复发性缺血性脑卒中患者二级预防措施执行情况调查

目的分析复发性缺血性脑卒中患者二级预防措施依从性,总结二级预防失败患者药物治疗不当的原因和教训。方法登记2008年5月至2011年6月因再发脑梗死入院患者,按改良TOAST分型进行基线资料以及二级预防执行情况分析,从抗血小板药物使用、血压控制、他汀药物使用情况、糖尿病、吸烟等5个方面调查二级预防措施长期执行情况。结果急性缺血性脑卒中638例,其中复发性缺血性脑卒中106例,动脉粥样硬化血栓形成是最主要的病因类型(78.3%),其两次卒中事件时间间隔小于小血管病变(P<0.05)。二级预防措施执行情况分析显示69.4%患者未规律服用抗血小板药物,54.5%高血压患者血压控制不达标,87.7%高脂血症患者未达到血脂控制目标,76.5%糖尿病患者血糖不达标,86.7%吸烟患者未戒除吸烟。结论二级预防各项措施与指南之间均存在较大差距,迫切需要在基层医务人员和患者中强化二级预防的教育。     

新发缺血性脑卒中患者登记随访系统卒中再发风险评估

目的通过对新发缺血性脑卒中患者进行登记、连续随访,评估卒中人群二级预防药物使用情况,及ABCD2-1评分与卒中再发的相关性。方法新发缺血性脑卒中住院患者为研究对象,登记患者基本情况,危险因素、用药情况、ABCD2-1评分,分别于发病后3、6、12月进行随访。结果脑卒中的易发年龄为45~60岁,且男性多于女性,分析其相关因素,如吸烟、高血压、高血脂、糖尿病等,发现男性缺血性脑卒中发病率高于女性,可能与男性吸烟比例高于女性相关(P0.01)。随访中调查二级预防药物(抗血小板聚集药物、他汀类药物)的使用能够有效地降低缺血性脑卒中的复发率(P0.05),但随着随访时间的延长,患者二级预防药物的使用率逐渐下降。对患者进行ABCD2-1评分,显示ABCD2-1评分与缺血性脑卒中复发率呈正相关(P0.05)。结论二级预防药物的使用能够有效降低缺血性脑卒中的复发率,ABCD2-1评分可有效预测缺血性脑卒中再发风险,应对缺血性脑卒中患者建立完善的评估、长期连续性随访系统,提高二级预防药物使用率,降低缺血性脑卒中的再发风险。     

青岛地区604例缺血性脑卒中患者抗血小板治疗现况调查

缺血性脑卒中是神经系统常见疾病,但有效治疗药物不多.循证医学证明抗血小板聚集药物是缺血性脑卒中急性期治疗和二级预防的有效药物之一~([1-3]),但临床上对其认识尚不普及,其规范化应用程度不够,临床研究较少.     

899例缺血性脑卒中二级预防干预调查

目的 了解缺血性脑卒中患者住院期间二级预防药物的应用情况,为改进缺血性脑卒中二级预防工作提供依据.方法 回顾性调查899例缺血性脑卒中患者住院期间二级预防药物的服药率.结果 在899例缺血性脑卒中患者中,合并高血压者有632例,合并糖尿病者有220例,既合并有高血压又合并糖尿病者有177例.入选的899例患者中,服用抗血小板药物者占91.9％ (826例),在短暂性脑缺血发作组和脑梗死组间差异有统计学意义(P＜0.01);服用调脂药物者占77.2％(694例),在短暂性脑缺血发作组和脑梗死组间差异无统计学意义;632例缺血性脑卒中合并高血压患者中服用降压药者占95.4％(603例);220例缺血性脑卒中合并糖尿病患者中服用降糖药者(包括使用胰岛素)占84.5％(186例);177例既合并有高血压又合并有糖尿病的脑卒中患者中均用药者占83.1％(147例).结论 住院期间脑梗死患者抗栓药物服用率较短暂性脑缺血发作高,缺血性脑卒中二级预防用药尚不令人满意,临床医生应对脑卒中的二级预防治疗给予重视.     

408例缺血性脑血管病二级预防抗血小板药物应用状况调查

目的 了解北京市部分二级医院缺血性脑血管病二级预防抗血小板药物的应用现状,为改进缺血性脑血管病二级预防工作提供依据.方法 本研究为现况调查,研究对象为以自愿形式参加的北京市4家二级医院中急性脑梗死及短暂性脑缺血发作(TIA)的住院患者,调查其住院期间以及出院3个月二级预防抗血小板药物的应用现况.结果 人选患者共458例.其中408例完成3个月随访.住院期间抗血小板药物应用率为93.7%,3个月随访发现.抗血小板药物的院外治疗依从性差,应用率明显下降,为69.6%(P=0.003);男性(OR=1.708),95%CI 1.083～2.691及TIA患者(OR=1.954,95%CI1.046～3.649)成为患者抗血小板药物依从性差的促进因素.结论 北京市部分二级医院缺血性脑血管病二级预防抗血小板药物的应用现状不容乐观,临床医生应对缺血性脑血管病患者二级预防抗血小板药物的依从性给予关注.     

