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缺血性卒中抗栓循证治疗证据等级I类证据随机对照试验，假阳性和假阴性错误低II类证据随机对照试验，假阳性和假阴性错误高III类证据非随机对列研究IV类证据回顾性非随机对列研究，V类证据经验性研究Cooketal.,Chest,19

92;102:305S-311S缺血性卒中抗栓循证治疗2急性缺血性卒中溶栓治疗缺血性卒中抗栓循证治疗3概述•静脉溶栓–组织纤溶酶原激活物（tPA）•NINDS•ECASSI&II,ATLANTIS–链激酶•MAST-I,MAST-E,ASK•动脉溶栓–前循环:大脑中动脉(PROACTII)–

后循环:基底动脉缺血性卒中抗栓循证治疗4•与安慰剂相比，3h内IVrtPA(0.9mg/kg)能改善90天时的预后•出血发生率为6.4%，安慰剂为0.6%，但死亡率无差异•所有亚组预后均优于安慰剂组•益处可持续1年rt-PA:NINDS缺血性卒中

抗栓循证治疗5•随机,多中心,双盲,安慰剂对照•620例;排除CT早期梗塞灶(预后不良)•干预–rtPA(1.1mg/kg)vs.placebo–起病6h内•主要终点–BarthelIndexandmodifiedRankinScaleat90days–rtPA与安慰剂组无明显差别rt-PA

:ECASSIHackeetal.,JAMA.1995;274:1017-1025缺血性卒中抗栓循证治疗6•随机,多中心,双盲,安慰剂对照•800例;排除CT早期明显梗塞灶•干预–rtPA(0.9mg/kg)vs.placeb

o–起病6h内•主要终点–modifiedRankinScaleScoreof≤1at90days–rtPA与安慰剂组无明显差别rt-PA:ECASSIIHackeetal.,Lancet.1998;352:1

245-1251缺血性卒中抗栓循证治疗7•随机,多中心,双盲,安慰剂对照•613例•干预–rtPA(0.9mg/kg)vs.placebo–起病3-5h内•主要终点–NIHSSof≤1at90days–rtP

A与安慰剂组无明显差别rt-PA:ATLANTISAlteplaseThrombolysisforAcuteNoninterventionalRxinIschStrokeClarketal.,JAMA.1999;282:2019-2026缺血性卒中抗栓循证治疗8rt-PA:小结•与

安慰剂相比，3h内IVrtPA(0.9mg/kg)能改善90天时的预后.I类证据•目前证据显示，超过3h予IVtPA无效.I类证据缺血性卒中抗栓循证治疗9链激酶（SK）研究药物剂量治疗窗结果MulticenterAcuteStrokeTrial-Eu

rope(MAST-E)NEJM1996;335:145-50SK1.5MU6hSK组出血和死亡率高提前终止试验MulticenterAcuteStrokeTrial-Italy(MAST-I)Lancet1995;346:1509-14SKaspirin1.5MU

300mg/d6hSK组，尤其是SK+aspirin组出血和死亡率高提前终止试验AustralianStreptokinaseTrial(ASK)Donnanetal.,Lancet1995;345:57

8-9SK1.5MU4h提前终止;治疗窗4h无明显益处，结果不良•与安慰剂相比，6h内予IVSK1.5MU预后不良(出血和死亡率高).I类证据缺血性卒中抗栓循证治疗10动脉溶栓•前循环–大脑中动脉阻塞•后

循环–椎基底动脉阻塞缺血性卒中抗栓循证治疗11•与安慰剂相比,6h内予IAProUK经造影证实MCAM1或M2段阻塞的患者有效.I类证据•15%绝对有效(numberneededtotreat=7)•增加颅内出血，死亡率无差异PROACTII:小结缺血性卒中抗栓循证治疗12

急性椎基底动脉阻塞•数项病例报道(IV、V类证据)•非随机化•无对照组Brandtetal.,CerebrovascDis,1995;5:182-7缺血性卒中抗栓循证治疗13小结•3h内静脉用tPA能降低90天时的残障功能.I类证据•

