中風(fēng)二級(jí)預(yù)防更新課件

UpdateofsecondarystrokepreventionUpdateofsecondarystrokepre1Introduction

Secondaryprevention：preventingastrokeafteratransientischaemicattack(TIA)orarecurrentstrokeafterafirststroke.卒中二級(jí)預(yù)防概念：在發(fā)生TIA或初次中風(fēng)后預(yù)防中風(fēng)發(fā)生或再次發(fā)生。

IntroductionSecondaryprev28to15%strokeorTIApatientssufferarecurrentstrokeinthefirstyear.Therecurrenceriskishighestinthefirstfewweeksanddeclinesovertime.有8~15%的中風(fēng)或TIA患者會(huì)在第一年內(nèi)再次中風(fēng)或發(fā)生中風(fēng)。且風(fēng)險(xiǎn)在最初的幾周是最高的，隨時(shí)間的延長(zhǎng)而下降。So,ImmediateevaluationofpatientswithastrokeorTIA,identificationofthepathophysiologyandinitiationofsecondarypreventionareofgreatimportance因此，發(fā)生TIA或中風(fēng)后立即進(jìn)行評(píng)估，了解其病理生理學(xué)情況積極啟動(dòng)二級(jí)預(yù)防措施是非常重要的。8to15%strokeorTIAp3Hypertension1.HOPE:

Ameta-analysiscomprisedsevenstudiesin15527patientswithTIA,ischaemicorhaemorrhagicstroke.薈萃分析7項(xiàng)研究涉及15527個(gè)TIA、缺血性或出血性中風(fēng)患者。

Followedupperiod:2–5y.隨訪周期：2~5年

Hypertension1.HOPE:4Result:

(1)Treatmentwithantihypertensivesreducedtheriskofstrokeby24%,riskofnon-fatalstrokeby21%,riskofmyocardialinfarction(MI)by21%andtheriskofallvasculareventsby21%.

服用控制高血壓藥物的卒中復(fù)發(fā)風(fēng)險(xiǎn)降低了24%,非致死性的卒中風(fēng)險(xiǎn)降低了21%,心肌梗塞風(fēng)險(xiǎn)降低了21%，所有的血管性事件降低了21%。

Result:5(2)thecombinationofanACEIwithadiureticwasmoreeffective(45%riskreduction)thanadiureticasmonotherapy(32%),monotherapywithanACEI(7%)orabeta-blocker(7%).

ACEI與利尿劑聯(lián)用更有效，優(yōu)于利尿劑、ACEI、β受體阻滯劑各自單用。

(2)thecombinationofan62.PROGRESS：

thefirstlarge-scaletrialspecificallyperformedinpatientsafterstroke.第一個(gè)針對(duì)中風(fēng)后病人實(shí)施的大型臨床試驗(yàn)。Method:Atotalof6105patientsweretreatedwithperindoprilasmonotherapyorincombinationwithindapamideorplacebo.

6105例中風(fēng)后病人或培哚普利單用或與吲噠帕胺、安慰劑聯(lián)用Followedupperiod:4y.

隨訪周期：4年2.PROGRESS：7Result:

1)Theabsoluteriskreductionforrecurrentstrokewas4%,andtherelativeriskreduction(RRR)was28%.卒中復(fù)發(fā)的絕對(duì)危險(xiǎn)度下降了4%，相對(duì)危險(xiǎn)度下降了28%.

Result:8

2)MonotherapywiththeACEinhibitorwasnotonlysuperiortoplacebobutalsodidnotachievethesamelevelofbloodpressureloweringthanthecombinationtherapy.TheRRRforcombinationtherapywas43%.

單用ACEI類不僅二級(jí)預(yù)防效果優(yōu)于安慰劑組，且與聯(lián)用相比不致于使血壓降得過(guò)低。聯(lián)用降低中風(fēng)復(fù)發(fā)的相對(duì)危險(xiǎn)度較高：43%.

2)MonotherapywiththeACE93.MOSES:Method:1352patientswithhypertensionwhohadsufferedastrokeinthelast24monthsweretreatedeitherwitheprosartan依普羅沙坦(600mg)orwithnitrendipin(10mg).

1352例在24個(gè)月內(nèi)發(fā)生過(guò)中風(fēng)的高血壓病人或用依普羅沙坦(600mg)治療或用尼群地平（10mg）治療。3.MOSES:10Result:1)Foranidenticaldropinbloodpressure,eprosartanwassuperiortonitrendipintopreventrecurrentvascularevents(21%RRR).

