氯吡格雷联合阿司匹林治疗对轻型卒中与短暂性脑缺血发作患者功能预后的影响：CHANCE与POINT试验联合分析

目的 评价氯吡格雷联合阿司匹林双抗治疗对轻型缺血性卒中与TIA患者功能预后的影响。 方法 提取CHANCE和POINT试验所有的个体数据。这两项试验中,所有纳入患者在症状发作12 h （POINT）或24 h（CHANCE）以内随机接受氯吡格雷联用阿司匹林或单用阿司匹林治疗。结局指标为3个 月时功能预后不良（mRS≥2）,三等级定义卒中复发[致残性或致死性卒中复发（mRS≥2）、非致残性 卒中复发（mRS 0或1）、无卒中复发]。 结果 共10 013例患者纳入分析,其中来自CHANCE试验5132例（51.3%）,来自POINT试验4881例 （48.7%）;氯吡格雷联用阿司匹林组4995例（49.9%）,单用阿司匹林组5018例（50.1%）。氯吡格雷联 用阿司匹林组3个月时功能预后不良的患者比例低于单用阿司匹林组（11.6% vs 12.6%,校正OR 0.82, 95%CI 0.72～0.94,P =0.005）。氯吡格雷联用阿司匹林组致残性或致死性卒中复发（4.6% vs 6.1%, 校正OR 0.73,95%CI 0.61～0.87,P <0.001）、非致残性卒中复发（1.9% vs 3.0%,校正OR 0.62,95%CI 0.47～0.80,P <0.001）和卒中复发的整体致残性（校正cOR 0.70,95%CI 0.60～0.81,P <0.001）低于单 用阿司匹林组。 结论 与单用阿司匹林治疗相比,氯吡格雷联用阿司匹林治疗可进一步改善轻型缺血性卒中和TIA 患者3个月时功能预后,减少致残性卒中复发。     

血栓弹力图评价缺血性脑血管病患者服用不同小剂量阿司匹林疗效

抗血小板药物能显著降低非心源性脑缺血性卒中或TIA患者再次严重血管事件的发生率[1].阿司匹林和氯吡格雷是经循证医学证实可常规应用的抗血小板聚集药,2010年中国缺血性卒中或TIA发作二级防治指南及2011年AHA/ASA关于缺血性卒中或TIA发作患者卒中预防指南指出:对于非心源性缺血性卒中和TIA的抗栓治疗,氯吡格雷75mg和阿司匹林50mg～325mg均可作为首选药物[2,3].     

缺血性卒中的抗栓治疗和溶栓治疗（摘要）

这篇关于卒中的预防和治疗的文章是美国胸科医师学会循证临床实践指南（第8版）抗血栓治疗和溶栓治疗中的一部分。1级推荐是证据充分的，并且表示做（或不做）带来的益处高于风险、负担和成本。2级推荐是根据不同患者的情况作出不同的选择。这篇文章中关键的推荐如下：对于急性缺血性卒中患者，若在有明确症状发作的5h内开始治疗，建议静脉用组织型纤溶酶原激活物（tPA）（级别1A）；对于发病5-4.5h的急性缺血性卒中的患者，建议临床医生不要静脉使用tPA（级别2A）；对于发病大于4.5h的患者，反对静脉使用tPA（级别1A）。对于没有溶栓治疗的急性缺血性卒中患者，建议早期使用阿司匹林治疗（级别1A）。对于活动受限的急性缺血性卒中患者，推荐预防性应用小剂量肝素或低分子量肝素皮下注射（级别1A）。对于非心源性栓塞性卒中或短暂性脑缺血发作（TIA）的患者（如：动脉粥样硬化性，腔隙性或隐源性）的长期卒中预防，推荐使用抗血小板药物（级别1A），包括阿司匹林（推荐剂量，50-100mg／d）；合用阿司匹林与缓释型双嘧达莫莫（25mg／200mg，每日2次）或氯吡格雷（75mg，每日1次）。在这些患者中，推荐合用阿司匹林与缓释型双嘧达莫（25mg／200mg，每日2次）优于阿司匹林（级别1A）；而且建议氯吡格雷优于阿司匹林（级别2B）；并且推荐：避免长期合用阿司匹林与氯吡格雷（级别1B）。对阿司匹林过敏的患者，推荐使用氯吡格雷（级别1B）。对于最近有卒中或TIA的心房颤动患者，推荐长期口服抗凝剂（目标INR2.5；范围2.0-5.0）（级别1A）。对于静脉窦血栓形成的患者，推荐在急性期使用普通肝素（级别1B）或低分子肝素抗凝治疗优于不抗凝治疗。     

