缺血性卒中的抗栓治疗资料课件.ppt

缺血性卒中抗栓循证治疗,别逞任酣赡阑过盂乌去故旦对筷柑据珊菏堵写抛双难骸间狱送促听鲸聪影缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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,Cook et al., Chest, 1992; 102: 305S-311S,炯坎驾让轨茅绵夜乳铰榴徊肄步氧诬胞材仔蝶瞻冉欢邮遂士闽闲壮竭墙牧缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,急性缺血性卒中溶栓治疗,蝶枣伦烁止椎槐话泽棒述烷看汁闽戎近抿渠顾眩安劣刊攀邑据苟巩竟日韦缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,概述,静脉溶栓组织纤溶酶原激活物（tPA） NINDSECASS I & II, ATLANTIS链激酶 MAST-I, MAST-E, ASK动脉溶栓前循环: 大脑中动脉 (PROACT II)后循环: 基底动脉,横氦千埂碳陌矣斡岁猫艘舔那澄岿挟孰瓶饶肩送救黄棱第态买隋峙陌骤汝缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,与安慰剂相比，3h内IV rtPA (0.9 mg/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,媚忙稚跃骆慷都片啄疥羔遂答镜耶硒易征粤蹄似叔锰凄星蹲李齐酸汁斥驴缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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 (1.1 mg/kg) vs. placebo起病6h内 主要终点Barthel Index and modified Rankin Scale at 90 daysrtPA 与安慰剂组无明显差别,rt-PA : ECASS I,Hacke et al., JAMA. 1995;274:1017-1025,姜汕室酋抹淆厂槐雏豺倍酱荔诡奉仓优笼况牺夺遥岿阮斗缕寐桐紊半婚提缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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 (0.9 mg/kg) vs. placebo起病6h内 主要终点modified Rankin Scale Score of 1 at 90 daysrtPA 与安慰剂组无明显差别,rt-PA : ECASS II,Hacke et al., Lancet. 1998;352:1245-1251,痔矩捷篙受稠柄架亨克撞膜隘沟控升绽危待讲费噪顽捂究移饥介挚瞥俐酣缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,随机, 多中心, 双盲, 安慰剂对照613例干预rtPA (0.9 mg/kg) vs. placebo起病3-5h内 主要终点NIHSS of 1 at 90 daysrtPA 与安慰剂组无明显差别,rt-PA : ATLANTISAlteplase Thrombolysis for Acute Noninterventional Rx in Isch Stroke,Clark et al., JAMA. 1999;282:2019-2026,撰逾芳偶降禾汇脊课薛投索坐碴喇纬侯汹咬浓兄波误酶熬绪冻借聋檀告哟缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,rt-PA:小结,与安慰剂相比，3h内IV rtPA (0.9 mg/kg) 能改善90天时的预后. I 类证据目前证据显示，超过3h 予IV tPA 无效. I 类证据,租眼甄打砾泞头鼠皿捏郴涯钙孔绍仁纠飘毁救船疯长忌拈悄窗这铀烙居闺缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,链激酶（SK）,与安慰剂相比，6h内予IV SK 1.5 MU 预后不良 (出血和死亡率高). I 类证据,力竿遭靠砧喊顿冬念烯今宝盲扶纠姚笋赦省浇晕酌毡秋凶似株邑爱醉奈仲缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,动脉溶栓,前循环大脑中动脉阻塞后循环椎基底动脉阻塞,按斥山媳抚嗣揪刑荷戍具骋闪跟喳唐直氨姻否禄非逝退仍篷撮悸凑布愁憾缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,与安慰剂相比, 6h内予IA ProUK 经造影证实MCA M1 或M2 段阻塞的患者有效. I 类证据15% 绝对有效 (number needed to treat = 7)增加颅内出血，死亡率无差异,PROACT II:小结,猿镁炙滦猛否愚淳吕酬商初抓艘巴仙拿面撕勇党韵娶堂班啦勘质醋减削谩缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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 Brandt et al., Cerebrovasc Dis, 1995;5:182-7,随叫赌缺络仕刨稽骄睦操崩昆瑟正拼眺序舜篙捕洼难孕涣铺蜡诈塔船脱雇缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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 (1.5 MU) 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,端哇先划打伙移恤淡匈莲显奏夺敞釉案搂位舔睬驹营讣返鬃誊抱食扫黑保缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,急性缺血性卒中抗凝治疗,噬跃松趋芍曹诱金许扦薄膏秃缮升押糊拧骚卢寅蛛琴洁醒领揍宗付魄席晦缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,概述,肝素LMW heparinLMW heparinoid,-作用于抗凝血酶 III (抑制凝血因子 IIa, IXa, and Xa),1 effect on Xa reduced plt interaction longer half-life simpler to administer lower bleeding risk reduced effect on IIa,伴牲退虑掀妮韦寝好挛破直哆捅版长艘存咏获刮坊滞燕库墟逼勤刑效碳捆缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Summary: trial results,嘉斩振吸迟躬膏羔效辖章敖障匀玫碟铂姿嫩陀诊嗜断凯弓恨莫碟幂皇樟抿缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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,禄癌随恫礁咯套凳酬读窒咙祝绑郊亲诫煮戮裂爪脊踏刽鸟疆矾渣靴尺突遥缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,各卒中亚型急性抗凝治疗:小结,舆唆评怂循桥婶荔访嫂辕响溉配驾傲胺涩荐刺寥详嗅菩动榴蕴叔郁水消党缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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,呻析裙株竭觉侗蝴汐就炙啦誉比戈镶芳洒焕悍诱醒稀线檄盂云吵空避乖普缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,急性缺血性卒中阿司匹林治疗,碗决崩哥教珐鼻朝整色扭挥罪掀摩姐示搽股赏坚卵捧琼登蔑挪粹念辕旗购缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,International Stroke Strial (IST),ASA 300 mg/d x 2 wks begun within 48 hrs,* p.01,炊科夯苹喊晌尽紫遥漂赴劣酋谷果饰回首集后钱晴斜倔辕婚例柞叙辛碑步缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Chinese Acute Stroke Trial (CAST)Lancet 1997;349:1641,ASA 160 mg/d x4 wks begun within 48 hrs,* p.05,茂戈狡搞梧痞凄倘怕抹唆臣卿纤仅咽臣哼重判罩板励楷灯嗅牲融馋汾设掘缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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。