静脉用链激酶(1.5MU)增加出血和死亡率.I类证据•6h内动脉用尿激酶前体(Pro-UK,未被FDA通过)能降低90天时的残障功能.I类证据•有证据支持在急性椎基底动脉阻塞中应用动脉溶栓.IV、V类证据缺血性卒中抗栓循证治疗14急性缺血性卒中抗

凝治疗缺血性卒中抗栓循证治疗15概述•肝素•LMWheparin•LMWheparinoid-作用于抗凝血酶III(抑制凝血因子IIa,IXa,andXa)•1effectonXa•reducedpltinteraction•lo

ngerhalf-life•simplertoadminister•lowerbleedingrisk•reducedeffectonIIa缺血性卒中抗栓循证治疗16Summary:trialresultsNdrugresultsCanadian225HepIVnodifferenceIST1

9,435HepscnodifferenceTOAST1281heparinoidnodifferencelargeartbetterat3mo?HK308LMWHdead/depat6moFISS767LMWHnodifferenceTAIST1486LMWH

nodifferenceTOPAS404LMWHnodifferenceamongdoses缺血性卒中抗栓循证治疗17各卒中亚型急性抗凝治疗•房颤和心源性栓塞•大动脉粥样硬化•椎基底动脉阻塞•TIA•进展性卒中•动脉夹层•静脉血

栓形成缺血性卒中抗栓循证治疗18各卒中亚型急性抗凝治疗:小结CCTsubgrpNresults心源性栓塞123618nodiff大动脉硬化0413,2851+(?)/3-后循环032318nodiffTIA1055nodiff进展性

卒中20204nodiff夹层00286nodiff静脉血栓20791+/1-缺血性卒中抗栓循证治疗19小结急性期抗凝减少深静脉血栓和肺栓塞发生，不增加颅内出血几率.I类证据缺血性卒中抗栓循证治疗20急性缺血性卒中阿司匹林治疗缺血性卒中抗栓循证治疗21InternationalStrok

eStrial(IST)ASA300mg/dx2wksbegunwithin48hrs2wkendptsASAN=9720NoASAN=9715Recurrentischemic2.8%*3.9%Allrecurrentstroke3.7%4.6%Majorextracranialb

leed1.1%*0.6%Death9.0%9.4%*p<.01缺血性卒中抗栓循证治疗22ChineseAcuteStrokeTrial(CAST)Lancet1997;349:1641ASA160mg/dx4wksbegunwi

thin48hrs4wkendptsASAN=10335PlaceboN=10320Recurrentischemic1.6%*2.1%Allrecurrentstroke3.2%3.4%Majorex

tracranbleed0.8%*0.6%Death3.3%*3.9%*p<.05缺血性卒中抗栓循证治疗23小结基于IST和CAST,阿司匹林在急性缺血性卒中后2-4周内，每1000例患者中有10人可减少死亡和复发。缺血性卒中抗栓循证治疗24非心源性卒中二级预防：抗栓治疗缺血性卒中抗栓

循证治疗25概述•抗血小板药Antiplatelet.阿司匹林Aspirin抵克立得（噻氯匹啶）Ticlid®(Ticlopidine)➢波力维（氯吡格雷）Plavix®(Clopidogrel)➢艾诺思Ag

grenox®(aspirin+extended-releasedipyridamole)•Warfarinfornon-cardioembolicarterialstroke:includinglargevesseldisease.•抗磷脂抗体综合征（ASP）.•颈椎动脉夹层.缺血性卒中抗栓循

证治疗26缺血性卒中抗栓循证治疗27高剂量阿司匹林随机对照试验*Riskofvascularevents(death,stroke,MI)inthecontrolgroup缺血性卒中抗栓循证治疗28低剂量阿司匹林随机对照试