具有基本相同的降壓效果，但在防止血管事件復(fù)發(fā)方面依普羅沙坦優(yōu)于尼群地平治療。2)TheoptimalsystolicbloodpressureintheMOSEStrialwas120–140mmHg.

MOSES的研究提示中風(fēng)后最佳收縮壓應(yīng)控制在120-140mmHg。

Result:1)Foranidenticaldro114.PRoFESS:Method:randomized20332patientswitharecentischaemicstroketoreceivetelmisartan替米沙坦at80mg/dayorplacebo.隨機(jī)將新近發(fā)生過(guò)中風(fēng)的20332名病人分為替米沙坦80mg/d和安慰劑組。Followedupperiod:2.4years.隨訪周期：2.4年。4.PRoFESS:12Result:Themeanbloodpressureoverthetrialperiodwaslowerinthetelmisartangroupby3.8/2.0mmHg.Recurrentstrokesoccurredin8.7%inthetelmisartangroupcomparedto9.2%intheplacebogroup,whichwasnotsignificant.

在試驗(yàn)期間替米沙坦組血壓比安慰劑組平均低3.8/2.0mmHg.其中風(fēng)復(fù)發(fā)率為8.7%，安慰劑組中風(fēng)復(fù)發(fā)率為9.2%，兩組間沒有顯著性差異。Result:Themeanbloodpressur13Conclusion:initiationoftelmisartanearlyafterastroke,didnotsignificantlylowertherateofrecurrentstrokes,othermajorvasculareventsornewdiabetes。

中風(fēng)后早期服用替米沙坦并不能顯著的阻止中風(fēng)復(fù)發(fā)，及其他血管事件和新法糖尿病。Conclusion:initiationoftelm14Highcholesterol1.HeartProtectionStudy(HPS)Total20536high-riskpatients,3280patientshadTIAorstrokeand1820ofthemwithoutconcomitantCHD.共20536高危病人，其中3280具有TIA或卒中病史，1820沒有伴隨心臟疾病。TheRRRachievedbysimvastatingivenfor5yearsforvasculareventswas20%andtheabsoluteriskreduction5.1%.給予辛伐他汀組（連續(xù)5年）血管事件相對(duì)危險(xiǎn)度下降了20%，絕對(duì)危險(xiǎn)度下降了5.1%.Highcholesterol1.HeartProtec152.SPARCL

(StrokePreventionbyAggressiveReductioninCholesterolLevels)Method:4731patientswithTIAorstrokewithoutCHDandLDLcholesterollevelsbetween100and190mg/dl.Thepatientsreceivedeither80mgatorvastatinorplacebo.

4731個(gè)具有TIA或中風(fēng)病史排除心臟病且LDL在100~190mg/dl被分為80mg阿托伐他汀組和安慰劑組.

Followedupperiod:averageof4.9y.Result:theprimaryendpoint(stroke)wasreducedby16%relativeand2.2%absolute.第一終點(diǎn)事件卒中發(fā)生率下降的相對(duì)值和絕對(duì)值分別為16%和2.2%2.SPARCL(StrokePreventionby16HPSVSSPARCLTherateofischaemicstrokewasreduced(218versus274)whereashaemorrhagicstrokesweremorefrequentwithatorvastatin(55versus33).這兩個(gè)臨床試驗(yàn)相比，阿托伐他汀組的卒中發(fā)生下降了相對(duì)要高一點(diǎn)，但發(fā)生出血性卒中的數(shù)目確相對(duì)多一點(diǎn)。HPSVSSPARC17TherapywithastatinshouldbeinitiatedearlyafteranischaemicstrokeorTIA.Thesuddendiscontinuationofastatininpatientswithastrokeoracutecoronarysyndromemightbeassociatedwithhighermorbidityandmortality.

