缺血性卒中的抗栓治疗.pptVIP

缺血性卒中的抗栓治疗 缺血性卒中的抗栓治疗 Optimum INR for prevention of 2° stroke associated with atrial fibrillation(EAFT NEJM 1995;333:5-10) “The target value for the INR should be set at 3.0” 缺血性卒中的抗栓治疗 Stroke Prevention with the ORal direct Thrombin Inhibitor in patients with non-valvular atrial Fibrillation(SPORTIF) SPORTIF III是一项开放试验 , SPORTIF V期是随机双盲多中心试验 ； 比较了口服直接凝血酶抑制剂西美加群（ximelagatran）与华法林（INR2~3）对心房颤动罹患卒中的影响 ； 两组预防缺血性卒中的疗效无统计学差异，华法林组并发出血的概率较高，西美加群组肝酶升高发生率为6%，比华法林组（0.8%）高很多，这也是尚未获得美国FDA批准的原因。 缺血性卒中的抗栓治疗 心肌梗死后一级预防: 短期抗凝 Pre-thrombolytic era Heparin decreases stroke incidence 1-3 Heparin decreases mural thrombus 4 1Med Research Council BMJ 1969;1:335-42 2Drapkin Merskey JAMA 1972;222:541-8 3VA Coop Study JAMA 1973;225:724-9 4Vaitkus Barnathau JACC 1993;22:100-9 缺血性卒中的抗栓治疗 心肌梗死后一级预防: 短期抗凝 Post-thrombolytic era baseline rates of death, reinfarction, stroke, PE markedly lower with thrombolytics ASA addition of heparin/LMWH may decrease mural thrombus formation, but increases risk of major bleeding without further reducing stroke risk 1Collins et al BMJ 1996;313:652-9 2Collins et al NEJM 1997;336:847-60 3FRAMI Kontny et al JACC 1997;30:962-9 4SCATI Lancet 1989;2:182-6 5Gissi-2 Vecchio et al Circulation 1991;84:512-9 缺血性卒中的抗栓治疗 心肌梗死后一级预防: 长期抗凝 Relative to control, coumarins in moderate or high dose (INR 2-4.8) Significantly decrease stroke incidence Significantly increase incidence of major bleeding Anand Yusuf JAMA 1999;282:2058-67 缺血性卒中的抗栓治疗 Modified from Anand Yusuf JAMA 1999;282:2058-67 …But no benefit relative to ASA Incidence of stroke and significant increase in major bleeding 缺血性卒中的抗栓治疗 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 sufficient re