抗血小板药物联合治疗在缺血性脑血管病中的应用

抗血小板药物具有不同的作用机制,用于治疗频发性动脉疾病,包括脑血管疾病。近期的脑血管及心血管试验表明,联合治疗可以有效的预防缺血性脑血管病。预防血栓形成的药物氯吡格雷,曾被誉为超级阿斯匹林,与阿斯匹林联合治疗脑缺血显示出比单独使用阿斯匹林更突出的功效。阿斯匹林与防治心绞痛控释药双嘧达莫联合治疗效果较为突出。尽管如此,缺血性脑血管病的抗血小板药物联合治疗仍然存在着某些争议。目前的研究旨在区分不同抗血小板联合剂的作用。     

Role of antiplatelet agents in cerebrovascular disease.

It is now generally accepted by neurologists that most transient ischaemic attacks, particularly in the carotid artery territory, have a thromboembolic basis. These emboli are, for the most part, fibrin-platelet aggregates. Others which contain atheromatous debris are more likely to produce longer lasting neurological deficits. If one assumes this hypothesis then it is reasonable to employ drugs which interfere with platelet aggregation in order to prevent cerebrovascular symptoms and signs. Acetylsalicylic acid (aspirin) prevents aggregation by inhibiting the 'release reaction' initiated by thromboxane A2. This inhibition lasts for the life of the affected platelets. Recent trials in the United States and Canada have demonstrated a positive clinical benefit from the employment of aspirin in patients suffering from transient cerebral ischaemic attacks and amaurosis fugax. There was a reduction or cessation of the attacks in both males and females and a 50% reduction of stroke morbidity and mortality in males.     

Combination antiplatelet agents for secondary prevention of ischemic stroke

Stroke is a leading cause of death and the primary cause of serious, long-term disability in the United States. Joint guidelines from the American Heart Association (AHA) and American Stroke Association (ASA), as well as recent guidelines from the Eighth American College of Chest Physicians (ACCP) Conference on Antithrombotic and Antiplatelet Therapy, recommend aspirin, clopidogrel, or extended-release dipyridamole plus aspirin as acceptable first-line options for secondary prevention of ischemic events in patients with a history of ischemic stroke or transient ischemic attack (TIA). The ACCP strongly recommends the combination of extended-release dipyridamole plus aspirin over aspirin monotherapy (highest level of evidence) and suggests clopidogrel monotherapy over aspirin monotherapy (lower level of evidence). The AHA-ASA guidelines suggest that either extended-release dipyridamole plus aspirin or clopidogrel monotherapy should be used over aspirin monotherapy. Both guidelines recommend avoiding the combination of clopidogrel and aspirin for most patients with previous stroke or TIA. Results from recent trials evaluating combination antiplatelet therapy have been published that enhance the AHA-ASA recommendations and provide the foundation for the updated ACCP guideline. To identify pertinent combination antiplatelet trials, a MEDLINE search of the literature from 1967-2007 was performed. Two trials were identified--the European-Australasian Stroke Prevention in Reversible Ischemia Trial (ESPRIT) and Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA). The ESPRIT compared aspirin monotherapy with the combination of aspirin plus extended-release dipyridamole for prevention of secondary ischemic events in patients with a history of TIA or minor stroke. The CHARISMA trial compared aspirin plus clopidogrel with aspirin alone in a population at high risk for atherothrombotic events using the composite outcome of myocardial infarction, stroke, and death from cardiovascular causes. Data from ESPRIT add to evidence that the combination of aspirin plus extended-release dipyridamole is superior to aspirin alone. The findings of the CHARISMA trial reinforce recommendations from both AHA-ASA and ACCP that the combination of aspirin and clopidogrel be reserved for special populations requiring this antiplatelet combination (e.g., those who have had coronary artery stenting).     

缺血性脑血管病患者脑微出血危险因素及抗血小板治疗的影响

目的 探析缺血性脑血管病患者合并发生脑微出血(cerebral microbleed,CMB)的相关危险性因素以及对抗血小板治疗的影响.方法 选取2018年6月至2020年6月南阳医学高等专科学校第一附属医院收治的缺血性脑血管病患者168例作为观察对象,根据常规的核磁共振检测以及磁敏感加权成像检测SWI将患者分为观察组...     