Discontinuationofstatintreatmentinstrokepatients.Stroke2006在初發(fā)中風(fēng)后對(duì)具有血脂異常者應(yīng)盡早開始服用他汀類調(diào)脂。具有中風(fēng)或冠心病的患者突然停用他汀類會(huì)出現(xiàn)比較高的復(fù)發(fā)率和致死率。

Therapywithastatinshou18Diabetes

mellitusRandomizedcontrolledstudieswereunabletoshowaneffectofglitazones列酮類onvasculareventsinstrokepatientswithdiabetesmellitusEffectsofpioglitazoneGlitazonesinpatientswithtype2diabeteswithorwithoutpreviousstroke:resultsfromPROACTIVE.Stroke2007;38

一隨機(jī)對(duì)照研究未能發(fā)現(xiàn)服用列酮類降糖藥能明顯降低具有糖尿病的中風(fēng)患者的血管事件的發(fā)生率。Aggressiveloweringofbloodglucosedoesnotreducetheriskofstrokeandmightevenincreasemortality.Intensivebloodglucosecontrolandvascularoutcomesinpatientswithtype2diabetes.NEnglJMed2008;358

過(guò)分降糖不但不會(huì)降低卒中的風(fēng)險(xiǎn)反而會(huì)增加惡性事件。DiabetesmellitusRandomize19SupplementationofvitaminsTheVISPstudywasunabletoshowabenefitofthetreatmentofhighhomocysteineinstrokepatientswithBvitaminsandfolicacid.

VISP的研究表明具有高同型半胱氨酸的中風(fēng)患者服用維生素B和葉酸未能額外獲益。TheHOPE-2studyalsofailedtodemonstratebenefit.

TheHeartOutcomesPreventionEvaluation(HOPE)2Investigators.HomocysteineloweringwithfolicacidandBvitaminsinvasculardisease.NEnglJMed2006;354

HOPE-2研究也得出與VISP基本相同的結(jié)論。Supplementationofvitamins20EffectoffolicacidandBvitaminsonriskofcardiovasculareventsandtotalmortalityamongwomenathighriskforcardiovasculardisease:arandomizedtrial.

JAMA2008;299:2027–2036

葉酸和維生素B在具有高風(fēng)險(xiǎn)心血管疾病女性受試者中對(duì)心血管事件和總致死率的效果included5522patientsaged>55yearsandavasculareventordiabetesmellitus包含5522例具有血管事件或糖尿病年齡大于55歲的女性受試者treatedthemfor5yearswitheitherplaceboor2.5mgfolicacid,50mgvitaminB6and1mgvitaminB12.對(duì)照組服用安慰劑，治療組服用2.5mg葉酸,50mg維生素B6and1mg維生素B12.resultedinasignificantreductioninhomocysteinelevelsbutnotinvascularevents.

結(jié)果：同型半胱氨酸水平下降但血管事件未明顯下降。EffectoffolicacidandBvit21Hormonereplacementtherapyaftermenopause

關(guān)于女性中風(fēng)患者的一項(xiàng)隨機(jī)安慰劑對(duì)照研究提示，絕經(jīng)后采取激素替代療法療法會(huì)增加中風(fēng)的死亡率，并給非致死性卒中帶來(lái)較差的預(yù)后。Hormonereplacementtherapyaf22Antiplatelet

therapy1.TheMATCHstudy:Object:high-riskpatientswithTIAorischaemicstrokeAim:clopidogrel75mg+ASA75mgPKclopidogrel75Result:combinationtherapyfailedtoshowsuperiorityonendpointvascularevent.

聯(lián)合用藥組未能體現(xiàn)在降低血管性終點(diǎn)事件中的優(yōu)勢(shì)。反而出血性并發(fā)癥的發(fā)生率較高。Reverselyresultedinasignificantincreaseinbleedingcomplications.-------notrecommended.Antiplatelettherapy1.TheMATC232.CHARISMA

(ClopidogrelforHighAtherothromboticRiskandIschemicStabilization,ManagementandAvoidance)

atrialcombinedprimaryandsecondarypreventionAim:clopidogrel+ASAPKASAResult:Combinationtherapyfailedtoshowabenefitanddisplayedahigherbleedingrate.聯(lián)合用藥治療未能明顯獲益。出血性并發(fā)癥的發(fā)生率較高。Symptomaticpatientsshowedatrendtowardsabenefitforcombinationantiplatelettherapy.

但在癥狀性中風(fēng)患者表現(xiàn)出一定的優(yōu)勢(shì)。2.CHARISMA(ClopidogrelforHi243.ESPS2(thesecondEuropeanstrokepreventionstudy)Method:6602patientswithTIAorstrokewererandomizedtoASA(25mgbid),ER-DP(200mgbid),ASA+ER-DPorplacebo.

