缺血性卒中抗栓循证治疗PPT格式课件下载.ppt

1、大脑中动脉（PROACT II）后循环:基底动脉 与安慰剂相比，3h内IV rtPA（0.9 mg/kg）能改善90天时的预后出血发生率为 6.4%，安慰剂为 0.6%，但死亡率无差异所有亚组预后均优于安慰剂组益处可持续1年rt-PA:NINDS 随机,多中心,双盲,安慰剂对照620例;排除CT早期梗塞灶（预后不良）干预rtPA（1.1 mg/kg）vs.placebo起病6h内 主要终点Barthel Index and modified Rankin Scale at 90 daysrtPA 与安慰剂组无明显差别rt-PA:ECASS IHacke et al.,JAMA.1995;274

2、:1017-1025随机,多中心,双盲,安慰剂对照800 例;排除CT早期明显梗塞灶 干预rtPA（0.9 mg/kg）vs.placebo起病6h内 主要终点modified Rankin Scale Score of 1 at 90 daysrtPA 与安慰剂组无明显差别rt-PA:ECASS IIHacke et al.,Lancet.1998;352:1245-1251随机,多中心,双盲,安慰剂对照613例干预rtPA（0.9 mg/kg）vs.placebo起病3-5h内 主要终点NIHSS of 1 at 90 daysrtPA 与安慰剂组无明显差别rt-PA:ATLANTISAl

3、teplase Thrombolysis for Acute Noninterventional Rx in Isch StrokeClark et al.,JAMA.1999;282:2019-2026rt-PA:小结与安慰剂相比，3h内IV rtPA（0.9 mg/kg）能改善90天时的预后.I 类证据目前证据显示，超过3h 予IV tPA 无效.I 类证据链激酶（SK）研究药物剂量治疗窗结果Multicenter Acute Stroke Trial-Europe（MAST-E）NEJM 1996;335:145-50SK1.5 MU6hSK组出血和死亡率高提前终止试验Multicent

4、er Acute Stroke Trial-Italy（MAST-I）Lancet 1995;346:1509-14SK aspirin1.5 MU300 mg/d6hSK组，尤其是SK+aspirin组出血和死亡率高提前终止试验Australian Streptokinase Trial（ASK）Donnan et al.,Lancet 1995;345:578-9SK1.5 MU4h提前终止;治疗窗4h无明显益处，结果不良与安慰剂相比，6h内予IV SK 1.5 MU 预后不良（出血和死亡率高）.I 类证据动脉溶栓前循环大脑中动脉阻塞后循环椎基底动脉阻塞与安慰剂相比,6h内予IA ProU

5、K 经造影证实MCA M1 或M2 段阻塞的患者有效.I 类证据15%绝对有效（number needed to treat=7）增加颅内出血，死亡率无差异PROACT II:小结急性椎基底动脉阻塞数项病例报道（IV、V 类证据）非随机化无对照组 Brandt et al.,Cerebrovasc Dis,1995;5:182-7小结3h内静脉用 tPA 能降低90天时的残障功能.I类证据静脉用链激酶（1.5 MU）增加出血和死亡率.I类证据6h内动脉用尿激酶前体（Pro-UK,未被FDA通过）能降低90天时的残障功能.I类证据有证据支持在急性椎基底动脉阻塞中应用动脉溶栓.IV、V类证据急性缺

6、血性卒中抗凝治疗概述肝素LMW heparinLMW heparinoid-作用于抗凝血酶 III（抑制凝血因子 IIa,IXa,and Xa）1 effect on Xa reduced plt interaction longer half-life simpler to administer lower bleeding risk reduced effect on IIaSummary:trial resultsNdrugresultsCanadian225Hep IVno differenceIST19,435Hep scno differenceTOAST1281heparinoi

7、dno differencelarge art better at 3 mo?HK308LMWH dead/dep at 6 moFISS767LMWHno differenceTAIST1486LMWHno differenceTOPAS404LMWHno difference among doses各卒中亚型急性抗凝治疗 房颤 和心源性栓塞大动脉粥样硬化椎基底动脉阻塞 TIA进展性卒中动脉夹层静脉血栓形成各卒中亚型急性抗凝治疗:小结CCTsubgrpNresults心源性栓塞123618no diff大动脉硬化0413,2851+（?）/3-后循环032318no diffTIA1055n