抗血小板药物抵抗与复发性缺血性脑卒中

缺血性脑卒中在抗血小板治疗期间1/3~1/2的患者卒中复发。卒中复发有多种原因,多认为病人的不依从性是实验室抗血小板药物抵抗的最常见原因,但需要正确识别卒中的原因和发病机制。目前还没有良好指征用于缺血性卒中抗血小板药物抵抗的检测,或根据检测结果调整药物剂量的方法。选择预防卒中复发的抗血小板药物取决于卒中发作的时间,轻度缺血性卒中在发病3个月内选用阿司匹林联合氯吡格雷优于单一的抗血小板药物,但对长期二级预防来说,联合应用抗血小板治疗不仅无益处,且有增加出血的风险。     

541例复发缺血性脑卒中与短暂性脑缺血发作患者二级预防现状

目的了解缺血性卒中二级预防药物治疗的依从性及影响抗血小板药物依从性的因素,为规范缺血性卒中二级预防提供依据。方法 2007年8月～12月期间连续收入北京21家医院神经内科病房的缺血性卒中及TIA患者,对其中复发性卒中541例患者进行回顾性分析。结果 541例复发性卒中患者,抗血小板治疗比例为58.4%,降压药、降糖药和他汀类药治疗比例分别为82.3%、85.3%和14.2%。年龄≥60岁(P=0.011)、退休(P=0.021)、脑卒中史(P0.001)、心绞痛史(P=0.001)、心梗史(P=0.037)及高血压史(P=0.016),是抗血小板依从性的促进因素。结论复发性卒中二级预防现状不容乐观,药物干预危险因素治疗依从性低。     

从东西方种族差异看缺血性卒中抗血小板治疗策略选择

全球卒中的疾病负担沉重,抗血小板治疗是缺血性卒中二级预防的必要手段,然而东西 方人群的疾病特点存在差异,可能对抗血小板治疗的选择产生影响。本综述从卒中发病特点、患者复 发和出血风险差异以及抗血小板治疗反应多样性等多角度出发,探讨适合亚洲人群的缺血性卒中抗 血小板治疗方案。     

预防缺血性卒中的抗血小板治疗

抗血小板治疗是通过药物阻滞血小板聚集而起到预防血栓形成,减少缺血性卒中事件的发生,是缺血性卒中一级和二级预防的重要组成部分。本文对抗血小板治疗在IS一级和二级预防中的应用等临床相关问题加以综述。     

心房颤动合并急性缺血性脑卒中的溶栓及抗凝治疗研究进展

急性缺血性脑卒中是常见病、多发病。心房颤动(房颤)是临床上常见的心律失常,尤以非瓣膜性房颤为著。房颤合并急性缺血性脑卒中的患者临床常见,且病情重、出血转化率高、复发率高,给治疗带来一定的难度。重组组织型纤溶酶原激活剂是目前治疗急性缺血性脑卒中最有效的药物,可减少急性缺血性脑卒中患者的致残率;口服抗凝药可减少房颤相关急性缺血性脑卒中的复发;抗血小板治疗对房颤合并急性缺血性脑卒中患者也有一定的二级预防作用。鉴于房颤合并急性缺血性脑卒中所特有的临床特征,选择适宜的药物治疗至关重要。     

Current Status of Antiplatelet Agents to Prevent Stroke

Stroke is one of the leading causes of disability; most are due to atherothrombotic mechanisms. About one third of ischemic strokes are preceded by other stroke or transient ischemic attacks. Stroke survivors are at high risk for vascular events (i.e., cerebrovascular and cardiovascular). Prevention of recurrent stroke and other major vascular events can be accomplished by control of risk factors. Nonetheless, the use of antiplatelet agents remains the fundamental component of secondary stroke prevention strategy in patients with noncardioembolic disease. Currently, the uses of aspirin, clopidogrel, or aspirin plus extended-release dipyridamole are valid alternatives for stroke or transient ischemic attack patients. To maximize the beneficial effects of these agents, the treatment should be initiated as early as possible and continue on a lifelong basis.     

Antiplatelet therapy in acute cerebral ischemia

BACKGROUND: Improved recognition of stroke signs and symptoms has paralleled the development of pharmacological strategies that may be examined to reduce stroke mortality and morbidity. Presently, tissue plasminogen activator is the only therapy that significantly improves outcome in acute stroke, with no agent demonstrating a significant reduction in mortality. SUMMARY OF REVIEW: Antiplatelet agents are a heterogenous class of drugs that have been successfully used for more than 2 decades in secondary stroke prevention. These agents include aspirin, with or without dipyridamole, and more recently, the adenosine antagonists ticlopidine and clopidogrel. However, studies of the use of antiplatelet agents within 48 hours of the ictus have examined only aspirin. Only 1 study, the Multicentre Acute Stroke Trial-Italy (MAST-I), entered patients within 6 hours of the ictus. These data suggest that an improvement in mortality may be related to the speed of administration. No significant adverse events were noted with early antiplatelet monotherapy. However, MAST-I did note a significant increase in early mortality in patients receiving aspirin plus streptokinase, a finding not adequately explained by an increase in the intracranial hemorrhage rate. CONCLUSIONS: The use of antiplatelet therapy in acute stroke, clinical or experimental, has only recently received attention. It is likely that the use of antiplatelet agents for acute stroke therapy will be less restrictive than that currently seen for thrombolytics. Future studies should include an examination of those agents that have previously demonstrated efficacy in secondary stroke prevention, most notably, aspirin. The recognition that all platelet stimuli share a final common pathway that is dependent on the surface glycoprotein IIb/IIIa (fibrinogen) receptor has resulted in the development of various agents which block this receptor and are currently the focus for clinical trials. The role of nitric oxide in stroke therapy will depend on minimizing the hypotensive side effects of this agent. Stroke models are needed to provide preliminary data on the efficacy of antiplatelet therapy, especially as relates to the interaction of antiplatelet agents with thrombolytics.     