6602例TIA或中風(fēng)病人隨機(jī)分為ASA組，ER-DP組、二者聯(lián)用組及安慰劑組。Result:Fortheprimaryendpointstroke,ASA+ER-DPwassuperiortoASAandplacebo

對(duì)第一終點(diǎn)事件卒中來(lái)說(shuō)，聯(lián)用效優(yōu)。ASAloweredtheriskofstrokeby18%anddipyridamolemonotherapyby16%.BleedingcomplicationswereseenmorefrequentlywithASAandtheASA+ER-DP,DPhadasimilarbleedingrateasplacebo

ASA及聯(lián)用組出血性并發(fā)癥較高，DP較低。3.ESPS2(thesecondEuropeans254.Ahead-toheadcomparisonofclopidogrelwithASA+ER-DP

(performedinthePRoFESSstudy)Method:Randomized20332patientswithischaemicstrokeandfollowedforameanperiodof2.4y.Result:Therewasnodifferenceinefficacyacrossallendpointsandvarioussubgroupsofpatients.

在所有終點(diǎn)事件的發(fā)生發(fā)面兩者之間沒有明顯差異。ASA+ER-DPresultedinmoreintracranialbleedingsandahigherdropoutrateduetoheadachecomparedwithclopidogrel(5.9%versus0.9%).

與clopidogrel相比ASA+ER-DP的顱內(nèi)出血率和因于頭疼的脫落率較高。4.Ahead-toheadcomparisonof261.EuropeanAtrialFibrillationtrial

(randomizedplacebo-controlledtrial)Numbersneededtotreat(NNT)are12/year.Result:

warfarin:RRR68%V300mgASA:RRR19%Anticoagulationincerebralischaemiaduetocardiacembolism

抗凝劑在心源性栓塞缺血性卒中患者中的應(yīng)用1.EuropeanAtrialFibrillation272.TheACTIVEstudyMethod:

RandomizedpatientswithAFintoASA+clopidogrelandwarfaringroups.

將受試的具有房顫卒中病人隨機(jī)分為ASA+clopidogrel和華法令組Result:

terminatedprematurelyduetoasignificantreductionofstrokeandsystemicembolisminfavourofwarfarin.

由于華法令在降低中風(fēng)發(fā)生和系統(tǒng)性栓塞方面表現(xiàn)出明顯的顯著性差異而提前終止。rateofbleedingcomplicationswasnotdifferentbetweenthetworegimens.

在出血性并發(fā)癥方面兩者無(wú)明顯差異。2.TheACTIVEstudy28Cryptogenic（隱源性）strokeandpatentforamenovale(PFO)ProspectivecohortstudieshaveshownthattreatmentwithaspirinorwarfarinreducestheriskofrecurrentstrokeintheaveragepatientwithPFOtothesameriskasinpatientswithoutPFO.一項(xiàng)前瞻性隊(duì)列研究顯示：阿司匹林或華法令可將具有PFO的病人中風(fēng)復(fù)發(fā)的危險(xiǎn)性降至非PFO病人同等水平。Suggest:Aspirinwasaseffectiveasanticoagulationandthereforeshouldbegiven

建議：在防止PFO病人中風(fēng)復(fù)方方面阿司匹林具有與抗凝劑同等效果，PFO病人應(yīng)該服用。Cryptogenic（隱源性）strokeandpa29Anticoagulationincerebralischaemiaofnon-cardiacorigin1.ESPIRIT(TheStrokePreventioninReversibleIschemiatrial)Aim:studiedoralanticoagulationwithanINRbetween3.0and4.5versusASA30mginpatientswithTIAorminorstrokewithoutcardiacsourceofembolism.

研究在非心源性栓塞的TIA和中風(fēng)病人中，比較將INR控制在3~4.5的情況下服用抗凝劑和服用阿司匹林30mg的效果優(yōu)劣。Anticoagulationincerebralis30Result:terminatedduetoasignificantlyincreasedbleedingriskwithanticoagulation.因抗凝劑明顯增加出血性風(fēng)險(xiǎn)而中止。、lowerrateofischaemiceventswithanticoagulationcounterbalancedbyanincreasedriskofintracranialbleedings.

