20130530 病例讨论---卒中+颈动脉狭窄+房颤的抗栓治疗VIP免费

北京天坛医院BeijingTiantanHospital颈动脉狭窄合并房颤的抗栓治疗北京天坛医院神经内科脑血管病中心杨中华北京天坛医院BeijingTiantanHospital病例资料•男性，68岁•既往：高血压，心房颤动•临床表现：突发右侧肢体无力，来我院住院时已经发病1个月，当地给予阿司匹林100mgQd•入院NIHSS=2分，仅仅遗留右侧面纹浅，右侧针刺觉减退•头MRI：左侧MCA皮层小片状梗死•颈部血管彩超:左侧ICA起始部狭窄70-99%北京天坛医院BeijingTiantanHospital如何平衡三者的关系卒中颈动脉狭窄房颤北京天坛医院BeijingTiantanHospital抗栓治疗方案选择•阿司匹林•氯吡格雷•阿司匹林+氯吡格雷•华法林•华法林+阿司匹林•华法林+氯吡格雷•华法林+阿司匹林+氯吡格雷北京天坛医院BeijingTiantanHospital抗血小板药物预防卒中的证据卒中颈动脉狭窄房颤急性期二级预防北京天坛医院BeijingTiantanHospital抗血小板药物急性期的证据卒中颈动脉狭窄房颤单抗双抗北京天坛医院BeijingTiantanHospitalInternationalStrokeTrial(IST)阿司匹林：n=9720;300mg/d14天(+肝素12500IU/5000IU/无肝素)安慰剂：n=9715(+肝素12500IU/5000IU/无肝素)19435名缺血性卒中患者发病48小时AF=16%随机开放6个月主要终点：14天死亡、6个月时死亡或残疾随访期InternationalStrokeTrialCollaborativeGroup,Lancet1997;349;1569-81研究设计北京天坛医院BeijingTiantanHospital降低卒中早期复发率、病死率InternationalStrokeTrialCollaborativeGroup,Lancet1997;349;1569-81阿司匹林对照14天缺血性卒中发生率P<0.0010.1040.1080.1120.1160.120.1240.1282.9%3.8%00.010.020.030.040.0511.3%12.9%P=0.02阿司匹林对照14天死亡或非致死性卒中发生率北京天坛医院BeijingTiantanHospitalChineseAcuteStrokeTrial(CAST)阿司匹林：n=10554;160mg/d，4w安慰剂：n=1055221106名缺血性卒中患者发病48小时AF=7%随机双盲随访期26天（平均住院时间）主要终点：4周治疗期内死亡、出院时死亡或残疾CAST(ChineseAcuteStrokeTrial)CollaborativeGroup,Lancet1997;349;1641-49研究设计北京天坛医院BeijingTiantanHospital降低卒中早期死亡率、复发率CAST(ChineseAcuteStrokeTrial)CollaborativeGroup,Lancet1997;349;1641-4901234567阿司匹林安慰剂早期死亡率早期复发率校正后的事件发生率%死亡/非致死性卒中发生率P=0.04P=0.01P=0.033.3%3.9%2.1%1.6%5.3%5.9%北京天坛医院BeijingTiantanHospital卒中早期使用双联抗血小板LancetNeurol2010北京天坛医院BeijingTiantanHospitalStroke.2012;43:1058-1066北京天坛医院BeijingTiantanHospital天坛医院-Chance研究方案研究编号：2008ZX09312-008北京天坛医院BeijingTiantanHospital抗血小板药物二级预防的证据卒中颈动脉狭窄房颤北京天坛医院BeijingTiantanHospitalATC荟萃分析(287RCT)阿司匹林显著降低卒中/TIA患者血管事件危险AntithromboticTrialists’Collaboration,BMJ2002;324;71-86既往卒中/TIA急性卒中血管事件危险%血管事件危险%北京天坛医院BeijingTiantanHospital氯吡格雷vsASA-CAPRIEtrialTimesincerandomisation(months)03691215182124273033Cumulativerisk(%)05101520Clopidogrel75mg/dayASA325mg/dayRRR:8.7%(p=0.043)36PatientsatriskASA3,7243,6913,6433,6013,5523,5082,756Clopidogrel3,7813,5763,6863,6383,5823,5442,823CAPRIESteeringCommittee.Lancet1996;348:1329–1339.ischaemicstrokemyocardialinfarctionvasculardeathischaemicstroke,myocardialinfarction,orsymptomaticatheroscleroticperipheralarterialdisease.北京天坛医院BeijingTiantanHospitalResultsforstrokepatientsStrokeMIASAClopidogrel8%RRR15%RRR23eventsprevented7eventspreventedCAPRIESteeringCommittee.Lancet1996;348:1329–1339.Totalnumber(n)ofevents(2yrfollow-up)33851315440100200300400*RRR=RelativeriskreductionTheRRR*ofvasculareventswas7.3%infavourofclopidogrel(p=0.26)n=6,431北京天坛医院BeijingTiantanHospital双抗卒中二级预防-MATCHtrialRRR:6.4%(p=0.244)Clopidogrel+ASAClopidogre...