验*Vascularevents(death,MI,stroke)inplacebo.**strokeinplacebo缺血性卒中抗栓循证治疗29•100,000ptsfrom145trials.•Allantiplateletagentswereincluded.•Clumpedallva

sculareventstogether.•Overalloddsreductionforvasculareventswas25%.•ForptswithminorstrokeorTIA(18trials)antiplateletagentsledtooddsr

eductionof22%forvasculareventsand23%fornonfatalstroke.•Didnotanswerquestionsaboutaspirindose.•Usedoddsratioinsteadofrelativerisk.•U

sedallantiplateletagents.缺血性卒中抗栓循证治疗30FDA.FederalRegister.1998;63:56802.缺血性卒中抗栓循证治疗31缺血性卒中抗栓循证治疗32†3-yearstudyendpoints,N=3,069.Endpoint†StrokeStr

oke,MI,orvasculardeathRRR21%9%(P=0.024)Hassetal.NEnglJMed.1989;321:501.Easton.InHassandEaston(eds).Ticlopidine

,PlateletsandVascularDisease.NewYork:Springer-Verlag;1993:141.*Ticlopidine(250mgbid)vsASA(650mgbid).(NS)缺血性卒中抗栓循证治疗33Ticlopidine(%)Aspirin(%)Diarrhe

aRashNauseaGastritis,ulcer,GIbleedingSevereneutropenia(ANC<450/mm3)Cerebralhemorrhage20.4*11.9*11.12.10.9*0.69.85.210.26.0*0

.00.7*P<0.05AdaptedfromHassetal.NEnglJMed.1989;321:501.缺血性卒中抗栓循证治疗34缺血性卒中抗栓循证治疗35MonthsofFollow-UpCumulativeEventRate(%)0481216ClopidogrelAspirin0

369121518212427303336Aspirin5.83%5.32%ClopidogrelEventRateperYear*P=0.043CAPRIESteeringCommittee.Lancet199

6;348:1329-1339.ARR=0.51NNT=1/0.005=196缺血性卒中抗栓循证治疗36Clopidogrel(%)ASA(%)GIcomplaintsAnybleedingdisorderRashDiarrheaGIbleedin

gIntracranialhemorrhage1.901.200.90*0.420.520.212.41*1.370.410.270.93*0.33*P<0.05CAPRIESteeringCommittee.Lancet.1996;348:1329-1339.缺血性卒中抗栓循证治疗37

ManagementofAtherothrombosiswithClopidogrelinHigh-riskpatients（MATCH）•氯吡格雷（75mg）+阿司匹林（75mg）与单用氯吡格雷（75mg）的疗效进行比较，结果是失败的

•两组的主要终点指标，即缺血性卒中、心肌梗死和血管源性死亡发生率与急性缺血事件（心绞痛、周围动脉症状恶化或TIA）无统计学差异•联合治疗同时增加了严重出血的概率缺血性卒中抗栓循证治疗38•TestedefficacyofASA/ER-DPfor

secondarystrokeprevention•Addressedclinicalquestions–Doeslow-doseASApreventstroke?–DoesER-DPpreventstro

ke?–IsASA/ER-DPsuperiortoASAalone?ToER-DPalone?–IsASA/ER-DPwelltolerated?TheESPS-2Group.JNeurolSci.1997;151:S3.Dienere

tal.JNeurolSci.1996;143:1.缺血性卒中抗栓循证治疗39PlaceboASAER-DPASA/ER-DP048121615.2%12.5%12.8%9.5%Incidence(%)ARR=5.7overPlaceboNNT=1/0.057=17

.5缺血性卒中抗栓循证治疗40缺血性卒中抗栓循证治疗41AdaptedfromDiener.Neurology.1998;51(suppl3):S17.TrialsToulouseTIA(N=284)AICLA(N=400)ACCSG(N=890)ES