缺血性卒中患者出院降压药物应用现状及其影响因素

目的 本研究旨在评估中国城市29家医院缺血性卒中（ischemic stroke,IS）合并高血压病患者出院时降压药物应用情况及其影响因素。方法 本调查为多中心横断面研究,通过连续收集诊断明确的IS患者人口学信息、既往病史、出院降压药物应用及医院资源信息,进行统计分析。结果 2011年3月1～31日期间,29家Ⅱ级或Ⅲ级医院神经内科出院的IS患者,893例合并高血压病,出院时降压药物应用率73.35％,处方一种降压药比例为41.99%。应用的降压药物中,比例最高的是钙离子拮抗剂（54.54%）。多因素分析后显示心房颤动［比值比（odds ratio,OR）0.39;95%可信区间（confidence interval,CI）0.22～0.68;P =0.0009］、心功能不全病史（OR 0.32;95%CI 0.15～0.65;P =0.0017）与应用降压药物有关,而未成立卒中单元（OR 1.98;95%CI 1.42～2.75;P <0.0001）及神经内科病床＜70张（OR 1.57;95%CI 1.12～2.19;P =0.0080）与未应用降压药物有关。结论 中国城市卒中合并高血压患者降压药应用率相对不足,应加以改进提高,并合理规范应用。     

非心源性卒中患者出院抗血小板药物应用现状及影响因素

目的本研究旨在评估中国城市29家医院非心源性性卒中患者出院时抗血小板药物应用情况及影响因素。方法本调查为多中心横断面研究,通过连续收集诊断明确的非心源性卒中患者人口学信息、既往史、出院抗血小板药物应用及医院资源信息,明确抗血小板药物应用情况及影响因素。结果 2011-03-01—03-31 29家二级或三级医院神经内科出院的994例非心源性卒中患者,出院时抗血小板药物应用率94.37%。抗血小板药物应用最多的是阿司匹林(59.27%)。多因素分析显示,女性(OR=0.530,95%CI0.302~0.930,P=0.0269)、脑出血史(OR=0.131,95%CI 0.040~0.430,P=0.0008)、消化道出血史(OR=0.085,95%CI0.034~0.210,P<0.0001)与未应用抗血小板药物有关。结论中国城市非心源性卒中患者抗血小板药物应用率相对不足,应加以改进,并合理规范应用。     

