卒中再发的风险与处理精品课件.ppt

卒中发作及复发的风险评估与处理,2,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：,2019/11/26,2,3,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.MMWRWeeklyAugust6,1999/48(30);649-656,1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,2019/11/26,3,4,心房颤动患者卒中风险评估及处理,2019/11/26,4,5,心房颤动患者的卒中风险,2019/11/26,5,6,CHADS2评分,2019/11/26,6,7,CHADS2评分的年卒中风险,2019/11/26,7,8,根据CHADS2评分及其风险程度选择治疗药物,2019/11/26,8,9,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6575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,2019/11/26,9,10,AHA卒中一级预防关于房颤的推荐,Adjusted-dosewarfarin(targetINR,2.0to3.0)isrecommendedforallpatientswithnonvalvularatrialfibrillationdeemedtobeathighriskandmanydeemedtobeatmoderateriskforstrokewhocanreceiveitsafely(ClassI;LevelofEvidenceA).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）Antiplatelettherapywithaspirinisrecommendedforlow-riskandsomemoderate-riskpatientswithatrialfibrillation,basedonpatientpreference,estimatedbleedingriskifanticoagulated,andaccesstohigh-qualityanticoagulationmonitoring(ClassI;LevelofEvidenceA).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）Forhigh-riskpatientswithatrialfibrillationdeemedunsuitableforanticoagulation,dualantiplatelettherapywithclopidogrelandaspirinoffersmoreprotectionagainststrokethanaspirinalonebutwithincreasedriskofmajorbleedingandmightbereasonable(ClassIIb;LevelofEvidenceB).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）,2019/11/26,10,11,AHA卒中二级预防关于房颤的推荐,1、ForpatientswithischemicstrokeorTIAwithparoxysmal(intermittent)orpermanentAF,anticoagulationwithavitaminKantagonist(targetINR2.5;range,2.0to3.0)isrecommended(ClassI;LevelofEvidenceA).推荐伴有房颤的缺血性卒中或TIA患者抗凝治疗（目标INR2.5，2.03.0）（I，A）2、Forpatientsunabletotakeoralanticoagulants,aspirinalone(ClassI;LevelofEvidenceA)isrecommended.Thecombinationofclopidogrelplusaspirincarriesariskofbleedingsimilartothatofwarfarinandthereforeisnotrecommendedforpatientswithahemorrhagiccontraindicationtowarfarin(ClassIII;LevelofEvidenceB).(Newrecommendation).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、ForpatientswithAFathighriskforstroke(strokeorTIAwithin3months,CHADS2scoreof5or6,mechanicalorrheumaticvalvedisease)whorequiretemporaryinterruptionoforalanticoagulation,bridgingtherapywithanLMWHadministeredsubcutaneouslyisreasonable(ClassIIa;LevelofEvidenceC).(Newrecommendation)卒中高危风险的房颤患者（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）,2019/11/26,11,12,非心脏病患者脑卒中风险评估及处理,2019/11/26,12,13,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,ChinJStroke,2008,12:880-888.,2019/11/26,13,14,动脉源性卒中的二级预防,2019/11/26,14,15,卒中风险分层指导抗血小板药物使用Essen评分,1.CAPRIESteeringCommittee.Arandomised,blinded,trialofclopidogrelversusaspirininpatientsatriskofischaemiceventsLancet1996;348:1329-1339,基于CAPRIE卒中亚组开发的卒中预测模型,2019/11/26,15,16,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;40:350-354,2019/11/26,16,17,研究人群,REACH登记研究68,236名患者,18,992TIA/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位未进行1年随访的患者,TIA=短暂性脑缺血发作,Stroke.2009;40:350-354,2019/11/26,17,18,ChristianWeimar,etal.TheEssenStrokeRiskScorePredictsRecurrentCardiovascularEvents.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%,2019/11/26,18,19,SCALA：近60%的患者处于高复发风险,WeimarC.RotherJ.etal.JNeurol,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,2019/11/26,19,20,ESSEN评分的应用,极高危,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,2019/11/26,20,21,AHA卒中二级预防指南颅内大动脉狭窄50%99%,ForpatientswithstrokeorTIAdueto50%to99%stenosisofamajorintracranialartery,aspirinisrecommendedinpreferencetowarfarin(ClassI;LevelofEvidenceB).PatientsintheWASIDtrialweretreatedwithaspirin1300mg/d,buttheoptimaldoseofaspirininthispopulationhasnotbeendetermined.Onthebasisofthedataongeneralsafetyandefficacy,aspirindosesof50mgto325mgofaspirindailyarerecommended(ClassI;LevelofEvidenceB).推荐阿司匹林(I，B)。剂量50mg325mg/天。（I，B）ForpatientswithstrokeorTIAdueto50%to99%stenosisofamajorintracranialartery,long-termmaintenanceofBP140/90mmHgandtotalcholesterollevel200mg/dLmaybereasonable(ClassIIb;LevelofEvidenceB).目标血压70%)inwhomthestenosisisdifficulttoaccesssurgically,medicalconditionsarepresentthatgreatlyincreasetheriskforsurgery,orwhenotherspecificcircumstancesexist,suchasradiationinducedstenosisorrestenosisafterCEA,CASmaybeconsidered(ClassIIb;LevelofEvidenceB).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（IIb，B）,2019/11/26,22,23,AHA卒中二级预防指南颅外段椎动脉疾病的治疗,Optimalmedicaltherapy,whichshouldincludeantiplatelettherapy,statintherapy,andriskfactormodification,isrecommendedforallpatientswithvertebralarterystenosisandaTIAorstrokeasoutlinedelsewhereinthisguideline(ClassI;LevelofEvidenceB).最佳的内科治疗（抗血小板治疗、他汀治疗、控制危险因素）Endovascularandsurgicaltreatmentofpatientswithextracranialvertebralstenosismaybeconside