PS-2(N=3,299)Overall(N=4,873)15%RRRRelativeRisk(ofstroke,MI,orvasculardeath)0.511.522.53ASA/DPBetterASABetter缺血性卒中抗栓循证治疗42Preventi

onRegimenforEffectivelyAvoidingSecondStrokes（PRoFESS）•是由30个国家参入，纳入18500例患者，为期4年的随机双盲多中心试验，直接比较艾诺思Aggrenox（双嘧达莫缓释剂200mg+阿司匹林25mg，ER-DP200mg+ASA

25mg，2次/d）与氯吡格雷（75mg，1次/d）在卒中二级预防中的疗效，预期结果将在2008年报道。缺血性卒中抗栓循证治疗43Warfarin-AspirinRecurrentStrokeStudy（WARS

S）2206patientsfollowedfor2yearsISorDeathMjrbleed/100pt-yrsWarfarin17.8%2.22Aspirin16.0%1.49p=.25Nosignifi

cantdifferencebetweenwarfarinandaspirin缺血性卒中抗栓循证治疗44TheWarfarin-AspirinSymptomaticIntracranialDiseas

estudy（WASID）•多中心前瞻性随机双盲试验•华法林INR为2~3，阿司匹林为1300mg•两组的卒中发生率和血管源性病死率无统计学差异•华法林组出血并发症的发生率较高促使试验提前终止•TheWarfarin-AspirinSymptomaticIn

tracranialDiseaseStudy.Neurology.1995Aug;45(8):1488-93.缺血性卒中抗栓循证治疗45EffectofTreatmentonRecurrentIschemicStrokeandDeathAtTwoYearsinAPASS/WARSS(B

rey,RL:presentedatthe27InternationalStrokeConference,SanAntonio,TX,February9,2002)051015202530aPL+aPL-AspirinWarfarinPrimaryEn

dpoint(%)抗磷脂抗体阳性组与阴性组无差异，阿司匹林与华法林无差异缺血性卒中抗栓循证治疗46颈动脉和椎动脉夹层•Naturalhistoryofcarotiddissection:(HartetalNeurolClinNorthAm1:155,1983)–Ce

rebralinfarctionin33%(23%minor,10%majororfatal.–TIAin45;Headandneckpainin16%;Pulsatiletinnitus4%;andbruitin2%.•Proper

managementiscontroversial.Mostptsdowell,eitherbecauseofordespitetreatment.缺血性卒中抗栓循证治疗47心源性卒中预防：抗血栓治疗缺血性卒中抗栓循证治疗48心源性卒中可能病因•Valvula

rheartdisease心脏瓣膜病–Rheumaticmitralvalvedisease风湿性二尖瓣病–Prostheticheartvalves人工心脏瓣膜–Mitralvalveprolapse二尖瓣脱垂–Aorticvalvedisease主动脉瓣病–Ao

rticarchatherosclerosis主动脉弓粥样硬化–Endocarditis(infectiveornonbacterialthrombotic)心内膜炎（感染性或非细菌性血栓）•Atrialfibrillation心房颤动•Myoc

ardialinfarction心肌梗死•Leftventriculardysfunction左心室功能不全•Patentforamenovale卵圆孔未闭缺血性卒中抗栓循证治疗49Rheumaticmitralva

lvedisease:2°strokeprevention•Norandomizedtrials•Observationalstudies:OACreducerecurrentembolicevents/fataleventsby2/3ormore1-3•Extrapolationfrom1lar

gerandomizedstudyinNVAF(EAFT)providesadditionaldataforpatientswithRHD+AF(butRHDexcluded)1SzekelyPBMJ1964

;1:209-122AdamsGFetalJNNP1974;37:378-833Fleming&BaileyPostgradMed1971;47:599-604LevelIII-IV:BenefitofOA

C缺血性卒中抗栓循证治疗50Prostheticheartvalves:mechanicalvalves1°strokeprevention•Observationaldata:APAmaybesufficienttopreventembolis

minabsenceofAF,butOACneededtopreventvalvethrombosis1-2•RCT:additionofASA100mgtowarfarin(INR3-4.5)cerebralembolism(4/186vs.12/184