嘉兴地区急性缺血性卒中合并心房颤动患者抗凝治疗现状分析

目的 调查嘉兴地区急性缺血性卒中合并心房颤动患者的抗凝治疗现状。 方法 回顾性分析2016年1月-2020年12月基于CT临床数据采集系统对卒中医疗质量改进的研究登 记库-Ⅱ（computer analysing system to improve stroke management quality evaluation-Ⅱ,CASE-Ⅱ）中的 嘉兴地区卒中中心登记的急性缺血性卒中合并心房颤动住院患者的信息。根据患者出院是否带有抗 凝药物分为出院抗凝组与出院未抗凝组,比较两组患者的基本特征,采用logistic回归分析出院抗凝 药物使用的影响因素;并进一步在既往诊断心房颤动且卒中高危（CHA2DS2-VASc≥2分）患者亚群中分 析抗凝药物使用的影响因素。 结果 共纳入患者2005例,平均年龄77±8岁,男性979例（48.8%）,NIHSS中位评分5（2～13）分。 无抗血栓治疗禁忌证患者1817例,出院时带抗血栓药物比例为83.9%（1525/1817）,其中抗凝药 物比例为41.3%（750/1817）。年龄（OR 0.964,95%CI 0.952～0.976）,基线NIHSS评分（OR 0.935, 95%CI 0.920～0.951）,住院时间（OR 1.045,95%CI 1.025～1.066）,深静脉血栓（OR 2.797, 95%CI 1.472～5.311）,住院期间是否发生任意的颅内出血（OR 0.085,95%CI 0.038～0.188）、消化 道出血（OR 0.503,95%CI 0.257～0.985）、肺炎（OR 0.646,95%CI 0.488～0.856）是急性缺血性卒中 合并心房颤动患者出院接受抗凝治疗与否的独立影响因素。既往诊断心房颤动且卒中高危患者接受 抗凝治疗比例仅为16.0%（153/954）,低龄（OR 0.957,95%CI 0.938～0.975）、低收缩压（OR 0.985, 95%CI 0.977～0.993）、卒中/TIA病史（OR 2.773,95%CI 1.954～3.936）是其接受抗凝治疗的独立保护 因素。 结论 嘉兴地区急性缺血性卒中合并心房颤动患者的抗凝治疗率较低,低龄、低基线NIHSS评分、 长住院时间、合并深静脉血栓的患者更多接受抗凝治疗,住院期间发生颅内出血、消化道出血和肺炎 的患者更少接受抗凝治疗。     

血小板高反应性、坚果消费状况与大动脉粥样硬化性脑梗死复发的相关性研究

目的 探讨血小板高反应性、坚果消费状况与大动脉粥样硬化性脑梗死复发的相关性。 方法 采用前瞻性队列研究，连续收集2016年10月-2018年10月在西安交通大学第二附属医院神经 内科住院治疗的大动脉粥样硬化性脑梗死患者的临床资料，包括患者的一般资料、对阿司匹林/氯 吡格雷治疗反应性和坚果消费情况。所有患者共随访6个月，根据缺血性卒中是否复发将患者分为复 发组和对照组。通过多因素Logistic回归分析探讨血小板高反应性、坚果消费情况与缺血性卒中复发 的关系。 结果 最终共纳入214例患者进行分析，其中缺血性卒中复发组36例（16.8%），对照组178例 （83.2%）。复发组糖尿病患病率、入院时基线LDL-C水平高于对照组，差异有统计学意义。复发组坚 果消费率为11.1%（4/36），低于对照组21.3%（38/178），但差异无统计学意义；复发组人群坚果摄 入量（P90）为6.6 g/d，坚果消费者的坚果摄入量（P50）为9.0 g/d，均较对照组偏低，但差异均无统 计学意义。复发组阿司匹林抵抗及氯吡格雷抵抗的检出率较对照组高（27.8% vs 17.4%；55.6% vs 31.5%），但只有氯吡格雷抵抗在两组间差异有统计学意义（P =0.006）。Logi sti c回归分析显示，氯 吡格雷抵抗（OR 2.813，95%CI 1.282～6.171，P =0.010）、糖尿病（OR 3.485，95%CI 1.571～7.729， P =0.002）、高LDL-C水平（OR 1.710，95%CI 1.078～2.710，P =0.023）是大动脉粥样硬化性脑梗死复发 的独立危险因素。 结论 氯吡格雷抵抗与大动脉粥样硬化性脑梗死复发有关；复发患者中坚果消费低于无复发患者， 但未能证明坚果消费是脑梗死复发的影响因素。     