抗凝劑降低缺血性卒中時(shí)間的比率被其增加率內(nèi)出血的風(fēng)險(xiǎn)所抵消。Result:terminatedduetoasi312.WARSS(TheWarfarinAspirinRecurrentStrokeStudy)

showedasimilarrateofischaemiceventsandbleedingcomplications:warfarin(INR1.4–2.8)VSASA(instrokepatientswithoutcardiacsourceofembolism)

在非心源性栓塞的卒中病人中華法令（INR1.4–2.8）與阿司匹林的卒中再發(fā)及出血并發(fā)癥事件方面大致相似。2.WARSS(TheWarfarinAspirin32CarotidendarterectomyandstentingwithballoonangioplastyNASCETandESC

(Twolargerandomizedtrials)Result:clearbenefitofcarotidsurgerythanmedicaltreatmentinpatientswithhigh-degreestenosis.在頸動(dòng)脈高度狹窄的病人中，血管內(nèi)膜切除術(shù)明顯優(yōu)于單純藥物治療。Takentogether,thetrialsfoundanabsoluteriskreductionof13.5%over5yearsforthecombinedendpointofstrokeanddeathinfavourofcarotidendarterectomy.總體而言，在5年隨訪期內(nèi)，頸動(dòng)脈血管內(nèi)膜切除術(shù)在降低卒中及死亡等終點(diǎn)事件方面的絕對(duì)危險(xiǎn)性下降13.5%，具有一定優(yōu)勢(shì)。

Carotidendarterectomyandste33Theriskreductionisevenhigherinstenosis>90%.當(dāng)頸動(dòng)脈狹窄程度>90%時(shí)手術(shù)可將風(fēng)險(xiǎn)降得更低。Patientswith<50%ICAstenosisdonotbenefitfromcarotidendarterectomy.當(dāng)頸內(nèi)動(dòng)脈狹窄程度<50%時(shí)，頸動(dòng)脈內(nèi)膜切除術(shù)不能明顯獲益。Theriskreductionisevenhig34Theshort-termcomplicationrates(strokeanddeath)were6.2%forstenosis>70%and8.4%for50–69%stenosis.ASAshouldbegivenpriorto,duringandaftercarotidsurgery.頸動(dòng)脈狹窄程度>70%和狹窄程度在50–69%者手術(shù)后短期內(nèi)復(fù)發(fā)和死亡的風(fēng)險(xiǎn)分別是6.2%和8.4%。阿司匹林在手術(shù)前后及手術(shù)期間都應(yīng)給服。Theshort-termcomplicationra35Thatisall,Thanksforyourattendance!Thatisall,Thanksforyourat36UpdateofsecondarystrokepreventionUpdateofsecondarystrokepre37Introduction

Secondaryprevention：preventingastrokeafteratransientischaemicattack(TIA)orarecurrentstrokeafterafirststroke.卒中二級(jí)預(yù)防概念：在發(fā)生TIA或初次中風(fēng)后預(yù)防中風(fēng)發(fā)生或再次發(fā)生。

IntroductionSecondaryprev388to15%strokeorTIApatientssufferarecurrentstrokeinthefirstyear.Therecurrenceriskishighestinthefirstfewweeksanddeclinesovertime.有8~15%的中風(fēng)或TIA患者會(huì)在第一年內(nèi)再次中風(fēng)或發(fā)生中風(fēng)。且風(fēng)險(xiǎn)在最初的幾周是最高的，隨時(shí)間的延長(zhǎng)而下降。So,ImmediateevaluationofpatientswithastrokeorTIA,identificationofthepathophysiologyandinitiationofsecondarypreventionareofgreatimportance因此，發(fā)生TIA或中風(fēng)后立即進(jìn)行評(píng)估，了解其病理生理學(xué)情況積極啟動(dòng)二級(jí)預(yù)防措施是非常重要的。8to15%strokeorTIAp39Hypertension1.HOPE:

Ameta-analysiscomprisedsevenstudiesin15527patientswithTIA,ischaemicorhaemorrhagicstroke.薈萃分析7項(xiàng)研究涉及15527個(gè)TIA、缺血性或出血性中風(fēng)患者。

Followedupperiod:2–5y.隨訪周期：2~5年

Hypertension1.HOPE:40Result:

(1)Treatmentwithantihypertensivesreducedtheriskofstrokeby24%,riskofnon-fatalstrokeby21%,riskofmyocardialinfarction(MI)by21%andtheriskofallvasculareventsby21%.

服用控制高血壓藥物的卒中復(fù)發(fā)風(fēng)險(xiǎn)降低了24%,非致死性的卒中風(fēng)險(xiǎn)降低了21%,心肌梗塞風(fēng)險(xiǎn)降低了21%，所有的血管性事件降低了21%。

Result:41(2)thecombinationofanACEIwithadiureticwasmoreeffective(45%riskreduction)thanadiureticasmonotherapy(32%),monotherapywithanACEI(7%)orabeta-blocker(7%).

