卒中巡讲汪昕幻灯片.pptVIP

颈动脉和椎动脉夹层 Natural history of carotid dissection: (Hart et al Neurol Clin North Am 1:155, 1983) Cerebral infarction in 33% (23% minor, 10% major or fatal. TIA in 45; Head and neck pain in 16%; Pulsatile tinnitus 4%; and bruit in 2%. Proper management is controversial. Most pts do well, either because of or despite treatment. 心源性卒中预防：抗血栓治疗 心源性卒中可能病因 Valvular heart disease心脏瓣膜病 Rheumatic mitral valve disease风湿性二尖瓣病 Prosthetic heart valves人工心脏瓣膜 Mitral valve prolapse二尖瓣脱垂 Aortic valve disease主动脉瓣病 Aortic arch atherosclerosis主动脉弓粥样硬化 Endocarditis (infective or nonbacterial thrombotic)心内膜炎（感染性或非细菌性血栓） Atrial fibrillation心房颤动 Myocardial infarction心肌梗死 Left ventricular dysfunction左心室功能不全 Patent foramen ovale卵圆孔未闭 Rheumatic mitral valve disease:2° stroke prevention No randomized trials Observational studies: OAC reduce recurrent embolic events/fatal events by 2/3 or more1-3 Extrapolation from 1 large randomized study in NVAF (EAFT) provides additional data for patients with RHD + AF (but RHD excluded) 1 Szekely P BMJ 1964;1:209-12 2Adams GF et al JNNP 1974;37:378-83 3Fleming Bailey Postgrad Med 1971;47:599-604 Level III-IV: Benefit of OAC Prosthetic heart valves: mechanical valves1° stroke prevention Observational data: APA may be sufficient to prevent embolism in absence of AF, but OAC needed to prevent valve thrombosis1-2 RCT: addition of ASA 100 mg to warfarin (INR 3-4.5) ? cerebral embolism (4/186 vs. 12/184)3 NonRCT: addition of ASA 500 mg tripled risk of major hemorrhage (14% vs. 5%)4 Level I evidence: benefit of OAC + ASA over OAC alone 1 Hartz R et al J Thorac CV Surg 1986;92:684-90 2Ribeiro P et al J Thorac CV Surg 1986;91:92-8 3 Turpie A et al NEJM 1993;329:524-9 4Chesebro J et al Am J Card 1983;51:1537-41 Prosthetic heart valves: mechanical valves2° stroke prevention No direct data ACCP recommendations: OAC + baby ASA based on extrapolation of 1° prevention data 6th ACCP Consensus Conference on Antithrombotic Therapy 2001 Prosthetic heart valves:biop