小卒中的防治.pptVIP

* * FASTER预研究评估双联抗血小板药物治疗较单用阿司匹林对急性TIA和缺血性小卒中后24小时内发生卒中的患者的早期预防效果。24小时内患者在接受阿司匹林的基础之上给予波立维负荷剂量300mg，再以每天波立维?75mg维持剂量治疗3个月，随访至90天。阿司匹林单药组90天内有21人再发卒中，联合治疗组有14人再发卒中，联合用药组的主要终点比单用阿司匹林绝对危险下降3.8%，相对风险降低28%。30天内联合用药组，出血的风险并没有增加，未抵消联合用药组的临床获益。该研究结果提示早期积极的双联抗血小板药物治疗能降低TIA或小卒中患者的早期的高复发率，且不增加出血风险，是安全的疗法。 * * * * * * 结合 CARESS CLAIR 研究结果，阿司匹林单药治疗的卒中复发多于氯吡格雷联合阿司匹林 * * MTACH的亚组分析显示在卒中发病1周内给予联合治疗有获益趋势，可使致残性或非致死性卒中相对风险降低17% * 而在缺血性卒中早期抗血小板治疗方面，波立维也有相关循证支持。 2008年发表于新英格兰杂志的PROFESS研究是迄今为止世界上规模最大的卒中二级预防研究。该研究旨在比较阿司匹林+缓释双嘧达莫复方制剂和波立维75mg的疗效和安全性。该研究总纳入人群中有40%的患者发病≤10天。2010年stroke杂志上就发表了针对这部分急性缺血性卒中患者(共1360例卒中发病72h，平均NIHSS=2.8)的亚组研究结果。一级终点结果表明，波立维75mg和阿司匹林+缓释双嘧达莫复方制剂30天死亡和神经功能缺损结局无显著差异，即疗效两者相当。但安全性方面，波立维75mg组用药依从性明显优于阿司匹林+缓释双嘧达莫复方制剂，阿司匹林+缓释双嘧达莫复方制剂组90天停止用药的患者比例为18%，而波立维75mg组仅为12.5%,P0.006，两组有显著差异。而且阿司匹林+缓释双嘧达莫复方制剂组有36例因不良反应而停药，大多数停药原因为头痛，而波立维75mg组仅有3例。相比较而言，尽早波立维75mg治疗显然更有优势。 * June 2006 * Of the 19,099 patients in the CAPRIE trial who received study treatment, 4496 patients had a prior history of a major acute event (MI or ischemic stroke)1 Overall, the annual event rate was lower with clopidogrel versus ASA (5.3 vs 5.8%) with a RRR of 8.7%1 Similarly, in patients who had a prior history of a major acute event, the annual event rate was lower in the clopidogrel group versus the ASA group (8.8 vs 10.2%) with a RRR of 14.9%1 Thus, the benefits of clopidogrel over ASA were amplified in the higher vascular risk group1 References 1. Ringleb PA et al. Stroke 2004; 35: 528–532. * June 2006 * In the CAPRIE study, 3866 patients had co-existing diabetes1 Patients without diabetes treated with clopidogrel were at lower risk of MI, ischemic stroke, vascular death or rehospitalization for ischemic events/bleeding than those treated with ASA (11.8 vs 12.7%; p=0.096; 9 events prevented per 1000 patients per year with clopidogrel versus ASA)1 Similarly, patients with diabetes treated with clopidogrel were at lower risk of MI, ischemic stroke, vascular death or rehospitalization for ischemic events