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1、卒中发作及复发的风险评估与处理,神经内科 马振兴,卒中的概念与分类,概念：急性起病的血供异常导致的脑或脊髓损伤称为卒中。分类：,2023/6/27,2,美国,中国,经年龄调整总的心血管疾病、冠心病、脑卒中死亡率的变化 1900-1996 美国,标化死亡率(1/10万),冠心病,脑卒中,总的心血管疾病,100,200,300,400,500,0,1900,1920,1940,1960,1990,1996,0,30,60,90,120,150,1985,1990,1995,2000,2005,2010(年),脑卒中,冠心病,2.MMWR Weekly August6,1999/48(30);649
2、-656,1中国心血管病报告2005,中国脑卒中和冠心病死亡率持续升高,2023/6/27,3,心房颤动患者卒中风险评估及处理,2023/6/27,4,心房颤动患者的卒中风险,2023/6/27,5,CHADS2评分,2023/6/27,6,CHADS2评分的年卒中风险,2023/6/27,7,根据CHADS2评分及其风险程度选择治疗药物,2023/6/27,8,美国胸科医师协会心房颤动风险专家共识,年龄75岁既往卒中病史、TIA 或系统性栓塞病史高血压病史糖尿病左室功能异常风湿性心脏病瓣膜修复术,1、高度风险:存在一种或以上危险因素；应予华法林抗凝(INR2.03.0)2、中度风险:年龄65
3、75之间，无任一危险因 素；由医师决定 抗凝或抗血小板治疗3、低度风险:年龄65,无任一危险因素;应予阿司匹林325mg口服,2023/6/27,9,AHA 卒中一级预防关于房颤的推荐,Adjusted-dose warfarin(target INR,2.0 to 3.0)is recommended for all patients with nonvalvular atrial fibrillation deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive i
4、t safely(Class I;Level of Evidence A).推荐所有卒中高危及许多中危风险的非瓣膜性房颤患者使用华法林(目标INR.2.03.0)。（I,A）Antiplatelet therapy with aspirin is recommended for low-risk and some moderate-risk patients with atrial fibrillation,based on patient preference,estimated bleeding risk if anticoagulated,and access to high-quali
5、ty anticoagulation monitoring(Class I;Level of Evidence A).推荐低危及部分中危患者使用阿司匹林抗血小板治疗。（I,A）For high-risk patients with atrial fibrillation deemed unsuitable for anticoagulation,dual antiplatelet therapy with clopidogrel and aspirin offers more protection against stroke than aspirin alone but with incre
6、ased risk of major bleeding and might be reasonable(Class IIb;Level of Evidence B).对于不适合抗凝治疗的高危患者，阿司匹林联合氯吡格雷双联抗血小板治疗较单用阿司匹林有更好的预防效果但大出血风险增加。（IIb，B）,2023/6/27,10,AHA 卒中二级预防关于房颤的推荐,1、For patients with ischemic stroke or TIA with paroxysmal(intermittent)or permanent AF,anticoagulation with a vitamin K
7、antagonist(target INR 2.5;range,2.0 to 3.0)is recommended(Class I;Level of Evidence A).推荐伴有房颤的缺血性卒中或TIA患者抗凝治疗（目标INR 2.5，2.03.0）（I，A）2、For patients unable to take oral anticoagulants,aspirin alone(Class I;Level of Evidence A)is recommended.The combination of clopidogrel plus aspirin carries a risk of
8、 bleeding similar to that of warfarin and therefore is not recommended for patients with a hemorrhagic contraindication to warfarin(Class III;Level of Evidence B).(New recommendation).推荐不能抗凝治疗的患者单用阿司匹林治疗（I，A）。由于双联抗血小板治疗（氯吡格雷联合阿司匹林）出血风险与华法令相当，不推荐用于有华法令出血禁忌症的患者。（III，B）3、For patients with AF at high ri
9、sk for stroke(stroke or TIA within 3 months,CHADS 2 score of 5 or 6,mechanical or rheumatic valve disease)who require temporary interruption of oral anticoagulation,bridging therapy with an LMWH administered subcutaneously is reasonable(Class IIa;Level of Evidence C).(New recommendation)卒中高危风险的房颤患者（
10、3个月内卒中或TIA史，CHADS2评分5或6分，机械瓣膜或风湿性心脏瓣膜病）如短时间内停用口服抗凝治疗，使用低分子肝素皮下注射替代是合理的。（IIa,C）,2023/6/27,11,非心脏病患者脑卒中风险评估及处理,2023/6/27,12,脑卒中/TIA预防中抗血小板治疗的分层用药,无上述情况的缺血性卒中或TIA,只有危险因素（一级预防）,缺血性卒中或TIA，伴有动脉粥样硬化性动脉狭窄有重要危险因素（糖尿病、冠心病、代谢综合征、持续吸烟）,缺血性卒中/TIA，伴脑动脉支架或其他成形术伴不稳定心绞痛伴无Q波心梗,临床描述,氯吡格雷 75mg/d 阿司匹林75-150mg/d,治疗方案,危险分
11、层,极高危,高危,中度高危,低危,氯吡格雷75mg/d,氯吡格雷 75mg/d或 阿司匹林75-150mg/d,阿司匹林75-150mg/d,Chin J Stroke,2008,12:880-888.,2023/6/27,13,动脉源性卒中的二级预防,2023/6/27,14,卒中风险分层指导抗血小板药物使用 Essen评分,1.CAPRIE Steering Committee.A randomised,blinded,trial of clopidogrel versus aspirin in patients at risk of ischaemic events Lancet 199