河北省南和县农村卒中患者二级预防药物依从性及其相关因素分析

目的 分析河北省南和县农村卒中患者应用二级预防抗血小板药物、他汀类药物和降压药物的服 药依从性现状，并探讨其影响因素。 方法 本研究使用群组随机对照试验“南和县实用创新型脑卒中防治项目”的基线调查数据。该横 断面调查于2017年7月抽取位于5个镇的50个村，每村抽取符合纳入和排除标准的卒中患者开展问卷 调查及体格检查。问卷主要信息包括：社会人口学信息、患病史、社会支持、服药依从性等。患者服 药依从性根据Morisky Green Levine量表评测。采用多因素Logistic回归分析法分析患者抗血小板药物、 他汀类药物和降压药物服药依从性的影响因素。 结果 共纳入1299例卒中患者，平均年龄65.7±8.2岁，男性746例（57.4%）。服用抗血小板类、他汀 类、降压药物的患者分别占依照诊断史估测应服药人数的72.0%（852/1184）、28.4%（340/1197）和 91.1%（1030/1131）。服药患者中，药物依从率分别为63.0%（537/852）、63.5%（216/340）和62.6% （645/1030）。多因素分析显示，自我感知照护需求低的患者（OR 0.58，95%CI 0.45～0.75，P＜0.001）， 服用抗血小板药物依从性好；有卒中复发史患者（OR 2.09，95%CI 1.17～3.71，P =0.013）服用他汀类 药物依从性差，无吸烟史患者（OR 0.43，95%CI 0.19～0.97，P =0.043）服用他汀类药物依从性好。 年龄较大（OR 0.97，95%CI 0.95～0.99，P =0.004）、服2种以上药物（OR 0.54，95%CI 0.39～0.75， P ＜0.001）、自我感知照护需求低（OR 0.58，95%C I 0.40～0.84，P =0.004）及无吸烟史患者 （OR 0.63，95%CI 0.41～0.84，P =0.046）服用降压类药物依从性好。 结论 河北省南和县农村卒中患者二级预防合理用药率较低，服药患者依从性不佳，服药依从性 与患者年龄、吸烟史、卒中复发史、服药数量、自我感知照护需求等因素相关。     

强化抗血小板治疗在缺血性脑卒中复发高危患者二级预防中的临床研究

目的观察强化抗血小板药物氯吡格雷在缺血性脑卒中复发高危患者二级预防中的长期疗效及安全性。方法采用艾森卒中风险评分（ESRS）量表筛选住院的急性非心源性缺血性脑卒中复发高危患者100例,随机分为氯吡格雷组和阿司匹林组,每组50例。两组均给予脑卒中常规治疗,氯吡格雷组予氯吡格雷75mg及阿司匹林100mg口服,1周后仅予氯吡格雷75mg,口服。阿司匹林组予阿司匹林200mg,口服,1周后改为100mg,口服。随访3个月和1年,观察两组缺血性脑卒中复发率及药物不良反应发生率。结果随访3个月时,脑卒中复发率：阿司匹林组为6．3％,氯吡格雷组为2．0％,差异无统计学意义（P〉0．05）;药物不良反应发生率：阿司匹林组为14％,氯吡格雷组为2％,差异有统计学意义（P〈0．05）。随访1年时,脑卒中复发率：阿司匹林组为13％,氯吡格雷组为2％,差异有统计学意义（P〈0．05）;药物不良反应发生率：阿司匹林组为38％,氯吡格雷组为6％,差异有统计学意义（P〈0．01）。结论缺血性脑卒中复发高危患者二级预防中强化抗血小板治疗可降低脑卒中复发风险,长期应用获益较高,安全性好。     

缺血性脑血管病二级预防药物依从性与卒中复发的关系研究

目的 调查中国缺血性脑血管病患者二级预防药物依从性的现状，探讨急性缺血性脑血管病患者 3个月二级预防药物的依从性与1年卒中复发的关系。 方法 研究纳入18岁以上的首发急性缺血性卒中或TIA患者。药物依从性被定义为随访期间规律服 用所有出院时所带的二级预防药物。采用多变量Logistic回归分析出院3个月二级预防药物依从性的影 响因素及出院3个月药物依从性与1年卒中复发之间的关系。 结果 研究共纳入2768例病例，平均年龄为（62.3±11.4）岁，女性988例（35.7％）。3个月随访 时，药物依从者2016例（72.8%），非依从性者752例（27.2%），药物依从性最高的是抗血小板药物 （95.3％），随后是降糖药物（90.9％）、降压药（90.2％）和降脂药物（85.4％），抗凝药的依从性最 低（73％）。糖尿病史（OR 1.40，95%CI 1.14～1.73，P =0.0016）和降糖药物使用史（OR 1.43，95%CI 1.14～1.79，P =0.0022）可能是药物依从性的影响因素，但校正年龄、性别后两者对药物依从性的影 响均无统计学意义。校正年龄、性别、医保类型、吸烟、疾病史、家族史等混杂因素后，Logistic回归 结果显示3个月二级预防药物依从性是出院1年的卒中复发率降低的独立影响因素（OR 0.36，95％CI 0.14～0.91，P =0.0301）。 结论 急性缺血性脑血管病患者3个月药物依从性良好是1年卒中复发率降低的独立影响因素。     

