缺血性脑卒中二级预防治疗的依从性研究

目的采取有效措施减少缺血性脑卒中再发,对缺血性脑卒中或短暂性脑缺血发作(TIA)患者采取ABCDE策略,观察患者出院后1年能否维持高水平药物治疗符合率。方法选择缺血性脑卒中或TIA患者178例,采取ABcDE策略进行规范的二级预防。观察患者出院时及出院后1年二级预防中抗血小板、降压、降糖和他汀类药物治疗的符合率。结果 178例患者中既往有缺血性脑卒中或TIA史126例,其住院前抗血小板治疗比例为41.3%,服用降压、降糖和他汀类药物治疗比例分别为89.9%、83.3%和13.5%;155例完成出院1年随访,降压治疗符合率为100%,抗血小板治疗符合率为97.2%,降糖和他汀类药物治疗符合率为98.2%和84.3%。结论采取ABCDE策略对缺血性脑卒中或TIA患者进行规范干预后,明显缩小二级预防循证证据与临床实践之间的差距,患者出院1年药物治疗符合率维持在较高水平。     

吕梁市缺血性脑卒中患者二级预防现状调查分析

目的 调查分析山西省吕梁市缺血性脑卒中患者二级预防现状.方法 对2010年8月-2011年2月就诊于山西省汾阳医院门诊的发病后1个月～6个月的缺血性脑卒中105例患者进行现场调查分析,记录患者预防中抗血小板、降压、降糖、调脂及应用其他药物的情况.结果 105例患者中卒中复发者11例占(10.48％),抗血小板治疗治疗率为100.00％,降压、降糖、调脂治疗的达标率分别为62.86％、72.00％、50.08％;其二级预防的抗血小板治疗、降压、降糖及调脂治疗的符合率仍低,不规范用药率很高.结论 吕梁市缺血性脑卒中的二级预防现状不容乐观,应加强对医生、患者及家属的健康教育,使他们认识到脑卒中的危害及有效的预防措施,达到二级预防的目的.     

2479例缺血性脑卒中登记患者三年随访研究

目的探讨卒中单元缺血性脑卒中登记患者正规降压治疗,抗血小板治疗和调脂治疗对其短期与长期预后的影响。方法收集2009年1月~2010年5月在卒中单元病房住院治疗的急性缺血性脑卒中患者2479例,男1638例,女841例,其中缺血性脑卒中合并高血压1784例,分为联合降压组361例和联合降压调脂组1423例;不合并高血压695例,分为单纯抗血小板组85例和联合调脂组610例,各组分别予抗血小板和(或)调脂和(或)降压药物治疗,均随访3年。比较3个月、1年和3年后,不同治疗方案患者预后不良发生率、复发率和病死率的差异。结果随访1年时,联合降压调脂组患者病死率和预后不良率均低于联合降压组(11.95%vs 24.93%,45.89%vs58.17%,P0.01);随访1年和3年时,复发率亦低于联合降压组(12.23%vs 27.98%,14.97%vs 27.15%,P0.01)。随访3个月时,联合调脂组患者病死率低于单纯抗血小板组(7.87%vs 15.29%,P0.05);随访1年和3年时,联合调脂组患者病死率、复发率和预后不良率均低于单纯抗血小板组(P0.05,P0.01)结论联合强化调脂,长期平稳有效降压和坚持抗血小板治疗可降低缺血性脑卒中的复发率,病死率和预后不良率。     

缺血性卒中或短暂性脑缺血发作患者抗血小板药治疗期间血小板高反应性

抗血小板药是指南推荐的缺血性卒中/短暂性脑缺血发作(transient ischemic attack, TIA)长期治疗及二级预防的基石, 用于降低复发性卒中及其他心血管事件风险。然而, 某些缺血性卒中/TIA患者在抗血小板治疗期间仍会出现缺血性事件, 称为治疗期间血小板高反应性(high on-treatment platelet reactivity, HTPR), 通常发生在服用阿司匹林或氯吡格雷的患者中。文章阐述了缺血性卒中/TIA患者中HTPR的发生率、危险因素和常用评价方法, 阐述HTPR在缺血性卒中/TIA患者中的临床意义, 并探讨HTPR患者的抗血小板治疗方案。     