抗血小板药物在社区缺血性脑血管病患者中的应用

目的:了解社区缺血性脑血管病患者的抗血小板药物的应用情况,为提高缺血性脑血管病二级预防效果提供依据.方法:收集本社区登记在册的缺血性脑卒中患者286例和短暂性脑缺血发作(TIA)患者36例,分析患者出院时以及出院后6个月时使用抗血小板药物种类和剂量,以及患者未服用抗血小板药物的原因.结果:出院时,有305例患者在使用抗血小板药物,其中275例为缺血性脑卒中患者,服药率为96.2%(275/286);30例为TIA患者,使用率为83.3%(30/36),出院6月时,59例缺血性脑卒中患者和20例TIA患者已停止使用抗血小板药物,停药率分别为21.5%(59/275)和66.7%(20/30).停药原因依次分别是社区医生认为不需要使用(27.85%)、担心药物不良反应(22.78%)、自认为疾病好转不愿坚持服用(17.72%)、相信中成药物(17.72%)、就医不便(12.66%),经济原因(1.27%).结论:缺血性脑血管病发病早期抗血小板药物应用比例较高,出院6月时依从性下降,需专科医师与全科医师共同努力提高缺血性脑血管病患者使用抗血小板药物的依从性.     

Ticlopidine: a new antiplatelet agent for cerebrovascular disease

Ticlopidine is a new prototype antiplatelet drug chemically unrelated to currently available agents. It causes an alteration in platelet membrane reactivity to a variety of aggregating stimuli and a marked prolongation of bleeding time, the mechanism of which remains unclear. Two major phase III multicenter trials, the ticlopidine-aspirin stroke study (TASS) and the Canadian-American ticlopidine study (CATS) reported that the agent may reduce the occurrence of stroke, myocardial infarction, or vascular death in patients of both sexes who have had recent cerebral ischemia. Ticlopidine has been well tolerated in preliminary studies, with the most commonly described adverse effects being rash and gastrointestinal complaints. The most important adverse effect is neutropenia, which was reported in both TASS and CATS, approximating a frequency of 0.9% and 0.8%, respectively. Ticlopidine holds considerable promise as adjunctive therapy in selected patients.     

缺血性脑血管病治疗进展

缺血性脑卒中的治疗核心是改善脑灌注和保护脑损伤，病理生理改变分阶段性，因此治疗方法也各不相同。本介绍了有关治疗的新进展，包括溶栓治疗，抗凝剂应用，抗血小板药应用，神经保护剂应用，以及脑内移植，抗脑水肿，降低颅内压等。     

抗血小板药在缺血性脑血管病中的应用

<正>血小板在缺血性脑卒中的自然病程中起重要作用,大样本的临床研究结果表明,以阿司匹林为代表的抗血小板药物能明显减少短暂性脑缺血发作或缺血性卒中后的神经功能改变。抗血小板药物并不是指一类药物,而是一组通过各种不同机制降低     

甘露糖结合凝集素与缺血性脑血管病的相关性

目的 检测缺血性脑血管病(ICVD)与甘露糖结合凝集素(MBL)基因单倍型、基因型频率及血浆含量的相关性.方法 采集100例ICVD患者(ICVD组)和60例健康人群(对照组)抗凝血,序列特异性引物-聚合酶链反应(SSP-PCR)法检测MBL单倍型,ELISA法检测血浆MBL含量.结果 ICVD组与对照组MBL基因单倍型和基因型构成比均不同(P＜0.05);ICVD组血浆MBL含量明显高于对照组[(3372.18±660.90)μg/L vs.(2065.29±195.67)μg/L](P＜0.01).结论 MBL可能参与ICVD发生发展过程.     

地奥心血康治疗缺血性脑血管疾病

用地奥心血康２００ｍｇ，ｐｏ，ｔｉｄ，连用３０ｄ，治疗脑梗死３０例（男性１７例，女性１３例；年龄６３±ｓ１７ａ）和椎基底动脉供血不足３７例（男性１８例，女性１９例；年龄６１±９ａ），与对照组口服复方丹参片３片（０．９ｇ）ｔｉｄ加氟桂利嗪５ｍｇ，ｂｉｄ进行比较。地奥心血康的有效率分别为９０％和１００％，而对照组分别为８３％和９４％。对椎基底动脉供血不足，地奥心血康组优于照组（Ｐ＜０．０５）。提示地奥心血康具有良好的促进脑血管循环作用。     