Survey of blood pressure control status in patients with ischemic stroke or transient ischemic attack in China

OBJECTIVE: We sought to assess the current status of blood pressure control and the use of antihypertensive drugs in patients with ischemic stroke (IS) or transient ischemic attack (TIA) in China. SUBJECTS AND METHODS: A cross-sectional study (across 19 urban outpatient clinics) on secondary stroke prevention measures was conducted. All subjects diagnosed with IS or TIA at neurological clinics were enrolled consecutively. Face to face interviews were conducted by a trained neurologist and research assistant using questionnaire at the same day of enrollment. RESULTS: A total of 2283 IS or TIA patients were included in the survey. A history of hypertension was present in 1509 patients, of which 896 (59.4%) had uncontrolled blood pressure. A history of hypertension was absent in 603 patients, of whom 162 (26.9%) had uncontrolled blood pressure. In addition, 495 (88.9%) of patients with diabetes mellitus had uncontrolled blood pressure (systolic blood pressure > or = 130 mmHg or diastolic blood pressure > or = 80 mmHg). In multivariate logistic regression analysis, having monthly income of > 1000 yuan [odds ratio (OR): 2.040; 95% confidence interval (CI): 1.277-3.259), female (OR: 1.546; 95% CI: 1.174-2.034) and smoking habits (OR: 1.428; 95% CI: 1.014-2.013) remained significantly associated with blood pressure control. In contrast, compound preparation (OR: 0.685; 95% CI: 0.473-0.993) was inversely associated with the likelihood of blood pressure control. CONCLUSION: Blood pressure control rate among IS or TIA patients in major metropolitan clinics is an important issue in China which might largely influence the efforts in stroke prevention and treatment. Further works are needed to develop substantive quality improvement strategies of stroke secondary prevention care.     

Antiplatelet agents and randomized trials

Patients who have transient ischemic attack (TIA) or ischemic stroke are at a high risk of having a first or recurrent stroke. The annual risk is between 5% and 15%; the risk is highest in the first 48 hours following a TIA and highest in the first 7 days following an ischemic stroke. Secondary prevention includes antithrombotic therapy, treatment of risk factors, and interventional treatment of carotid stenosis. Antithrombotic options can include antiplatelet drugs such as aspirin, aspirin plus extended-release dipyridamole (ER-DP), clopidogrel, or clopidogrel plus aspirin. Oral anticoagulation is used in patients with a cardiac source of embolism such as atrial fibrillation. Aspirin monotherapy offers a modest risk reduction for recurrent stroke and for the combined endpoint of nonfatal stroke, myocardial infarction (MI), and vascular death. The combination of ER-DP and aspirin was shown to be superior to aspirin monotherapy in several trials. Clopidogrel is superior to aspirin in high-risk patients suffering from stroke, MI, or peripheral arterial disease. The combination of clopidogrel plus aspirin is not superior to aspirin or clopidogrel monotherapy and carries a significantly higher bleeding risk. The combination might offer benefit in short-term secondary prevention after TIA or stroke. Another ongoing trial is currently investigating the possible benefit and side effects of aspirin plus ER-DP versus clopidogrel in secondary stroke prevention.     

Combined clopidogrel–aspirin treatment for high risk TIA or minor stroke does not increase cerebral microbleeds

Abstract

Objectives:

To study whether Clopidogrel–Aspirin combined treatment for high risk transient ischaemic attack (TIA) or minor stroke results in increased number of lesions associated with anti-thrombotic cerebral haemorrhage or cerebral micro-bleeds (CMB) than aspirin alone treatment.