海南省缺血性脑卒中二级预防中抗血小板药物治疗的现状及影响因素分析

目的调查分析缺血性脑卒中二级预防中抗血小板药物的使用现状及影响因素。方法入选海南省10家综合性医院再次住院的缺血性脑卒中患者1300例,调查患者入院时抗血小板药物的应用状况,采用单因素及多因素logistic回归模型对资料进行分析。结果缺血性脑卒中患者抗血小板治疗知晓率为60.4%,治疗率为49.2%。多因素logistic回归分析显示,教育程度、医疗保险、健康教育是患者服用抗血小板治疗的独立危险因素。结论缺血性脑卒中二级预防中抗血小板治疗现状令人堪忧,临床医师需提高认识,加强对脑卒中患者的健康教育,建议患者长期服药,提高脑卒中后抗血小板治疗的知晓率及治疗率。     

缺血性脑卒中伴高血压患者血压控制状况调查

目的了解缺血性脑卒中患者血压控制及降血压药物使用情况,分析影响降压药物使用的因素。方法选择2014年1~12月连续收住我院神经内科病房的住院且确诊为缺血性脑卒中和短暂性脑缺血发作患者总计740例,将360例复发性脑卒中纳入分析,高血压314例(87.2%),糖尿病142例,对入选患者血压控制及降血压药物使用情况进行调查。结果 314例高血压患者中,血压达标率为28.3%;142例糖尿病患者中,血压达标率为9.2%。314例高血压患者,服用任1种抗高血压药物248例,药物治疗率79.0%,有21.0%未服用任何降压药物。2型糖尿病、冠心病、吸烟、饮酒、服用抗血小板药物与降压药物治疗有关(P0.05)。冠心病(OR=0.275,95%CI:0.094~0.804,P=0.018)及服用抗血小板药物(OR=0.547,95%CI:0.310~0.966,P=0.038)是影响患者降压治疗的独立危险因素。结论缺血性脑卒中患者血压控制达标率与指南要求存在差距,伴糖尿病患者血压控制达标率更不理想,应加强脑卒中患者血压控制。     

非心源性缺血性脑卒中二级预防中抗栓治疗的进展

<正>脑卒中是重要的死亡和残疾病因,除各种不良生活方式和血管性危险因素外,脑卒中和短暂性脑缺血发作(TIA)史本身就是重要复发危险因素,尤其是近期发生者。因此,为预防非心源性缺血性脑卒中或TIA的复发,抗血小板治疗(APT)是一个重要的预防措施。自2014年美国卒中学会及我国的相关缺血性脑卒中二级预防指南发表,针对非心源性缺血性脑卒中开展了几项重要的随机对照试验(RCT)和一些系统分析~([1-2])。本研究就此予以介绍。1双联抗血小板治疗(DAPT)我国开展的CHANCE试验证明,对高危轻型     

提高缺血性脑卒中患者二级预防中抗血小板药物治疗的依从性研究

目的以指南培训为干预手段,考评海南省缺血性脑卒中患者二级预防中抗血小板药物治疗状况改善情况。方法调查2011年1月~2012年3月在海南省10家二级或三级综合性医院再次住院的1300例缺血性脑卒中患者抗血小板药物的应用情况;10家医院参与课题研究并对相关医师进行技术培训;2015年再次对该群患者1279例(脱落21例)对比调查、评估抗血小板药物的应用状况;分析干预前后患者抗血小板药物治疗的改善情况。结果干预后,缺血性脑卒中患者二级预防中抗血小板聚集药物治疗的知晓率和治疗率均显著提高,2011年知晓率60.4%,治疗率49.2%,2015年知晓率86.5%,治疗率76.9%(P0.01)。使用剂量过小和中断服药的比例显著降低,2011年剂量过小20.1%,中断服药5.3%,2015年剂量过小2.7%,中断服药3.5%(P0.05,P0.01)。10家医院神经内科医师抗血小板药物治疗知识测试评分显著提高,2011年为(55.6±10.7)分,2015年为(78.2±15.5)分(P0.01)。2015年二级医院与三级医院抗血小板药物治疗差异消失(r=0.092,P=0.405)。结论课题研究和指南培训改善了缺血性脑卒中患者二级预防中抗血小板药物治疗的现状,缩小了不同级别医院的差距。     

