Antiplatelet Agents for Stroke Prevention

Stroke is one of the leading causes of disability and death. Ischemic stroke is a syndrome with heterogeneous mechanisms and multiple etiologies, rather than a singularly defined disease. Approximately one third of ischemic strokes are preceded by another cerebrovascular ischemic event. Stroke survivors are at high risk of vascular events (i.e., cerebrovascular and cardiovascular events), particularly during the first several months after the ischemic event. The use of antiplatelet agents remains the fundamental component of secondary stroke prevention. Based on the available data, antiplatelet agents should be used for patients with noncardioembolic stroke. The use of combination therapy (aspirin plus clopidogrel) has not been proven to be effective or safe to use for prevention of early stroke recurrence or in long-term treatment. There is no convincing evidence that any of the available antiplatelet agents are superior for a given stroke subtype. Currently, the uses of aspirin, clopidogrel, or aspirin combined with extended release dipyridamole are all valid alternatives after an ischemic stroke or transient ischemic attack. However, to maximize the effects of these agents, the treatment should be initiated as early as possible and be continued on a lifelong basis.     

抗血小板药预防脑卒中的应用进展

以阿司匹林为代表的抗血小板药已被证实在对脑卒中预防有确实的疗效。阿司匹林、氯吡格雷等抗血小板药物作为脑卒中预防的基础用药,其疗效确切并已经列入相关脑卒中预防指南。替卡格雷、西洛他唑、三氟柳、沙格雷酯等新型抗血小板药物在部分地区的临床试验中也已经取得了令人满意的脑卒中预防结果。但是多年来,阿司匹林的最佳预防剂量仍在商榷中,在患者应用抗血小板药物的过程中,存在一定比例的出血并发症。当两种抗血小板药物合用更可能导致出血并发症的发生比例增高。寻求抗血小板药的疗效及出血并发症间的平衡点,促进抗血小板药物的进步与发展。文中就抗血小板药物在预防脑卒中的应用进展作介绍。     

Treatment of Risk Factors to Prevent Stroke

Much of the decline in stroke incidence and mortality for the past several decades in Western countries has been attributed to better treatment of risk factors. Many epidemiological studies and clinical trials confirmed the importance of managing hypertension. Comparative trials of anti-hypertensive drugs or drug classes have not yielded clear results, but blood pressure variability may play an important role beyond the absolute value of blood pressure. Diabetes therapy remains a conundrum. Although diabetes is clearly a risk factor for ischemic stroke, treatment trials targeting different glycemic goals have not indicated that glucose lowering results in stroke prevention. Trials focused on insulin resistance are ongoing and they may be able to help establish the management of diabetes/impaired glucose tolerance. Evidence for treatment of dyslipidemia has contrasted science to diabetes mellitus. Dyslipidemia has not been strongly or consistently linked to ischemic stroke but the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial showed the impact of statin treatment in stroke prevention. The results of clinical trials investigating dabigatran and rivaroxaban clearly indicate alternative strategies to vitamin K antagonists in stroke prevention for persons with atrial fibrillation. Evidence for stroke prevention by life style modification, treating metabolic syndrome, sleep disordered breathing, lipoprotein (a), hyperhomocysteinemia, and coagulation disorders are also discussed.     

如何预防心房颤动及其造成的卒中

心房颤动(atrial fibrillation,Af)为临床上常见的心律失常.慢性心房颤动其诊断相当简单,但治疗则相对棘手.心房颤动发生的机会随着年龄增加而上升,小于65岁人口中约有1%患有心房颤动,在大于65岁人群中则约有5%,其中男性又较女性为多,年龄愈大时男女的比例则愈接近.     

急性缺血性卒中的抗血小板治疗

急性缺血性卒中患者血小板被激活，抗血小板治疗可减少早期脑梗死的复发，减轻脑损伤的体积，降低早期死亡和改善存活者的长期预后。但抗血小板治疗增加非致死性或症状性颅内出血的发生率。阿司匹林是证据最充分且得到各国指南推荐的治疗急性缺血性卒中的抗血小板药物，对未溶栓治疗的急性缺血性卒中患者应尽早开始阿司匹林治疗。氯吡格雷、血小板糖蛋白Ⅱb/IIIa受体抑制剂、双嘧达莫、西洛他唑等单药用于治疗急性缺血性卒中的安全性和疗效目前尚无足够的证据。抗血小板药物联合应用的疗效和可能的风险尚需进一步研究。     

院内缺血性卒中的诊疗现状与挑战

院内卒中是指因其他疾病住院的患者在住院期间发生的急性卒中,其中最常见的类型是缺血性卒中.与社区卒中相比,院内缺血性卒中的危险因素和发病机制更为复杂,除了栓塞、低灌注、高凝状态,医源性因素也是重要的致病原因之一.院内缺血性卒中患者的不良功能预后和死亡率均较社区患者显著增高,研究提示基础疾病较多、围手术期栓塞所致脑梗死范围...     