Methods:

The patients recruited in CHANCE test in our hospital participated in this study. We made a comparison between treatments Aspirin–Clopidogrel combined group and the Aspirin alone group in the numbers of CMB and subsequent cerebral haemorrhages. In addition, we analysed the association between the increased numbers of CMB and subsequent intracerebral haemorrhages. All 129 patients with high risk TIA with microbleeds or minor stroke within 24?hours after the onset (average age 65.9?±?9.3, 48.7% were male patients) were divided randomly into two groups: (1) 67 patients were given combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300?mg, then 75?mg per day for 90?days, plus aspirin at a dose of 75?mg per day for the first 21?days);(2) the rest patients were given aspirin treatment (75?mg per day for 90?days). All participants received open-label aspirin at a clinician-determined dose of 75–300?mg on the first day.

Results:

The CMB were found in 52.7% of all patients in both groups. There was no siginificant difference between the Aspirin group and the Aspirin–clopidogrel treated group, though the latter showed some slight increase in CMB (Odds ratios (OR)?=?1.16, 95% confidence intervals (CI) =?0.54–2.47, P?=?0.71). But the numbers of CMB were remarkably associated with the number of primary existing CMB (OR?=?6.46, 95%CI 2.57–16.23, P?<?0.001), especially that of primary existing CMB ≥?3.In addition, the increasing numbers of CMB associated with primary CMB lesions, which located in corticosubcortical area (CSC) (OR?=?4.69, 95%CI 1.51–14.53, P?=?0.007).

Conclusions:

For the treatment of high-risk TIA or minor stroke patients, the clopidogrel–aspirin treatment did not increase the number of CMB than Aspirin alone. It appears that the extent of CMB was associated with the extent of existing CMB occurred in previous stroke, which was mostly located in cortical, subcortical zone.     

Antiplatelet drugs: how to select them and possibilities of combined treatment

Antiplatelets are the pivotal drugs in preventing recurrent stroke or other major vascular events in patients who have undergone TIA or stroke. Aspirin is the most widely used, although its effect is very modest (relative risk reduction 20%), and most physicians use between 100 and 325 mg daily as a maintenance dose. For patients who develop stroke on aspirin treatment, the options are either to increase the dose of aspirin or to administer another anti-aggregate. No study has yet been performed to support these approaches. In patients who cannot tolerate aspirin, the options are clopidogrel 75 mg once daily or dipyridamole 400 mg combined with 50 mg aspirin. An approach which is very appealing, but not yet proven is to combine different antiplatelet drugs with different modes of action, such as aspirin and clopidogrel, in order to achieve a better and more effective antithrombotic effect. Further controlled trials are needed to justify this approach.     

Clopidogrel response in ischemic stroke patients: Is polymorphism or gender more important? Results of the CRISP study

Clopidogrel (CLP) is a second generation thienopyridine drug commonly used in secondary prevention of ischemic stroke (IS). Its antiplatelet response maybe variable due to genetic and non-genetic factors. Adipokines may affect platelet aggregation through ADP mediated platelet signalling. However, the combined effect of CYP genetic variants and adipokines on antiplatelet response of clopidogrel is unclear. Patients of IS/Transient ischemic attack (TIAs) within 3 months were prospectively screened following clopidogrel treatment. Major exclusions were cardioembolic and non atherosclerotic strokes. Antiplatelet effect of clopidogrel along with adipokine (Leptin and adiponectin) levels and genotyping of CYP, P2Y12 gene were investigated. Rare genetic variants were confirmed by DNA sequencing. 204 patients with ischemic stroke/TIAs were screened and 163 were recruited. 85 (52.1%) patients were poor responders to clopidogrel. Antiplatelet response to clopidogrel was weaker in females [Median 8.0 (IQR: 3.0–14.0)] compared to males [Median 5.0 (IQR: 2.0–10.0)]. In female subgroup analysis, association was found among high leptin levels and PPI (+) usage in poor responders. None of the genetic variants (CYP2C19*2,*3,*4*, CYP2C9*3, CYP2B6 and P2Y12) were found to influence the antiplatelet effects (p > 0.05). On multivariable logistic regression, a poor clopidogrel response was associated with female gender (Adjusted OR 2.55, 95% CI: 1.05–6.18) and PPI usage (Adjusted OR 2.42, 95% CI: 1.09–5.34). Despite a high prevalence of clopidogrel resistance in the North Indian stroke patients, female gender rather than genetic polymorphisms of CYP and P2Y12 genes may influence its antiplatelet effect. Further research may ascertain the role of gender on clopidogrel response.     