)3•NonRCT:additionofASA500mgtripledriskofmajorhemorrhage(14%vs.5%)4LevelIevidence:benefitofOAC+ASAoverOA

Calone1HartzRetalJThoracCVSurg1986;92:684-902RibeiroPetalJThoracCVSurg1986;91:92-83TurpieAetalNEJM1993;329:524-94ChesebroJetalAmJCard198

3;51:1537-41缺血性卒中抗栓循证治疗51Prostheticheartvalves:mechanicalvalves2°strokeprevention•Nodirectdata•ACCPrecommendations:OAC+babyASAbasedonextrapo

lationof1°preventiondata6thACCPConsensusConferenceonAntithromboticTherapy2001缺血性卒中抗栓循证治疗52Prostheticheartvalves:bioprosthetic

valves1NunezetalAnnThoracSurg1982;33:354-8•ButnodifferenceinembolicratewithOAC(4.6%,7/260)incomparisontoASA(3.7%,5/135),andsignif

icantlyhigherrateofhemorrhagiccomplications(5.5%vs.0.4%)1•(Interestingly,lowrateoflateembolisminptswithAFdespitelackofchronicACinbothofthesestudie

s1°prevention:LevelIVevidence:benefitofearlyOACovernoOACLevelVevidence:nodifferencebetweenOAC&ASA2°prevention:noevidence缺血性卒中抗栓循证治疗53MitralV

alveProlapse:2°strokepreventionLevelVevidence:neitherASAnorACcompletelyeffectiveNwarfarinASANoRxWatson19791110/21/9Hanso

n19802221/40/120/6•StrokerecurrenceinMVP:caseseries•MVP+AF:extrapolatedatafromEAFT1WatsonRTNeurol1979;29:886-92HansonM

etalStroke1980;11:499-506缺血性卒中抗栓循证治疗54Atherosclerosisofthethoracicaorta:benefitofOAC50patientswithatheroma>4mmLev

elIII:benefit34patientswithmobileatheromaLevelIII:benefitFerrariEetalJACC1999;33:1317-22缺血性卒中抗栓循证治疗55主动脉弓粥样硬化TunickPetalAmJCardiol2002;90:

1320-5LevelIIIevidence:benefitofstatins缺血性卒中抗栓循证治疗56主动脉弓粥样硬化:OACTunickPetalAmJCardiol2002;90:1320-5LevelIIIevidence:nobenefitofOAC缺血

性卒中抗栓循证治疗57主动脉弓粥样硬化:APATunickPetalAmJCardiol2002;90:1320-5LevelIIIevidence:nobenefitofAPA缺血性卒中抗栓循证治疗58主动脉弓粥样硬化:他汀类T

unickPetalAmJCardiol2002;90:1320-5LevelIIIevidence:benefitofstatins缺血性卒中抗栓循证治疗59•1°strokeprevention–Retrospectivedata

shownobenefitofOACfornativevalveendocarditis,benefitforprostheticvalveendocarditis1-5•2°strokeprevention:–Nodata感染性心内膜炎1DavenportetalSt

roke1990;21:993-92PaschalisetalEurNeurol1990;30:87-93YehetalCirculation1967;35:I77-814DelahayeetalEurHeartJ

1990;11:1074-85WilsonetalCirculation1978;57:1004-7LevelVevidence缺血性卒中抗栓循证治疗60•?Pathogenesis:fibrinthrombidepositsonvalvesassocwithcoagulopathy(usua

llyDIC)•Reportedincidenceofembolismvaries(14-91%)•Rx:Retrospectivedatasuggestbenefitofheparin,butnotOAC1-3–68%withrecurrentemboliwhenheparind/c’

d–ICHrisklowerthanininfectiveendocarditis1RogersetalAmJMed1987;83:746-562LopezetalAmHeartJ1987;113:773-843SacketalMedicine1977;56:1-37非细菌性血栓性心内膜

炎LevelVevidence:nobenefitofOAC;benefitofheparininTrousseausyndrome(mainlywithDIC)缺血性卒中抗栓循证治疗61EuropeanAtrialFibrillationTrial：EAFT(Lancet1993;342:125