ACEI與利尿劑聯(lián)用更有效，優(yōu)于利尿劑、ACEI、β受體阻滯劑各自單用。

(2)thecombinationofan422.PROGRESS：

thefirstlarge-scaletrialspecificallyperformedinpatientsafterstroke.第一個(gè)針對(duì)中風(fēng)后病人實(shí)施的大型臨床試驗(yàn)。Method:Atotalof6105patientsweretreatedwithperindoprilasmonotherapyorincombinationwithindapamideorplacebo.

6105例中風(fēng)后病人或培哚普利單用或與吲噠帕胺、安慰劑聯(lián)用Followedupperiod:4y.

隨訪周期：4年2.PROGRESS：43Result:

1)Theabsoluteriskreductionforrecurrentstrokewas4%,andtherelativeriskreduction(RRR)was28%.卒中復(fù)發(fā)的絕對(duì)危險(xiǎn)度下降了4%，相對(duì)危險(xiǎn)度下降了28%.

Result:44

2)MonotherapywiththeACEinhibitorwasnotonlysuperiortoplacebobutalsodidnotachievethesamelevelofbloodpressureloweringthanthecombinationtherapy.TheRRRforcombinationtherapywas43%.

單用ACEI類不僅二級(jí)預(yù)防效果優(yōu)于安慰劑組，且與聯(lián)用相比不致于使血壓降得過(guò)低。聯(lián)用降低中風(fēng)復(fù)發(fā)的相對(duì)危險(xiǎn)度較高：43%.

2)MonotherapywiththeACE453.MOSES:Method:1352patientswithhypertensionwhohadsufferedastrokeinthelast24monthsweretreatedeitherwitheprosartan依普羅沙坦(600mg)orwithnitrendipin(10mg).

1352例在24個(gè)月內(nèi)發(fā)生過(guò)中風(fēng)的高血壓病人或用依普羅沙坦(600mg)治療或用尼群地平（10mg）治療。3.MOSES:46Result:1)Foranidenticaldropinbloodpressure,eprosartanwassuperiortonitrendipintopreventrecurrentvascularevents(21%RRR).

具有基本相同的降壓效果，但在防止血管事件復(fù)發(fā)方面依普羅沙坦優(yōu)于尼群地平治療。2)TheoptimalsystolicbloodpressureintheMOSEStrialwas120–140mmHg.

MOSES的研究提示中風(fēng)后最佳收縮壓應(yīng)控制在120-140mmHg。

Result:1)Foranidenticaldro474.PRoFESS:Method:randomized20332patientswitharecentischaemicstroketoreceivetelmisartan替米沙坦at80mg/dayorplacebo.隨機(jī)將新近發(fā)生過(guò)中風(fēng)的20332名病人分為替米沙坦80mg/d和安慰劑組。Followedupperiod:2.4years.隨訪周期：2.4年。4.PRoFESS:48Result:Themeanbloodpressureoverthetrialperiodwaslowerinthetelmisartangroupby3.8/2.0mmHg.Recurrentstrokesoccurredin8.7%inthetelmisartangroupcomparedto9.2%intheplacebogroup,whichwasnotsignificant.

在試驗(yàn)期間替米沙坦組血壓比安慰劑組平均低3.8/2.0mmHg.其中風(fēng)復(fù)發(fā)率為8.7%，安慰劑組中風(fēng)復(fù)發(fā)率為9.2%，兩組間沒有顯著性差異。Result:Themeanbloodpressur49Conclusion:initiationoftelmisartanearlyafterastroke,didnotsignificantlylowertherateofrecurrentstrokes,othermajorvasculareventsornewdiabetes。

中風(fēng)后早期服用替米沙坦并不能顯著的阻止中風(fēng)復(fù)發(fā)，及其他血管事件和新法糖尿病。Conclusion:initiationoftelm50Highcholesterol1.HeartProtectionStudy(HPS)Total20536high-riskpatients,3280patientshadTIAorstrokeand1820ofthemwithoutconcomitantCHD.共20536高危病人，其中3280具有TIA或卒中病史，1820沒有伴隨心臟疾病。TheRRRachievedbysimvastatingivenfor5yearsforvasculareventswas20%andtheabsoluteriskreduction5.1%.給予辛伐他汀組（連續(xù)5年）血管事件相對(duì)危險(xiǎn)度下降了20%，絕對(duì)危險(xiǎn)度下降了5.1%.Highcholesterol1.HeartProtec512.SPARCL

(StrokePreventionbyAggressiveReductioninCholesterolLevels)Method:4731patientswithTIAorstrokewithoutCHDandLDLcholesterollevelsbetween100and190mg/dl.Thepatientsreceivedeither80mgatorvastatinorplacebo.