降纤酶与川芎嗪治疗急性缺血性脑血管疾病的比较

目的：比较降纤酶与川芎嗪治疗急性缺血性脑血管疾病（ＡＩＣＤ）的疗效。方法：降纤酶组３２例（男性１７例，女性１５例；年龄５９±ｓ９ａ）用降纤酶１０ＩＵ加入０．９％氯化钠注射液２５０ｍＬｉｖ，ｄｒｉｐ，ｑｄ×３ｄ，ｄ４剂量减半，ｉｖ，ｄｒｉｐ，ｑｄ×３ｄ，均于１～１．５ｈ滴完。川芎嗪组３１例（男性１７例，女性１４例；年龄５７±８ａ）用川芎嗪２００ｍｇ加入０．９％氯化钠注射液２５０ｍＬ静滴×１２ｄ。结果：降纤酶组与川芎嗪组总有效率分别为９７％与８１％（Ｐ＜０．０１）；血小板聚集率、血液粘度２组均有显著下降，凝血因子Ｉ与血脂仅降纤酶组有显著下降（Ｐ＜０．０５或Ｐ＜０．０１），２组均无严重不良反应。结论：降纤酶治疗ＡＩＣＤ明显优于川芎嗪     

Current concepts in clinical therapeutics: ischemic cerebrovascular disease

The classification, epidemiology, pathophysiology, diagnosis, and treatment of ischemic cerebrovascular disease (ischemic stroke) are reviewed, and the major drugs used in the prevention of this disease are discussed. Ischemic stroke is a major problem in terms of morbidity and mortality because of the high prevalence of atherosclerosis in the United States population. The pathogenesis of cerebral ischemia is multifactorial, beginning with an atherosclerotic plaque on the arterial wall that may result in stenosis or ulceration with subsequent thrombosis or embolization. Platelets may adhere to the exposed arterial wall endothelium, stimulating further platelet aggregation and accumulation of leukocytes and fibrin. Consequences of cerebral ischemia include transient ischemic attacks and brain infarcts. Diagnosis is based mainly on patient history and ancillary radiologic studies. Treatment of ischemic cerebrovascular disease is primarily preventive, since the brain has limited capacity to recover neurologic function after an infarction. Transient ischemic attacks are treated with either antiplatelet agents, anticoagulants, or surgery. Treatment of stroke is also preventive, although anticoagulation is sometimes used to prevent stroke progression. Agents that may reverse neurologic impairment following an acute stroke, such as prostacyclin, calcium-channel blockers, and opiate antagonists, are being investigated. Antiplatelet therapy is indicated in subsets of patients with cerebral vascular insufficiency. Anticoagulation therapy, if needed, should be given for only three to four months.     

性激素与缺血性脑血管疾病关系的研究

目的：研究性激素对脑梗塞发病的影响。方法：应用放射免疫分析法测定了48例男性脑梗塞患者及相应30例男性健康对照组的血清孕酮（P）雌二醇（E2）和睾酮（T）水平，用化学比色方法测定了血脂（TG、TC、HDL－C）。结果：血清P、HDL－C在脑梗塞患者较对照组显著降低，P＜0．01。血清E2在脑梗塞患者较对照组显著升高，P＜0．05，而TG、TC两组间无显著差异（P＞0．05），脑梗塞组血清P水平与HDL－C水平呈显著正相关P＜0．05，而血清E2水平与HLD－C水平无明显相关，血清T在脑梗塞组和对照组无明显差异，结论：P水平过低，E2水平过高影响了男性缺血性中风的发病机理，性激素比例失衡与脑梗塞的发病有密切关系。     

Current and future therapies for ischemic cerebrovascular disease

Stroke is the third leading cause of death in the adult population. It makes great demands on patients, who must not only survive the complications of the acute stages but also must cope with the great physical and economic costs of long-term disabilities. Therefore, there is an urgent need to establish generally useful treatments for ischemic stroke. Currently, there are three treatment approaches based on pathophysiologic concepts derived from basic research: (i) pharmacologic strategies for arterial recanalization, (ii) neuronal protection and (iii) the inhibition of undesirable damaging host responses. The key to current treatment is the emergent administration of tissue plasminogen activator (t-PA). Thrombolytic treatment improves outcome when given to carefully selected patients within 3 h of stroke onset. Numerous neuroprotective agents have been developed in the last decade, and a new wave of therapies is now on the horizon that could potentially minimize ischemic brain damage. This article highlights recent advances in pharmacological interventions for ischemic stroke.     