5-1262)Oralanticoagulants(225)vs.Aspirin(230)HR(95%CI)1°Endpoint0.60(.41-.87)Allstroke0.38(.23-.64)Bleeding2.8(1.7-4.8)MajorbleedingOAC2.8%/y

rvs.ASA0.9%/yrLevelIEvidence:benefitofOAC缺血性卒中抗栓循证治疗62OptimumINRforpreventionof2°strokeassociatedwithatrialfibrillation(EAFTNEJM1995;333:5-10)“The

targetvaluefortheINRshouldbesetat3.0”缺血性卒中抗栓循证治疗63心肌梗死后一级预防:短期抗凝•Pre-thrombolyticera–Heparindecreasesstrokeincidence1-3–Heparindecreasesmuralthrombu

s41MedResearchCouncilBMJ1969;1:335-422Drapkin&MerskeyJAMA1972;222:541-83VACoopStudyJAMA1973;225:724-94Vaitkus&Barnathau

JACC1993;22:100-9缺血性卒中抗栓循证治疗65心肌梗死后一级预防:短期抗凝•Post-thrombolyticera–baselineratesofdeath,reinfarction,stroke,&PEmarkedlylowerwiththromboly

tics&ASA–additionofheparin/LMWHmaydecreasemuralthrombusformation,butincreasesriskofmajorbleedingwithoutfu

rtherreducingstrokerisk1CollinsetalBMJ1996;313:652-92CollinsetalNEJM1997;336:847-603FRAMIKontnyetalJ

ACC1997;30:962-94SCATILancet1989;2:182-65Gissi-2VecchioetalCirculation1991;84:512-9缺血性卒中抗栓循证治疗66心肌梗死后一级预防:长期抗凝•Relativetocontrol,coum

arinsinmoderateorhighdose(INR2-4.8)–Significantlydecreasestrokeincidence–Significantlyincreaseinciden

ceofmajorbleedingAnand&YusufJAMA1999;282:2058-67缺血性卒中抗栓循证治疗67ModifiedfromAnand&YusufJAMA1999;282:2058-67…ButnobenefitrelativetoASAIncidence

ofstrokeandsignificantincreaseinmajorbleeding缺血性卒中抗栓循证治疗68RR(95%CI)Anticoagulation*.19(.13-.27)Aspirin#.44(.29-.65)LevelIIIevid

ence:benefitofAC>ASAfor1°prevention左心室功能不全:卒中危险因子多变量分析(LohEetalNEJM1997;336:251-257)*similarriskatalllevelsofEF<40%#si

milarriskatalllevelsofEF<35%缺血性卒中抗栓循证治疗69Rate(Events/100Pt-Yr)Anticoagulation0(0/40)NoAnticoagulation0.35(1

/288)LowRiskforPrimaryOccurrence慢性室壁瘤系统栓塞(LapeyreACetalJACC1985;6:534-538)缺血性卒中抗栓循证治疗70PatentForamenOvaleinCryptogenicStrokeStudy(PICSS)(Ho

mmaSetalCirculation2002;105:2625-31)•Design:Prospective,randomized,double-blind,multi-centerclinicaltrial•Eligibility:–EnrolledinWARSS–Agreetohave

additionalTEE•Treatment:Warfarin(targetINR1.4-2.8,mean2.1)vs.aspirin325mg•1°endpoint:Recurrentischemicstrokeordea

thwithin2years•601patients–42%withcryptogenicstrokeasqualifyingevent–34%withPFO缺血性卒中抗栓循证治疗71PICSSLevelIIEvidence:Nodifferencefro

maspirinoverallorinanysubgroupNoincreasedeventrateinPFO+ASAvs.PFOonlyNoincreasedratewithlargerPFOsize缺血性卒中抗栓循证治疗7