4731個(gè)具有TIA或中風(fēng)病史排除心臟病且LDL在100~190mg/dl被分為80mg阿托伐他汀組和安慰劑組.

Followedupperiod:averageof4.9y.Result:theprimaryendpoint(stroke)wasreducedby16%relativeand2.2%absolute.第一終點(diǎn)事件卒中發(fā)生率下降的相對(duì)值和絕對(duì)值分別為16%和2.2%2.SPARCL(StrokePreventionby52HPSVSSPARCLTherateofischaemicstrokewasreduced(218versus274)whereashaemorrhagicstrokesweremorefrequentwithatorvastatin(55versus33).這兩個(gè)臨床試驗(yàn)相比，阿托伐他汀組的卒中發(fā)生下降了相對(duì)要高一點(diǎn)，但發(fā)生出血性卒中的數(shù)目確相對(duì)多一點(diǎn)。HPSVSSPARC53TherapywithastatinshouldbeinitiatedearlyafteranischaemicstrokeorTIA.Thesuddendiscontinuationofastatininpatientswithastrokeoracutecoronarysyndromemightbeassociatedwithhighermorbidityandmortality.

Discontinuationofstatintreatmentinstrokepatients.Stroke2006在初發(fā)中風(fēng)后對(duì)具有血脂異常者應(yīng)盡早開始服用他汀類調(diào)脂。具有中風(fēng)或冠心病的患者突然停用他汀類會(huì)出現(xiàn)比較高的復(fù)發(fā)率和致死率。

Therapywithastatinshou54Diabetes

mellitusRandomizedcontrolledstudieswereunabletoshowaneffectofglitazones列酮類onvasculareventsinstrokepatientswithdiabetesmellitusEffectsofpioglitazoneGlitazonesinpatientswithtype2diabeteswithorwithoutpreviousstroke:resultsfromPROACTIVE.Stroke2007;38

一隨機(jī)對(duì)照研究未能發(fā)現(xiàn)服用列酮類降糖藥能明顯降低具有糖尿病的中風(fēng)患者的血管事件的發(fā)生率。Aggressiveloweringofbloodglucosedoesnotreducetheriskofstrokeandmightevenincreasemortality.Intensivebloodglucosecontrolandvascularoutcomesinpatientswithtype2diabetes.NEnglJMed2008;358

過(guò)分降糖不但不會(huì)降低卒中的風(fēng)險(xiǎn)反而會(huì)增加惡性事件。DiabetesmellitusRandomize55SupplementationofvitaminsTheVISPstudywasunabletoshowabenefitofthetreatmentofhighhomocysteineinstrokepatientswithBvitaminsandfolicacid.

VISP的研究表明具有高同型半胱氨酸的中風(fēng)患者服用維生素B和葉酸未能額外獲益。TheHOPE-2studyalsofailedtodemonstratebenefit.

TheHeartOutcomesPreventionEvaluation(HOPE)2Investigators.HomocysteineloweringwithfolicacidandBvitaminsinvasculardisease.NEnglJMed2006;354

HOPE-2研究也得出與VISP基本相同的結(jié)論。Supplementationofvitamins56EffectoffolicacidandBvitaminsonriskofcardiovasculareventsandtotalmortalityamongwomenathighriskforcardiovasculardisease:arandomizedtrial.

JAMA2008;299:2027–2036

葉酸和維生素B在具有高風(fēng)險(xiǎn)心血管疾病女性受試者中對(duì)心血管事件和總致死率的效果included5522patientsaged>55yearsandavasculareventordiabetesmellitus包含5522例具有血管事件或糖尿病年齡大于55歲的女性受試者treatedthemfor5yearswitheitherplaceboor2.5mgfolicacid,50mgvitaminB6and1mgvitaminB12.對(duì)照組服用安慰劑，治療組服用2.5mg葉酸,50mg維生素B6and1mg維生素B12.resultedinasignificantreductioninhomocysteinelevelsbutnotinvascularevents.