代谢综合征与脑卒中

代谢综合征(MS)患者是具有多重心脑血管病危险因素的高风险病人。MS与脑卒中密切相关,是独立于传统心脑血管危险因子之外的脑卒中危险因子。MS患者脑卒中风险和死亡率分别是无MS的3倍和5~6倍。胰岛素抵抗可能是联系MS与脑卒中的共同桥梁。控制体质量、调整情绪是预防MS的重要措施,综合治疗是防治MS脑卒中的基本原则,包括降糖、调脂、降压、减肥、抗血小板等。     

代谢综合征与脑卒中

代谢综合征(MS)患者是具有多重心脑血管病危险因素的高风险病人.MS与脑卒中密切相关,是独立于传统心脑血管危险因子之外的脑卒中危险因子.MS患者脑卒中风险和死亡率分别是无MS的3倍和5～6倍.胰岛素抵抗可能是联系MS与脑卒中的共同桥梁.控制体质量、调整情绪是预防MS的重要措施,综合治疗是防治MS脑卒中的基本原则,包括降糖、调脂、降压、减肥、抗血小板等.     

缺血性脑血管病二级预防抗栓药物应用分析

目的了解缺血性脑血管病二级预防抗栓药物的应用情况,为提高缺血性脑血管病二级预防抗栓治疗的依从性提供临床依据。方法短暂性脑缺血发作(TIA)及初发急性脑梗死患者共582例,出院6个月完成随访者515例,调查住院期间及出院6个月患者抗栓药物的使用情况,并分析影响抗栓药物使用的因素。结果住院期间服用阿司匹林者519例,服用氯吡格雷者11例,服用华法林者29例;出院6个月时服用阿司匹林者共436例,服用氯吡格雷者3例,服用华法林者2例。TIA、生活能力低下、服用非阿司匹林抗栓药物及未接受脑卒中健康教育可明显降低脑卒中患者使用抗栓药物的依从性。结论缺血性脑血管病急性期抗栓药物的应用比例较高,但随访至6个月时依从性下降,专科医师应对缺血性脑血管病患者二级预防抗栓药物的依从性给予足够的关注。     

A review of therapeutic strategies for risk reduction of recurrent stroke

Although cardiovascular disease (CVD) is a major source of morbidity and mortality in the United States, a relatively small percentage of deaths related to CVD result from ischemic stroke. However, the impairment and costs associated with stroke are large--and largely preventable. Large-scale trials have demonstrated benefit with antihypertensive therapy for secondary prevention, showing significantly reduced rates of stroke and cardiovascular events. Statins have shown efficacy in primary stroke prevention, and one trial showed reduced incidence of stroke and cardiovascular events in patients with recent stroke or transient ischemic attack (TIA). The merits of antiplatelet therapy in primary and secondary stroke prevention have been demonstrated across numerous trials and meta-analyses. Trials assessing aspirin plus clopidogrel or aspirin plus extended-release dipyridamole for preventing secondary stroke have produced somewhat contradictory findings. This review discusses the relationship between CVD and risk of secondary stroke or TIA and summarizes secondary prevention strategies, focusing on antiplatelet agents, to provide guidance for the practicing cardiologist. Certain combination therapies appear to be more effective for secondary prevention of stroke or TIA than therapy with single antiplatelet agents. The choice of agents may be important, based on results of several trials. The ongoing, large-scale, comparative Prevention Regimen for Effectively Avoiding Second Strokes (PR. FESS) trial should provide cardiologists with more definitive recommendations.     

