缺血性脑卒中抗血小板药物治疗.ppt

* Current antiplatelet agents include: Thromboxane A2 inhibitor Acetylsalicylic acid (ASA) Phosphodiesterase inhibitor Dipyridamole Glycoprotein (GP)IIb/IIIa blockers Parenteral: abciximab, eptifibatide, tirofiban Oral GPIIb/IIIa blockers (lotrafiban, orbofiban, sibrafiban, xemilofiban) have been examined in major clinical trials, but failed to demonstrate efficacy vs ASA. ADP-receptor antagonists Clopidogrel Ticlopidine TIA/MIS的处理原则（二级预防的最佳时机） 1.紧急处理：查找病因和开始治疗 2. 针对病因的处理 3.个体化，具体化，现实化（理论转化为实际；群体转化为个体；理想转化为现状；国外转化为国人） 4. 几个比率的平衡：疗效/不良反应；利益/cost; 商业行为/病人利益；行政法规/医护人员负担/病人实际利益 5.疗效的不可见性：确保患者的知情权，酌情处理 紧急处理 EXPRESS（特快）和SOS（… - - - …）命名的临床研究更形象的说明紧急干预的重要性 就具体病因给予相应干预治疗能减低其后严重卒中发生率达80%-90% EXPRESS研究发现TIA/MIS后24小时给予现有的“合并”治疗能明显减少早期至3个月内的卒中率达80% 处理针对TIA/MIS的病因 因TIA/MIS无脑组织损害或损害极轻，无需脑保护手段或药物治疗。溶栓无益 处理应针对血管的病因，病原常为多重性，应合并处理 具体处理建议 个体化 参考“指南”及其update，跟踪最近的RCT资料和meta-analysis, system review 等资料 二级预防手段 药物 手术 二级预防治疗的创始人和开拓者 Prof. Henry J.M. Barnett ( Barney) Aspirin, Endarterectomy , Other… Aspirin first-ever Trail Canadian Cooperative Study Group. A randomised trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med. 1978; 299: 53–59? Five hundred and eighty-five patients with threatened stroke were followed in a randomized clinical trial for an average of 26 months to determine whether aspirin or sulfinpyrazone, singly or in combination, influence the subsequent occurrence of continuing transient ischemic attacks, stroke or death. Eighty-five subjects went on to stroke, and 42 died. Aspirin reduced the risk of continuing ischemic attacks, strok or death by 19 per cent (P less than 0.05) and also reduced risk for the harder, more important events of stroke or death by 31 percent (P less than 0.05), but this effect was sex-dependent: among men, the risk reduction for stroke or death was 48 per cent (P less than 0.005), whereas no significant trend was observed among women. For sulfinpyrazone, no risk reduction of ischemic attacks was obs