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1、掌握危险分层工具(ESRS)识别卒中高危患者及长期预防,缺血性卒中/TIA复发的决定因素,何人复发：卒中易损病人,识别卒中易损病人的意义,二级预防分层用药依据,二级预防分层用药依据,缺血性卒中TIA二级预防中抗血小板药物规范化应用的中国专家共识,氯吡格雷(75mg/日)、阿司匹林(50325mg/日)、缓释双嘧达莫(200mg)与阿司匹林（25mg）复方制剂（2次/日）都可作为首选的抗血小板药物（I类推荐，A级证据）。依据各种抗血小板治疗药物的获益、相应风险及费用进行个体化治疗（II类推荐，C级证据）。动脉粥样硬化性缺血性卒中/TIA以及既往有脑梗死病史、冠心病、糖尿病或周围血管病者优先考虑氯
2、吡格雷(75mg/日)（I类推荐，B级证据）。,一级预防FraminghamSCORESPAF-III, CHADS2 index (Atrial Fibrillation),二级预防Recurrent Stroke Risk ScoresHigh grade carotid stenosis,危险分层概念,Framingham 卒中风险评估(FSP),1,2,3,4,5,6,7,8,9,10,100,90,80,70,60,50,40,30,20,10,0,累计卒中风险,随访时间（年）,个体卒中风险（10年后）,注：1磅=0.45392公斤； 1英尺=2.54厘米,DAgostino RB
3、et al. Stroke. 1994;25:40-43,已经验证的危险分层工具,Primary Secondary preventionTitelFraminghamSPI IIABCDEssenPrediction given10 years2 years7 days2 yearsIndex eventasymptomatic IS or TIATIAIS or TIARange0-380-150-60-9High-risk group 17742ItemsAge age 70 age 60 age 60 /75 diabetesdiabetesarterialDiabetessystol
4、ic RRprior strokehypertensionarterialantihypertentscoronary hearthemiaparesishypertensionsmokingdiseaseaphasiaPrior MICardiac diseasecardiac failureduration of Other cardio-atrial fibrillationstroke index eventsymptoms 10min /vascular diseaseleft ventricular(vs. TIA)1hPAD hypertrophySmoking prior IS
5、 / TIAReferenceDAgostino. StrokeKernanRothwell. LancetDiener. Exp Opin1994;25:40-32000;31:456-622005;366:29-36Pharmacother2005;6(5):755-764.,危险分层工具,寻找面临卒中复发的高危人群,ESRS : Essen Stroke Risk Score Essen卒中风险评分量表1,1. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in
6、patients at risk of ischaemic events Lancet 1996;348:1329-1339,SCALA：方法,验证Essen风险评分的前瞻性横断面研究德国的85个卒中单元852名患者在2005年7月到10月间入组患者排除插管和颅内出血的患者不干预17.5（SD 0.88）个月后以中心化随访为主,Weimar C. Rother J. et al. J Neurol, 2007, 254 (11).1562-1568,SCALA：近60%的患者处于高复发风险,Weimar C. Rother J. et al. J Neurol, 2007, 254 (11).
7、1562-1568,J. Neurol. Neurosurg. Psychiatry 2008;79;1339-1343;,ESRS评分3患者的再发风险是 3患者的一倍,Christian Weimar, et al. The Essen Stroke Risk Score Predicts Recurrent Cardiovascular Events. Stroke, 2009, 40:350-354.,REACH:ESRS评分越高，卒中和复合心血管事件发生率越高,REACH研究入选15,605例病情稳定的缺血性卒中/TIA门诊患者(排除房颤患者)，随访1年无论住院或门诊患者，ESRS是评
8、估卒中患者再发风险的理想工具，识别高危患者,事件率/年%,Diener HC, et al. Clopidogrel for the secondary prevention of stroke. Expert Opin Pharmacother, 2005,6(5):755-764.,CAPRIE ：缺血性卒中患者的ESRS分析,基于CAPRIE亚组6431位卒中患者，ESRS评分6的卒中极高危患者比例较低(仅96位患者，占1.4%)，未纳入卒中高危：动脉粥样硬化性卒中以及既往有脑梗死病史、冠心病、糖尿病或周围血管病 易损斑块或动脉-动脉栓塞,卒中事件率/年(%),ESRS3分的高危患者，预
9、防卒中再发，氯吡格雷优于阿司匹林,The REACH Registry,An International, Prospective Observational Study in Subjects at Risk of Atherothrombotic Events in an Outpatient Setting,GLB.CLO.06.02.06,North America: 27,746Canada: 1,976USA: 25,770,Thailand: 515,Taiwan: 1,057,South Korea: 505,Singapore: 880,Philippines: 1,039,
10、Malaysia: 525,Indonesia: 499,Hong Kong: 175,China: 708,Asia: 10,951,Japan: 5,048,Interlatina includes Panama, Costa Rica, Dominican Republic, Ecuador, Guatemala and Peru,A Large and Far-Reaching International Survey of Atherothrombosis*1,*Data shown may differ slightly from published abstracts owing
11、 to a subsequent database lock.,1. Bhatt DL et al, on behalf of the REACH Registry Investigators.JAMA 2006; 295(2): 180-189.,一年致死性和非致死性卒中（白）以及联合心血管事件（斜纹）,Stroke. 2009;40:350-354.,Copyright 2008 BMJ Publishing Group Ltd.,Weimar, C et al. J Neurol Neurosurg Psychiatry 2008;79:1339-1343,Survival free o
12、f recurrent stroke during follow-up in patients with an Essen Stroke Risk Score (ESRS) =3 (n = 700).,Copyright 2008 BMJ Publishing Group Ltd.,Weimar, C et al. J Neurol Neurosurg Psychiatry 2008;79:1339-1343,Survival free of recurrent stroke during follow-up in patients with an Essen Stroke Risk Scor
13、e (ESRS) =3 (n = 700).,Essen卒中危险评分（ESRS）,JNNP 2008;(6),Essen评分应用,0,1,2,3,4,5,6,7,8,9,极高危,高危：卒中危险4,低危：卒中危险4,JNNP 2008;(6),寻找面临卒中复发的高危人群,1. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:1329-1339,ESRS : Essen Stroke Risk Score Essen卒中风险量表1,3为高危患者，卒中风险4%/年,需要更强的抗血小板药物,