缺血性脑卒中患者二级预防中抗血栓药物使用现况调查

目的调查缺血性脑卒中患者二级预防中抗血栓药物的使用情况,并分析其影响因素。方法本研究为现况调查,其对象为在北京天坛医院神经内科门诊就诊既往诊断明确的脑梗死或短暂性脑缺血发作患者(发病后4周~5年),调查其近两周内的抗血栓药物使用情况及相关影响因素。依据患者是否使用抗血栓药物,将入选患者分为两组:即治疗组与未治疗组。结果符合入选标准的缺血性脑卒中患者共计669例,最后共有607例缺血性脑卒中患者进入本研究结果分析中。其中未接受抗血栓药物治疗者163例(26.9%)。使用阿司匹林的患者中438例,其中剂量25~40 mg/d的患者152例(34.7%)。在抗血栓药物的影响因素方面,较好的日常生活能力OR=1.009,95%CI:1.002~1.017、医疗保险OR=1.822,95%CI:1.123~2.956、高血压OR=1.533,95%CI:1.030~2.282是脑卒中患者接受药物治疗的促进因素。结论缺血性脑卒中幸存者均应给予抗血小板药物或抗凝药物,除非预计患者不久将死亡或有严重的禁忌证,其用药剂量应遵循临床指南。     

MATCH results: implications for the internist

The long-awaited results of the Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischemic Attack (MATCH) study, a large-scale trial undertaken to evaluate the safety and efficacy of clopidogrel + aspirin for secondary prevention of stroke, have been published. The efficacy of any antiplatelet therapy, including aspirin, is modest when it is used as monotherapy, and combination therapy with 2 antiplatelet agents has shown promise in reducing the risk for secondary stroke in patients who have had a previous transient ischemic attack (TIA) or ischemic stroke. However, unlike the Second European Stroke Prevention Study (ESPS-2), which demonstrated a significant reduction in risk for secondary stroke with aspirin + extended-release dipyridamole versus aspirin alone the results of the MATCH trial indicated that the reduction in risk achieved by adding aspirin to clopidogrel is not significantly greater than that achieved with clopidogrel alone. Furthermore, a significant increase in life-threatening bleeding complications was associated with the combination of clopidogrel + aspirin. Given these findings, clopidogrel + aspirin cannot be recommended at this time for the secondary prevention of stroke in patients who have had a previous ischemic stroke or TIA.     

New transient ischemic attack and stroke: outpatient management by primary care physicians

BACKGROUND: Patients with transient ischemic attack (TIA) or stroke frequently first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to identify a group of patients seen by primary care physicians in an office setting for a first-ever TIA or stroke and characterize their evaluation and management. METHODS: Practice audit based on retrospective, structured medical record abstraction from 27 primary care medical practices in 2 geographically separate communities in the eastern United States. RESULTS: Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P =.12). Only 6% were admitted to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P =.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brain imaging study (computed tomography or magnetic resonance imaging) was ordered on the day of the index visit in 30% (23% TIA, 37% stroke; P =.04), regardless of whether the patient was referred to a specialist. Carotid ultrasound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocardiograms in 19% (18% TIA, 21% stroke; P =.60), and echocardiograms in 16% (19% TIA, 14% stroke; P =.34). Fewer than half of patients with a prior history of atrial fibrillation (n = 24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P =.70) were not hospitalized and had no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stroke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. CONCLUSIONS: Further primary care physician education regarding the importance of promptly and fully evaluating patients with TIA or stroke may be warranted, and barriers to implementation of established secondary stroke prevention strategies need to be carefully explored. Arch Intern Med. 2000;160:2941-2946     