8、o diff进展性卒中20204no diff夹层00286no diff静脉血栓20791+/1-小结急性期抗凝减少深静脉血栓和肺栓塞发生，不增加颅内出血几率.I类证据 急性缺血性卒中阿司匹林治疗急性缺血性卒中阿司匹林治疗International Stroke Strial（IST）ASA 300 mg/d x 2 wks begun within 48 hrs2 wk endptsASAN=9720No ASAN=9715Recurrent ischemic2.8%*3.9%All recurrent stroke3.7%4.6%Major extracranial bleed1.1%*

9、0.6%Death9.0%9.4%*p.01Chinese Acute Stroke Trial（CAST）Lancet 1997;349:1641ASA 160 mg/d x4 wks begun within 48 hrs4 wk endptsASAN=10335PlaceboN=10320Recurrent ischemic1.6%*2.1%All recurrent stroke3.2%3.4%Major extracran bleed0.8%*0.6%Death3.3%*3.9%*p.05小结小结基于 IST 和 CAST,阿司匹林在急性缺血性卒中后2-4周内，每1000例患者中有1

10、0人可减少死亡和复发。非心源性卒中二级预防：抗栓治疗抗栓治疗概述抗血小板药Antiplatelet.阿司匹林Aspirin抵克立得（噻氯匹啶）Ticlid（Ticlopidine）波力维（氯吡格雷）Plavix（Clopidogrel）艾诺思Aggrenox（aspirin+extended-release dipyridamole）Warfarin for non-cardioembolic arterial stroke:including large vessel disease.抗磷脂抗体综合征（ASP）.颈椎动脉夹层.Aspirin高剂量阿司匹林随机对照试验#StudyASA dos

11、e#of ptsAgef/u Prim.Endpoint%of RR1AITIA 1977Medical group1300mgA 88;P 9060.237mTIA,CI,RI,death20 only with TIA.*P（15.7）2AITIA 1977 surgical group650mgA 65;P 6060.3?TIA,CI,RI,deathSame as medical*P（15.7）3CCSG 1978ASA+SP1300mgA 144;P 139?26mTIA,S,death-6 to 31%*P（7.6）4Reuther 19781500mgA 29;P 295924m

12、TIA,SNS*P（8.3）5AICLA 1983ASA+DP990mgA 198;P 20463.536mFatal;nonfatal CI no TIA included41*P（7.5）6Danish CS 19831000mgA 101;P 1025925mS or Death-77*P（9.6）7Swedish CS 19871500mgA 253;P 2526824mS or Death0*P（10.9）*Risk of vascular events（death,stroke,MI）in the control group低剂量阿司匹林随机对照试验#Study ASA dose

13、in mg.#of ptsAgeF/uPrim.Endpoint%in RR1Danish Low 1988（post CEA）50-100A150P15158.925TIA,S,MI,vascular death11%（NS）*P（7.3）2UK TIA 19911200300Placebo81580681459.848Major S,MI,Vasc.Death 15%vs P;NS between doses*P（5.7）3SALT 199175A676P68466.932S or death16%*P（10.6）4ESPS 250A1649P164966.724S,death or bo

14、th18%*P（15.8）*Vascular events（death,MI,stroke）in placebo.*stroke in placeboAntiplatelet Trialists100,000 pts from 145 trials.All antiplatelet agents were included.Clumped all vascular events together.Overall odds reduction for vascular events was 25%.For pts with minor stroke or TIA（18 trials）antipl

15、atelet agents led to odds reduction of 22%for vascular events and 23%for nonfatal stroke.Did not answer questions about aspirin dose.Used odds ratio instead of relative risk.Used all antiplatelet agents.Is there a consensus.The FDA reviewed trials of aspirin vs placebo（including ESPS-2,SALT,and UK-TIA trials）to reduce the risk of stroke and death in patients with prior TIA or stroke.“The positive findings at lower dosages（eg,50,75,and 300 mg daily）,along with the higher incidence of side effects expected at the higher dosage（eg,1,300 mg daily）,are sufficie