2•RheumaticMVdz:LevelIII-BenefitovernoOAC•Aorticarchatheroma:LevelIII-BenefitoverAPAin1study;NobenefitofOACorAPAinanother(butbenefitofstatins)•Infect

iveendocarditis:–Nativevalve:LevelV-Nobenefit–Prostheticvalve:LevelV-benefit•NBTE:LevelV-Nobenefit(?benefitofheparin)•Atrialfibrillation:Leve

lI-BenefitoverASA[INR2.9(2.5-4.0)]•PFO:LevelII-NobenefitoverASA(INR1.4–2.8)•MVP:LevelV–Notcompletelyeffec

tive•Atrialfibrillation:LevelI-BenefitoverASA[INR2.9(2.5-4.0)]•PFO:LevelII-NobenefitoverASA(INR1.4–2.8)•MVP:LevelV–Notcompletel

yeffective•Nodata–Aorticvalvedisease–Prostheticheartvalves–MI–LVdysfunction口服抗凝剂（OAC）二级预防:小结缺血性卒中抗栓循证治疗73•Mechanicalprostheticvalve:LevelI-Be

nefitofOAC+lowdoseASAoverOACalone•Bioprostheticvalve:LevelV-BenefitovernoOACin1st6weeksaftervalvereplacement•MI:LevelI-Nob

enefitoverASA•LVEF≤40%:LevelIII-Benefit[?INR]overASA•LVaneurysm:lowriskfor1°occurrence口服抗凝剂（OAC）一级预防:小结缺血性卒中抗栓循证治疗74心源性

卒中二级预防（研究中）•NVAF:–SPORTIFV(StrokePreventionbyOralThrombinInhibition)•Fixeddoseximelagatran(thrombininhibitor)vs.warfarin(INR2-3)•LV

dysfunction–WARCEF(Warfarinvs.AspirininReducedCardiacEF)•Warfarin(INR2.5-3)vs.ASA325mginEF30%–WATCH(Warfarin&AntiplateletTherapyinChronicHear

tFailure)•Warfarin(INR2.5-3)vs.ASA162mgvs.Clopidogrel75mginEF35%•AorticAtheroma:–ARCH(AorticArchRelatedCerebralHazard)•warfarin(INR2-3)v

s.ASA+clopidogrelinmobileor4mm-thickatheroma•PFO:–RESPECT(EvaluationofRecurrentStrokeComparingPFOClosuretoEstablishedCurrentStandardCareTrea

tmentTrial)•PercutaneousPFOclosurevs.antithromboticRx(ASA,clopidogrel,Aggrenox,ASA+clopidogrel,warfarinincryptogenicstrokewithPFO)缺血性

卒中抗栓循证治疗75结语1•抗血栓治疗仅能作为卒中预防策略组成部分之一；•没有任何药物能完全消除卒中的复发风险，多项大规模试验结果为正确、合理地选择抗血栓治疗提供了证据；缺血性卒中抗栓循证治疗76结语2•3h内IVrt-PA(0.9mg/kg)疗效得到公认；•3h

-6h内IAProUK证实有效；•急性期阿司匹林疗效得到公认；•急性期抗凝仅能降低DVT和PE发生率，但对动脉血栓疗效无差异缺血性卒中抗栓循证治疗77结语3•若无禁忌，心源性栓塞通常宜选择抗凝治疗，西美加群是一种有前景的华法林替代物；•目

前无证据支持抗凝治疗用于PFO、抗磷脂抗体综合征、颅内动脉粥样硬化或腔隙性梗塞患者，而推荐使用阿司匹林；•阿司匹林联合华法林治疗不能增强预防作用，反而会带来更大的出血风险；•阿司匹林和氯吡格雷预防卒中复

发的效果相近，阿司匹林联用氯吡格雷并不优于单用氯吡格雷，且出血风险更高；•在抗血小板药联合治疗试验中，只有ESPS2试验能证实阿司匹林联用ER-DIP有协同作用，期待PRoFESS试验能得出同样结论。

缺血性卒中抗栓循证治疗78