缺血性卒中二级预防的药物依从性调查

目的评估缺血性卒中患者抗血栓药物和危险因素用药的依从性、停药和药物变更原因及影响因素。方法通过电话随访获得卒中患者出院后1年时用药等方面的情况。结果2002年10月至2003年4月北京天坛医院神经内科缺血性卒中患者412例,其中374例患者进入调查,其中完成电话随访者296例(79.1%)。患者抗血栓药物的依从性为35.1%;伴有高血压、糖尿病和高血脂患者1年后仍接受治疗者的比例分别为77.9%、80.2%和48.4%。医保或公费(OR2.117,95%CI1.174～3.821)可促进患者对药物的依从,非阿司匹林抗血栓药物(OR0.352,95%CI0.153～0.812)和较低的日常生活能力指数(62.5±13.3)(MannWhitneyU检验,P=0.000)可明显降低卒中患者的药物依从性。结论卒中二级预防中药物依从性差主要表现为停药和剂量减小。支付方式、收入水平、抗血栓药物的种类以及患者的个人生活能力等可影响卒中患者的药物依从性。     

动脉粥样硬化血栓形成型脑梗死急性期治疗与预后的关系

目的探讨动脉粥样硬化血栓形成型脑梗死患者急性期抗血小板、调脂和抗氧化治疗与预后的关系。方法将689例动脉粥样硬化血栓形成型脑梗死患者根据是否服用抗血小板药物、他汀类调脂药物或抗氧化剂普罗布考分为观察组和对照组。随访12个月,根据改良Rankin量表评分评价两组的预后,比较两组的改善率、复发率、预后不良发生率和病死率。结果观察组的改善率高于对照组（P〈0．05）,观察组随访3、12个月的预后不良发生率和病死率明显低于对照组（P〈0．05）,两组复发率比较无统计学差异（P〉0．05）。结论抗血小板、他汀类调脂治疗或抗氧化治疗能改善动脉粥样硬化血栓形成型脑梗死患者的预后,明显降低预后不良的发生率和病死率。     

Secondary stroke prevention with antiplatelet therapy with emphasis on the cardiac patient: a neurologist's view

The prevention of secondary vascular events is of paramount importance in patients with a history of stroke or transient ischemic attack (TIA). Most cardiologists are aware of the benefits of clopidogrel plus aspirin versus those of other antiplatelet regimens in patients with acute coronary syndrome. Using a representative post-stroke patient as an example, this article reviews data evaluating the effectiveness of antiplatelet regimens in preventing secondary vascular events in stroke and TIA patients. These results differ from those seen in clinical trials of acute coronary syndrome patients. Clinical studies provide little evidence that clopidogrel, with or without aspirin, is more efficacious in this setting than aspirin alone. Moreover, the increased risk of bleeding episodes with clopidogrel and aspirin in combination probably outweighs any small reductions in secondary event risk. In contrast, extended-release dipyridamole (ER-DP) plus aspirin reduces secondary stroke risk to a significantly greater extent (23% relative risk reduction) than aspirin alone. Currently available clinical trial data support the use of ER-DP plus aspirin, but not clopidogrel plus aspirin, to prevent secondary vascular events after stroke or TIA.     

襄阳市急性冠脉综合征患者出院后服药情况和相关因素分析

目的 观察和分析襄阳市急性冠脉综合征患者服药情况和相关因素。方法 收集我院已诊断急性心肌梗死或不稳定型心绞痛患者,使用标准的问卷来研究患者坚持服药以及未坚持服药的原因,采用logistic回归分析出院后6个月与12个月的服药情况。结果 在出院的时候药物治疗比例很高（98%服用阿司匹林,85%服用β-受体拮抗剂,97.8%服用他汀类药物）,但是在随后的随访中服药比例是减少的。只有72%的出院患者同时服用4种药物（阿司匹林,倍他乐克,血管紧张素转换酶抑制剂或血管紧张素受体拮抗剂和他汀类药物）。而在出院后1年服药比例减少至52.9%,使用logistic回归分析提示在出院以及随访中,医疗保险、血脂异常、高血压病和介入治疗为重要的服药的相关因素,而医生对很大比例的患者服药情况未予宣教,部分药物费用过高也是影响坚持联合用药的原因。结论 襄樊市已诊断急性冠脉综合征患者出院1年时按规范服药率为52.9%,影响服药依从性的因素是是否患有并发症、宣传不到位和费用高。