Clopidogrel in addition to aspirin reduces in-hospital major cardiac and cerebrovascular events in unselected patients with acute ST segment elevation myocardial

We sought to assess the effect of clopidogrel on in-hospital events in unselected patients with acute ST elevation myocardial infarction (STEMI). In a retrospective analysis of consecutive patients enrolled in the Acute Coronary Syndromes (ACOS) registry with acute STEMI we compared outcomes of either adjunctive therapy with aspirin alone or aspirin plus clopidogrel within 24 hours after admission.A total of 7,559 patients were included in this analysis, of whom 3,541 were treated with aspirin alone, and 4,018 with dual antiplatelet therapy.The multivariable analysis with adjustment for baseline characteristics and treatments showed that the rate of in-hospital MACCE (death, non-fatal reinfarction, non-fatal stroke) was significantly lower in the aspirin plus clopidogrel group,compared to the aspirin alone group in the entire cohort and all three reperfusion strategy groups (entire group odds ratio 0.60, 95% CI 0.49-0.72 , no reperfusion OR 0.69,95% CI 0.51-0.94,fibrinolysis OR 0.62,95% CI 0.44-0.88, primary PCI OR 0.54, 95% CI 0.39-0.74).There was a significant increase in major bleeding complications with clopidogrel (7.1% vs. 3.4%, p<0.001). In clinical practice early adjunctive therapy with clopidogrel in addition to aspirin in patients with STEMI is associated with a significant reduction of in-hospital MACCE regardless of the initial reperfusion strategy.This advantage was associated with an increase in major bleeding complications.     

Preceding Antithrombotic Treatment is Associated With Acute Ischemic Stroke Severity and Functional Outcome at 90 Days Among Patients With Atrial Fibrillation

BackgroundAntithrombotic therapies are known to prevent ischemic stroke (IS) for patients with atrial fibrillation (AF), but are often underused in clinical practice. The aim of present study was to investigate the prevalence of patients with acute IS with known history of AF who were not receiving antithrombotic treatment before stroke and to evaluate the association of preceding antithrombotic treatment with stroke severity and outcomes at 90 days after admission.Materials and MethodsThis was a retrospective, multi-center, observational study of 748 patients with acute IS and known history of AF admitted to 6 participating hospitals between March 2016 and October 2017. The primary outcome was stroke severity at admission as assessed using National Institutes of Health Stroke Scale (NIHSS) score. The secondary outcome was functional outcome at 90 days after admission as measured by modified Rankin Scale (mRS) score.ResultsA total of 748 patients, 54 (7.2%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥ 2) and 100 (13.4%) had subtherapeutic warfarin anticoagulation (INR < 2), 340 (45.5%) were receiving antiplatelet treatment, and 254 (34.0%) were not receiving any antithrombotic treatment prior to stroke. Compared with no antithrombotic treatment, therapeutic warfarin (OR: 0.64; 95% CI: 0.52-0.82; P = .022), and antiplatelet therapy only (OR: 0.89; 95% CI: 0.76-0.96; P = .041) were associated with lower odds ratio of moderate or severe stroke (NIHSS ≥ 16). Patients receiving preceding therapeutic warfarin (OR: 1.32; 95% CI: 1.22-3.57; P = .025), antiplatelet therapy only (OR: 1.13; 95% CI: 1.07-2.59; P = .043), and subtherapeutic warfarin with INR 1.5 to 1.99 (OR: 1.15; 95% CI: 1.10-2.66; P = .042) had higher odds ratio of better functional outcome (mRS ≤ 2) at 90 days.ConclusionsAmong patients with AF who had experienced an acute IS, inadequate therapeutic warfarin preceding the stroke was very prevalent in China. Therapeutic warfarin was associated with less severe stroke and better functional outcome at 90 days.     