去纤酶治疗缺血性脑血管病62例

缺血性脑血管病患者即例(男42例,女20例;年龄50±8yr),均用去纤酶2U稀释于生理盐水250mL,静滴,每周2次,5-6次为一个疗程(部分患者曾用2-3个疗程)治疗。结果表明该药临床有效率为92％,并可显著改善患者的血液流变学及甲皱微循环异常;副作用轻微。     

452例缺血性脑血管疾病DSA分析

目的探讨缺血性脑血管病患者脑动脉狭窄或闭塞的分布特征,为脑血管病防治提供参考。方法 452例缺血性脑血管病患者的DSA资料,按年龄大小分为青年组、中年组和老年组。结果 452例经DSA检查确诊为动脉粥样硬化性狭窄或闭塞,其中,35.2%仅有颅内病变,31.8%仅有颅外病变,33.0%颅内、外病变并存;颅内病变的发生率为68.1%,稍高于颅外病变的64.8%。青年组单纯颅内病变的比例较高（75.0%）;中年组（38.5%）低于青年组（P〈0.01）;老年组（28.1%）低于中年组（P〈0.05）;老年组以颅内外病变并存的比例较高（36.8%,P〈0.01）。后循环病变老年组高于中年组（P〈0.05）,中年组高于青年组（P〈0.01）。危险因素中高血压、吸烟、糖尿病、血脂异常、脑卒中史、脑血管病家族史,在颅内、颅外及颅内外病变并存的患者间比较差异无统计学意义,高龄在颅外及颅内外动脉病变并存中的比例明显高于在颅内动脉病变中的比例（P〈0.01）。结论缺血性脑血管病患者中,颅内动脉粥样硬化性病变的发生率高于颅外段,随着年龄的增长,颅外动脉病变及颅内外动脉病变并存的比例逐渐增多,后循环病变增多。高龄是颅外动脉病变的显著性危险因素。     

Recent advances in antiplatelet agents

Platelet aggregation plays a key role in the pathogenesis of thromboembolic diseases such as myocardial infarction, stroke, unstable angina and peripheral artery disease. Until recently, aspirin was the only antiplatelet agent available to prevent or treat these events. Over the past several years, there has been a substantial expansion in the antiplatelet armamentarium as well as in the understanding of the clinical importance of antiplatelet therapy in limiting the complications of thrombosis. Aspirin was one of the first agents to be adopted and it remains as the standard therapy with the higher amount of available clinical information. Following aspirin, ADP receptor antagonists like ticlopidine and clopidogrel as well as phosphodiesterase inhibitors dipyridamole and cilostazol have been introduced. Glycoprotein (GP) IIb/IIIa receptor antagonists like eptifibatide, tirofiban and abciximab are the newer antiplatelet agents which act at the end of the common pathway of platelet aggregation. Although results of clinical studies with the first oral GPIIb/IIIa antagonists were disappointing, agents of the new generation might expand the potential application of GPIIb/IIIa targeted therapy. This review will highlight recent advances in the development of aspirin, phosphodiesterase inhibitors, ADP receptor antagonists and the platelet glycoprotein IIb/IIIa inhibitors. The emphasis of this paper has been placed on the chemical aspects of these agents.     

巴曲酶治疗急性缺血性脑血管病的临床观察

目的：评价巴曲酶治疗急性缺血性脑血管病的疗效。方法：将１４１例随机分为２组：治疗组７０例,在１２小时内给予巴曲酶,１０Ｂｕ加生理盐水２５０ｍｌ静脉点滴１小时左右,第３天和第５天均用５Ｂｕ,同时使用常规治疗药物。治疗观察期间不给予中医或物理治疗。对照组７１例,仅给予常规药物治疗。两组均于治疗后的第１,３,５,１４天分别评价疗效。     

艾地苯醌治疗缺血性脑血管疾病的药理作用及临床应用

动物实验证实艾地苯醌具有对发生脑卒中的大鼠脑线粒体功能有激活作用、对脑能量代谢及脑功能障碍有改善作用,艾地苯醌的T_(1/2)为7.69h,T_(max)3.31h,C_(max)为290ng/mL,24h尿中排泄率为32％。艾地苯醌治疗脑动脉硬化症和脑梗死后遗症30例(男24例,女6例;年龄67±23a)总改善率90％,情感障碍、智力低下、行动异常等改善率73％-81％,不良反应轻微。