫和西洛他唑的效果似乎不及阿司匹林3。替格瑞洛被广泛用于预防冠状动脉血栓事件5,但其在TIA或卒中后二级预防中的效果不太明确。一项试验在急性轻型缺血性卒中或高危TIA患者中直接比较了替格瑞洛和阿司匹林单独用药的效果,结果表明替格瑞洛组的次要结局(早期复发性缺血性卒中)风险较低6,尤其是在卒中发病后12小时内开始用药的情况下,并且替格瑞洛组的颅内出血或颅外大出血风险未增加。然而,在上述试验中,替格瑞洛未显著降低卒中、心肌梗死或死亡(复合主要终点)的风险,P值为0.07。





作者信息

Peter M. Rothwell, F.Med.Sci.
From the Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.

 

参考文献

1. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of Urgent Treatment of Transient Ischaemic Attack and Minor Stroke on Early Recurrent Stroke (EXPRESS Study): a prospective population-based sequential comparison. Lancet 2007;370:1432-42.

2. Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953-60.

3. Rothwell PM, Algra A, Chen Z, Diener H-C, Norrving B, Mehta Z. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: timecourse analysis of randomised trials. Lancet 2016;388:365-75.

4. Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med 2016;374:1533-42.

5. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045-57.

6. Johnston SC, Amarenco P, Albers GW, et al. Ticagrelor versus aspirin in acute stroke or transient ischemic attack. N Engl J Med 2016;375:35-43.

7. Pan Y, Elm JJ, Li H, et al. Outcomes associated with clopidogrel-aspirin use in minor stroke or transient ischemic attack: a pooled analysis of Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) and PlateletOriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trials. JAMA Neurol 2019;76:1466-73.

8. Bath PM, Woodhouse LJ, Appleton JP, et al. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet 2018;391:850-9.

9. Johnston SC, Amarenco P, Denison H, et al. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA. N Engl J Med 2020;383:207-17.

10. Amarenco P, Albers GW, Denison H, et al. Efficacy and safety of ticagrelor versus aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 2017;16:301-10.

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