大脑中动脉分布区缺血性卒中患者的临床和影像学特征及复发危险因素

目的 分析大脑中动脉（middle cerebral artery，MCA）分布区非心源性缺血性卒中患者的临床和影像 学特征及复发的危险因素。 方法 连续入选发病7 d以内的MCA分布区非心源性缺血性卒中患者。收集患者的人口学信息、血管 病的危险因素和发病时的主要症状及体征，评价患者的头颅磁共振影像包括急性梗死灶的部位、 数量、分布特征、责任动脉有无狭窄、缺血性卒中的病因分型。随访患者1年内有无缺血性卒中或短暂 性脑缺血发作（transient ischemic attack，TIA）复发，通过多元Logistic回归分析患者复发的危险因素。 结果 研究共入组926例患者，责任MCA狭窄≥70%的患者（447例）常见多发梗死灶（338例，75.6%） 和分水岭梗死（317例，70.9%），而责任MCA无狭窄或狭窄程度<70%患者（479例）常见MCA穿支分 布区单发梗死灶（247例，55.3%）。冠状动脉粥样硬化性心脏病[比值比（odds ratio，OR）7.55，95%可 信区间（confidence interval，CI）2.85～20.0，P <0.001]、缺血性卒中病史（OR 3.49，95%CI 1.52～8.01， P =0.003）、缺血性卒中发病前3个月内反复TI A史（OR 22.7，95%CI 8.35～61.6，P <0.001）、新发梗死 灶为多发（OR 5.26，95%CI 1.33～20.8，P =0.018）是患者1年内缺血性卒中或TIA复发的危险因素。 结论 对于非心源性缺血性卒中患者，MCA分布区梗死灶的分布特征与MCA狭窄程度有关。新发梗 死灶为多发、既往有缺血性心脑血管病病史的患者1年缺血性卒中或TIA复发风险高。     

Network meta-analysis of prasugrel, ticagrelor, high- and standard-dose clopidogrel in patients scheduled for percutaneous coronary interventions

Since novel antiplatelet treatments (prasugrel, ticagrelor, high-dose clopidogrel) have been predominantly tested against standard-dose clopidogrel, data on direct comparisons between these therapies are scarce. We therefore indirectly compared their efficacy and safety in patients undergoing percutaneous coronary intervention. Electronic databases were searched systematically to identify head-to-head randomised controlled trials (RCTs). Network meta-analysis was performed using generalised linear mixed models with adjustment for length of follow-up. Findings were corroborated by mixed treatment comparison through Bayesian methods. Fourteen RCTs were identified and included in the analysis (high- vs. standard-dose clopidogrel: 9 trials, prasugrel vs. high-dose clopidogrel: 2 trials, prasugrel vs. standard-dose clopidogrel: 2 trials, ticagrelor vs. standard-dose clopidogrel: 1 trial). No significant differences were found for efficacy outcomes except for stent thrombosis favouring prasugrel (vs. ticagrelor: odds ratio [OR] 0.63, 95% confidence interval [CI]: 0.42, 0.94; vs. high-dose clopidogrel: OR 0.70, 95%CI: 0.48, 1.01). Prasugrel exhibited a similar bleeding risk as high-dose clopidogrel, but more major (OR 1.43, 95%CI 1.07, 1.90) and major or minor bleeding (OR 1.36, 95%CI 1.09, 1.69) compared to ticagrelor. Ticagrelor was also associated with less major or minor bleeding compared to high-dose clopidogrel (OR 0.81, 95%CI 0.69, 0.96). No differences were seen for non CABG-related major bleeding between the three strategies. Results were corroborated in a subgroup analysis comprising only patients with acute coronary syndromes. In the absence of head-to-head clinical trials, network meta-analysis suggests potentially relevant differences in efficacy and bleeding risk among novel antiplatelet treatments and may thereby advance understanding of their differential therapeutic properties.