結(jié)果：同型半胱氨酸水平下降但血管事件未明顯下降。EffectoffolicacidandBvit57Hormonereplacementtherapyaftermenopause

關(guān)于女性中風(fēng)患者的一項(xiàng)隨機(jī)安慰劑對(duì)照研究提示，絕經(jīng)后采取激素替代療法療法會(huì)增加中風(fēng)的死亡率，并給非致死性卒中帶來(lái)較差的預(yù)后。Hormonereplacementtherapyaf58Antiplatelet

therapy1.TheMATCHstudy:Object:high-riskpatientswithTIAorischaemicstrokeAim:clopidogrel75mg+ASA75mgPKclopidogrel75Result:combinationtherapyfailedtoshowsuperiorityonendpointvascularevent.

聯(lián)合用藥組未能體現(xiàn)在降低血管性終點(diǎn)事件中的優(yōu)勢(shì)。反而出血性并發(fā)癥的發(fā)生率較高。Reverselyresultedinasignificantincreaseinbleedingcomplications.-------notrecommended.Antiplatelettherapy1.TheMATC592.CHARISMA

(ClopidogrelforHighAtherothromboticRiskandIschemicStabilization,ManagementandAvoidance)

atrialcombinedprimaryandsecondarypreventionAim:clopidogrel+ASAPKASAResult:Combinationtherapyfailedtoshowabenefitanddisplayedahigherbleedingrate.聯(lián)合用藥治療未能明顯獲益。出血性并發(fā)癥的發(fā)生率較高。Symptomaticpatientsshowedatrendtowardsabenefitforcombinationantiplatelettherapy.

但在癥狀性中風(fēng)患者表現(xiàn)出一定的優(yōu)勢(shì)。2.CHARISMA(ClopidogrelforHi603.ESPS2(thesecondEuropeanstrokepreventionstudy)Method:6602patientswithTIAorstrokewererandomizedtoASA(25mgbid),ER-DP(200mgbid),ASA+ER-DPorplacebo.

6602例TIA或中風(fēng)病人隨機(jī)分為ASA組，ER-DP組、二者聯(lián)用組及安慰劑組。Result:Fortheprimaryendpointstroke,ASA+ER-DPwassuperiortoASAandplacebo

對(duì)第一終點(diǎn)事件卒中來(lái)說(shuō)，聯(lián)用效優(yōu)。ASAloweredtheriskofstrokeby18%anddipyridamolemonotherapyby16%.BleedingcomplicationswereseenmorefrequentlywithASAandtheASA+ER-DP,DPhadasimilarbleedingrateasplacebo

ASA及聯(lián)用組出血性并發(fā)癥較高，DP較低。3.ESPS2(thesecondEuropeans614.Ahead-toheadcomparisonofclopidogrelwithASA+ER-DP

(performedinthePRoFESSstudy)Method:Randomized20332patientswithischaemicstrokeandfollowedforameanperiodof2.4y.Result:Therewasnodifferenceinefficacyacrossallendpointsandvarioussubgroupsofpatients.

在所有終點(diǎn)事件的發(fā)生發(fā)面兩者之間沒有明顯差異。ASA+ER-DPresultedinmoreintracranialbleedingsandahigherdropoutrateduetoheadachecomparedwithclopidogrel(5.9%versus0.9%).

與clopidogrel相比ASA+ER-DP的顱內(nèi)出血率和因于頭疼的脫落率較高。4.Ahead-toheadcomparisonof621.EuropeanAtrialFibrillationtrial

(randomizedplacebo-controlledtrial)Numbersneededtotreat(NNT)are12/year.Result:

warfarin:RRR68%V300mgASA:RRR19%Anticoagulationincerebralischaemiaduetocardiacembolism

抗凝劑在心源性栓塞缺血性卒中患者中的應(yīng)用1.EuropeanAtrialFibrillation632.TheACTIVEstudyMethod:

RandomizedpatientswithAFintoASA+clopidogrelandwarfaringroups.

將受試的具有房顫卒中病人隨機(jī)分為ASA+clopidogrel和華法令組Result:

terminatedprematurelyduetoasignificantreductionofstrokeandsystemicembolisminfavourofwarfarin.

由于華法令在降低中風(fēng)發(fā)生和系統(tǒng)性栓塞方面表現(xiàn)出明顯的顯著性差異而提前終止。rateofbleedingcomplicationswasnotdifferentbetweenthetworegimens.