中国卒中防治研究现状

本研究报告选编自卫生部《中国心血管病报告2005》,内容涉及我国脑血管病防治研究领域的各个方面,重点是脑血管病流行情况报告及我国循证医学研究成果。本报告入选的资料经过严格的评估,根据循证医学要求,证据级别多为Ⅰ级和Ⅱ级水平,即大样本前瞻性或横断面人群流行病学调查、大样本随机对照临床研究、大样本疾病注册登记、大样本社区防治典型案例等,均为国内外公开发表的高质量学术研究报告。但由于时间仓促,面对我国几十年脑血管病防治研究工作和浩如烟海的信息资源,难免有所遗漏．在此谨表歉意,更希望有关专家和学者给予支持,将有关信息反馈给我们,以便我们不断更新报告的内容。王伊龙     

肿瘤合并缺血性卒中的研究现状及展望

2014年在Chin Med J(Engl)上发表的“1982-2010年中国主要死亡原因的变化趋势”指出,在中国居民死亡的主要原因中,肿瘤和卒中位列前二位[1]。2018年发表的《中国脑卒中防治报告(2017)》[2]显示,卒中在中国为第一位死亡原因,已成为中国疾病负担的首位原因,且患病率呈上升趋势。《中国急性缺血性脑卒中诊治指南2018》指出,急性缺血性卒中是最常见的卒中类型,占我国卒中的69.6%~70.8%[3]。2019年6月,Lancet杂志发表的一项病死原因调查研究分析了1990-2017年中国居民的死亡原因,结果显示卒中、缺血性心脏病、肺癌、慢性阻塞性肺疾病和肝癌分别位居我国病死率的前五位[4]。缺血性卒中和肿瘤是中国居民目前的主要死亡原因。肿瘤和缺血性卒中往往好发于高龄人群,且肿瘤患者罹患缺血性卒中的风险更高,而缺血性卒中的发生又必将影响针对恶性肿瘤的治疗,两者共同作用严重影响患者的生活质量和整体预后。     

青年卒中的研究现状和展望

卒中是当今世界范围内严重威胁人类生命和健康的疾病,2008年全国第三次死因回顾抽样调查显示卒中已高居国内死亡原因首位。回顾传统观念,卒中一直以来被认为是中老年人群的常见病和多发病;由于时代、环境以及疾病谱等因素的变化,卒中的发病有日益年轻化的趋势。随着对青年卒中研究的深入,逐渐揭示了一些青年卒中的特殊性,本文就青年卒中的研究现状和未来发展趋势做一综合探讨。     

住院患者不明原因栓塞性卒中诊治现状研究

目的 了解目前中国不明原因栓塞性卒中（embolic stroke of undetermined source,ESUS）诊治现状。 方法 回顾性分析2011年1月-2012年12月在北京大学第三医院神经内科住院的缺血性卒中患者,将 住院及随访期间未完善24 h心电监测（Holter）但已完成其他评估并符合ESUS标准者,定义为可疑 ESUS（suspected ESUS,sESUS）,将完善了包括24 h心电监测等在内全部评估并符合ESUS诊断标准者, 定义为“确定ESUS”（definite ESUS,dESUS）,以上均划分为ESUS组;其他卒中亚型为非ESUS组。比较 两组间一般情况、危险因素及临床特点;并随访ESUS组患者二级预防及复发情况。 结果 研究共纳入缺血性卒中患者900例,按照住院资料诊断dESUS 9 例（1.0%）,sESUS 9 5例 （10.6%）,合计104例（11.6%）;非ESUS组796例。ESUS患者活动中起病85例（81.7%）、病情波动58例 （55.8%）、入院时美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NIHSS）评 分2.0（0,4.0）分,非ESUS组分别是538例（67.6%）,245例（30.8%）和3.0（1.3,5.0）分,差异均有显 著性（P分别为0.010、<0.001、<0.001）。对ESUS组患者急性期及二级预防抗栓药物使用的调查发现, 随访dESUS患者均为抗血小板治疗,其中6例出现1年内缺血性卒中复发;sESUS患者也全部为抗血小板 治疗,其中10例出现1年内缺血性卒中复发。 结论 目前ESUS在缺血性卒中患者中比例较高,与非ESUS患者相比,其病情波动较大,神经功能缺 损较轻。对该类患者应该加强24 h心电图的监测以助查找病因。     

抗血小板治疗与短暂性脑缺血发作后的卒中预防

短暂性脑缺血发作（transient ischemic attack,TIA）是早已公认的脑缺血标志。随着新型神经影像学技术相继应用于流行病学研究和临床试验，人们发现根据症状和体征迅速消失界定TIA并不科学，而继续信守TIA为良性过程的传统观念正在严重妨碍缺血性卒中的二级预防^[1]。大量证据表明，TIA一旦发生，就意味着这些患者随时面临缺血性卒中的高危风险。因此，应像冠心病患者发生心绞痛后积极预防心肌梗死那样，对TIA患者进行及时、有效的干预，从根本上降低TIA后的卒中风险。最近，许多研究对抗血小板药用于TIA后缺血性卒中的二级预防进行了有益探讨。     

Secondary Stroke Prophylaxis with Clopidogrel Produces Sufficient Antiplatelet Response

Background

Antiplatelet therapy is a cornerstone prevention strategy for secondary ischemic stroke (IS) and transient ischemic attack (TIA). Yet, a proportion of patients who receive antiplatelet therapy experience recurrent ischemic cerebrovascular events. A recent meta-analysis found an increased risk of recurrent stroke in clopidogrel- or aspirin-treated patients with ischemic stroke who had high on-treatment platelet reactivity (HTPR). Few studies have focused specifically on clopidogrel HTPR. Therefore, the aim of this study was to examine the relationship between clopidogrel HTPR and recurrent ischemic events in a population of Danish patients with IS.

Employment Status Prior to Ischemic Stroke and Weekly Variation of Stroke Onset

ObjectivesTo investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome.Materials and methodsSymptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes.ResultsWe screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome.ConclusionsPatients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.