颅内动脉狭窄流行病学、内科治疗、支架治疗解析.ppt

* * * All patients were placed on aspirin 325 mg daily and loaded with clopidogrel 300 to 600 mg daily with clopidogrel 75 mg daily continued for a minimum of 3 months. After 3 months, aspirin was reduced to 81 mg daily and clopidogrel 75 mg daily was continued unless patients reported cost difficulties or adverse events, at which time they were switched to aspirin monotherapy. 让我们再来看一下2011年国际上最新公布的SAMMPRIS研究结果。该研究是迄今首个前瞻性、随机、由NINDS（美国国立神经疾病与卒中研究院）牵头、比较积极药物治疗和联用支架成形术对症状性颅内动脉严重狭窄预防卒中复发的研究，发表在权威新英格兰杂志上。 * * SAMMPRIS研究人群包含颅内大动脉严重狭窄70-99%导致的发病30天内的非致残性缺血性卒中患者，随机接受积极药物治疗或联合Wingspan支架置入术，其中积极药物治疗组包括氯吡格雷和ASA治疗90天、降压、降脂、控制血糖以及生活方式的改变，美国共50家中心参与研究，计划纳入764例患者，然而451例的中期报告发现支架组30天内卒中或死亡率高达14.7%，显著高于药物治疗组5.8%的比例，导致研究被提前终止。这张图是两组1年终点事件率的比较，从图中可以看到，Wingspan支架组的年终点事件率为20%，而积极药物治疗组仅12%，P=0.009，有显著差异。因此，SAMMPRIS研究结论证实积极药物治疗对症状性颅内动脉严重狭窄患者的获益较支架组更有优势，而氯吡格雷在积极抗栓治疗中具有重要的地位。 * TOSS-Ⅱ: 西洛他唑组和氯吡格雷组的症状性颅内 动脉狭窄进展无明显差异 End Point Cilostazol, n (%) Clopidogrel, n (%) P Progression (primary outcome) 20 (9.3) 32 (15.5) 0.092 Regression 61 (30.2) 49 (23.7) 0.139 Cilostazol did not reduce the progression of symptomatic ICAS (20 of 202) compared to clopidogrel (32 of 207) (odds ratio, 0.61; P0.092), Sun U. Kwon, et al. Stroke. 2011;42 氯吡格雷比西洛他唑有减少新发缺血灶的趋势 More patients in the cilostazol group had new ischemic lesions at the follow-up MRA than those receiving clopidogrel, as well as in the territory of the symptomatic ICAS, but this difference was not statistically significant. End Point Cilostazol, n (%) Clopidogrel, n (%) P Any new ischemic lesion 34 (18.7) 23 (12.0) 0.078 New ischemic lesions in the territory of symptomatic ICAS 22 (12.0) 17 (8.9) 0.321 Sun U. Kwon, et al. Stroke. 2011;42 氯吡格雷有进一步降低临床事件的趋势 There was no statistical difference in the occurrence of clinical events by treatment group, although events tended to be more frequent in the cilostazol group. End Point Cilostazol, n (%) Clopidogrel, n (%) P Total cardiovascular events 15 (6.4) 10 (4.4)