12、6;348:1329-1339,基于CAPRIE卒中亚组开发的卒中预测模型,2023/6/27,15,ESSEN评分：预测卒中复发或严重血管事件的风险,REACH登记研究68,236名患者,“结果显示：ESRS可以预测处于稳定期的卒中门诊和住院患者发生卒中和复合CV事件(CV死亡、心梗、卒中)的风险”,CV=心血管;ESRS=Essen卒中风险评分;,Stroke.2009;40:350-354,2023/6/27,16,研究人群,REACH登记研究68,236名患者,18,992 TIA/缺血性卒中,16,448名合格患者,排除2,544位房颤患者,15,605名患者入组研究,排除843位未
13、进行1年随访的患者,TIA=短暂性脑缺血发作,Stroke.2009;40:350-354,2023/6/27,17,Christian Weimar,et al.The Essen Stroke Risk Score Predicts Recurrent Cardiovascular Events.Stroke,2009,40:350-354.,REACH:ESSEN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，ESSEN评分有助于识别高危患者，评估卒中患者再发风险,事件率/年%,2
14、023/6/27,18,SCALA：近60%的患者处于高复发风险,Weimar C.Rother J.et al.J Neurol,2007,254(11).1562-1568,Essen卒中风险评分,SCALA研究（前瞻性观察队列），85家卒中单元，德国，852例，急性缺血性卒中/TIA，不予干预，平均随访17.5个月,2023/6/27,19,ESSEN评分的应用,高危，卒中风险4,中危，卒中风险4,氯吡格雷75mg/d,阿司匹林50-325mg/d,2023/6/27,20,AHA卒中二级预防指南颅内大动脉狭窄50%99%,For patients with stroke or TIA
15、due to 50%to 99%stenosis of a major intracranial artery,aspirin is recommended in preference to warfarin(Class I;Level of Evidence B).Patients in the WASID trial were treated with aspirin 1300 mg/d,but the optimal dose of aspirin in this population has not been determined.On the basis of the data on
16、 general safety and efficacy,aspirin doses of 50 mg to 325 mg of aspirin daily are recommended(Class I;Level of Evidence B).推荐阿司匹林(I，B)。剂量50mg325mg/天。（I，B）For patients with stroke or TIA due to 50%to 99%stenosis of a major intracranial artery,long-term maintenance of BP 140/90 mm Hg and total choles
17、terol level 200 mg/dL may be reasonable(Class IIb;Level of Evidence B).目标血压140/90 mm Hg，胆固醇200 mg/dL（IIb，B）For patients with stroke or TIA due to 50%to 99%stenosis of a major intracranial artery,the usefulness of angioplasty and/or stent placement is unknown and is considered investigational(Class I
18、Ib;Level of Evidence C).血管成形术/支架置入术的作用未知，可以开展研究（IIb,C）For patients with stroke or TIA due to 50%to 99%stenosis of a major intracranial artery,EC-IC bypass surgery is not recommended(Class III;Level of Evidence B).不推荐颅内外血管搭桥术（III，B）,2023/6/27,21,AHA卒中二级预防指南颅外段颈动脉疾病的外科治疗,For patients with recent TIA o
19、r ischemic stroke within the past 6 months and ipsilateral severe(70%to 99%)carotid artery stenosis,CEA is recommended if the perioperative morbidity and mortality risk is estimated to be 70%by noninvasive imaging or 50%by catheter angiography(Class I;Level of Evidence B).CAS可以作为CEA的替代方案（I,B）Among p
20、atients with symptomatic severe stenosis(70%)in whom the stenosis is difficult to access surgically,medical conditions are present that greatly increase the risk for surgery,or when other specific circumstances exist,such as radiation induced stenosis or restenosis after CEA,CAS may be considered(Cl
21、ass IIb;Level of Evidence B).外科手术难以到达、风险过大、或其他特殊情况（射线导致的狭窄、CEA后再狭窄）时可考虑CAS（II b，B）,2023/6/27,22,AHA卒中二级预防指南颅外段椎动脉疾病的治疗,Optimal medical therapy,which should include antiplatelet therapy,statin therapy,and risk factor modification,is recommended for all patients with vertebral artery stenosis and a TI
22、A or stroke as outlined elsewhere in this guideline(Class I;Level of Evidence B).最佳的内科治疗（抗血小板治疗、他汀治疗、控制危险因素）Endovascular and surgical treatment of patients with extracranial vertebral stenosis may be considered when patients are having symptoms despite optimal medical treatment(including antithrombotics,statins,and relevant risk factor control)(Class IIb;Level of Evidence C)最佳内科治疗不能控制发作时应考虑血管内治疗或外科手术治疗（IIb,C）,2023/6/27,23,小结,房颤患者卒中风险评估及治疗 CHADS2评分、不同风险的治疗非房颤患者卒中风险评估及治疗 专家共识、AHA指南,2023/6/27,24,