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.     

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。     

Reducing the risk of stroke in type 2 diabetes: pathophysiological and therapeutic perspectives

Reducing the excess cerebrovascular burden in patients with type 2 diabetes remains a major therapeutic challenge, especially with respect to the high risk of recurrent events. Targeting the traditional metabolic risk factors of hypertension, dyslipidemia, and hyperglycemia has failed to remove this excess risk, and agents targeting thrombotic risk (i.e., antiplatelet and anticoagulant drugs) remain poorly studied in the context of stroke in diabetes. This may relate to the accumulation of risk factors in type 2 diabetes as well as to diabetes-specific pathophysiologic factors. Regrettably, there is a lack of prospective evidence to support the efficacy of interventions in the secondary prevention of cerebrovascular events in type 2 diabetes, particularly recurrent stroke events. Overall, there is a need for rigorous evaluations of new therapeutic approaches in both primary and secondary prevention of stroke and management of acute stroke in patients with type 2 diabetes. This systematic review of the published literature summarizes the evidence regarding current therapeutic interventions and their impact on the risk of stroke in people with type 2 diabetes, and highlights potential strategies for improving outcomes.     

Long-term prevention of ischaemic stroke and stroke recurrence

Stroke is the third most important cause of mortality, but the leading cause of severe handicap, dependency, and loss of social competence. Because of the high recurrence rate, active secondary prevention is mandatory once a stroke has occurred. Secondary prevention of stroke implies the primary prevention of cardiovascular disorders as well. Among the modifiable risk factors hypertension is worst and should be normalized according to recent WHO criteria, also in the elderly. Smoking is another major risk factor and hard to delete. Diabetes mellitus and hyperlipidaemia are also important risk factors and should be treated consequently by diet and medication. Moderate alcohol intake, normalization of body weight and regular physical activity also contribute considerably to prevention of stroke. Whether hyperhomocysteinaemia should be normalized has not yet been clarified. Cardiovascular disorders are an important source of ischemic strokes, particularly atrial fibrillation. Low dose anticoagulation can dramatically reduce stroke risk. Carotid endarterectomy in symptomatic stenoses is the most expensive means of stroke prevention. In less severe stenoses, or ICA occlusions, antiplatelet agents are the treatment of choice. Composite drugs with ASS and other antiplatelet agents seem to be superior to either compound alone. Dissections of the cervical arteries should not be operated on but may be treated by anticoagulation or antiplatelet agents in the acute and subacute phase. The potency of a consequent and comprehensive stroke prevention in preventing disability and death is much greater than any sophisticated acute stroke treatment.     

Antiplatelet resistance in stroke

Although the exact prevalence of antiplatelet resistance in ischemic stroke is not known, estimates about the two most widely used antiplatelet agents - aspirin and clopidogrel - suggest that the resistance rate is high, irrespective of the definition used and parameters measured. Inadequate antiplatelet responsiveness correlates with an increased risk of recurrent ischemic vascular events in patients with stroke and acute coronary syndrome. It is not currently known whether tailoring antiplatelet therapy based on platelet function test results translates into a more effective strategy to prevent secondary vascular events after stroke. Large-scale clinical trials using a universally accepted definition and standardized measurement techniques for antiplatelet resistance are needed to demonstrate whether a 'platelet-function test-guided antiplatelet treatment' strategy translates into improved stroke care. This article gives an overview of the clinical importance of laboratory antiplatelet resistance, describes the challenges for platelet-function test-guided antiplatelet treatment and discusses practical issues about the management of patients with aspirin and/or clopidogrel resistance.     

New modalities and aspects of antiplatelet therapy for stroke prevention

Antiplatelet therapy is indicated for secondary prevention of ischaemic stroke. The first-line antiplatelet agent is aspirin. The effect of aspirin is, however, very limited, and this limited effect of aspirin is argued with termed 'aspirin resistance'. Strategies against aspirin resistance may include alternative use of other antiplatelet agents, combination of aspirin with other antiplatelet agents and investigation into molecular targets to develop novel antiplatelet agents. Progress in antiplatelet therapy should be directed at further reducing the risk of ischaemic events including ischaemic stroke without increasing the risk of haemorrhagic events including haemorrhagic stroke.