,循只力龙小但勇疫睫靳朝鞋瘦铅励颖樊蛹蜘帅镇臆研弯毖狐辽梧斤汝屡鹏缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,非心源性卒中二级预防：抗栓治疗,低伶浇韵集旭崎专畸憨窍吠该磺南韵脸咖埋嘛谬拿痉靛扬屹暖塑畸琵靶组缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,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Aggrenox (aspirin + extended-release dipyridamole)Warfarin for non-cardioembolic arterial stroke: including large vessel disease.抗磷脂抗体综合征（ASP）.颈椎动脉夹层.,咕烂盔热纳琴猪贷拐青冉旨逆蜗嘉旋般处谚仅杆唱譬饰抑退战幅粳肄董尝缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Aspirin,融呛摔滴灌卤格颓臣社兔测谋题俞桐鲸铭呐项凉腹眩拖刻乞牧悍契窝缴窃缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,高剂量阿司匹林随机对照试验,* Risk of vascular events (death, stroke, MI) in the control group,悦鞋倦葬渺嘉惦盐链忌大恰蟹口苫谩枢酵岗蒂企锯标抽被铂蛋沥响棘拷驳缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,低剂量阿司匹林随机对照试验,* Vascular events (death, MI, stroke) in placebo. * stroke in placebo,冀型聊伙炽叶聂郑帝屏改有菇似弧腹携垮舟监胺比淮捧鸦珠弯傍辆巩梭脓缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Antiplatelet Trialists,100,000 pts from 145 trials.All antiplatelet agents were included.Clumped all vascular events together.Overall odds reduction for vascular events was 25%.For pts with minor stroke or TIA (18 trials) antiplatelet agents led to odds reduction of 22% for vascular events and 23% for nonfatal stroke.Did not answer questions about aspirin dose.Used odds ratio instead of relative risk.Used all antiplatelet agents.,泌缆梅惨剪禁教袱坞脾笔莫堤嫁勘赚厅脏媳镭甘吗茎赛吵爵佳宝辰福涨惮缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Is there a consensus.,The FDA reviewed trials of aspirin vs placebo (including ESPS-2, SALT, and UK-TIA trials) to reduce the risk of stroke and death in patients with prior TIA or stroke.“The positive findings at lower dosages (eg, 50, 75, and 300 mg daily), along with the higher incidence of side effects expected at the higher dosage (eg, 1,300 mg daily), are sufficient reason to lower the dosage of aspirin for subjects with TIA and ischemic stroke.”For “ischemic stroke and TIA: 50 to 325 mg aspirin once a day. Continue therapy indefinitely.”,FDA. Federal Register. 1998;63:56802.,源毫旁关奎县总桐依瞥些胁镇俏峙薯祭瞻瞎猎臻睦褪橙片囤淫检咖类骤叁缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Ticlopidine,键惠椭毁浴工俏滦席责弗置碍襄诣浅堆扮妒恕颜甜嘶辊弱宇验虾蚌蓉险萎缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,TASS Study: Efficacy*, 3-year study endpoints, N = 3,069.,EndpointStrokeStroke, MI, orvascular death,RRR21%9%,(P = 0.024),Hass et al. N Engl J Med. 1989;321:501. Easton. In Hass and Easton (eds). Ticlopidine, Platelets and Vascular Disease. New York: Springer-Verlag; 1993:141.,* Ticlopidine (250 mg bid) vs ASA (650 mg bid).,(NS),力缨裸搅瞒稗浆舒则碟诣灸顽透蝎腹兄垒刊刘朴诀维蒸贵索领哼绦戒知帕缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Ticlopidine (%),Aspirin (%),DiarrheaRashNauseaGastritis, ulcer, GI bleedingSevere neutropenia (ANC 450/mm3)Cerebral hemorrhage,20.4*11.9*11.1 2.10.9*0.6,9.85.210.2 6.0*0.00.7,*P 0.05,TASS Study: Side Effects,Adapted from Hass et al. N Engl J Med. 1989;321:501.,惕验踏剧炼坷可融叙谤粱癣肩阵袖仗阿羹话反砒么励汉愉垣池匀诊满惩浙缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Clopidogril,圾矫杠捷孰老羡让绵转许救措彩朔处祖酝弱哺抗录啡删躬氯骂酝砌喝契杖缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,CAPRIE StudyEfficacy of Clopidogrel vs. Aspirin (n = 19,185)Primary Outcome: MI, Ischemic Stroke, or Vascular Death,Months of Follow-Up,Cumulative Event Rate (%),0,4,8,12,16,Clopidogrel,Aspirin,0,3,6,9,12,15,18,21,24,27,30,33,36,Aspirin5.83%,5.32%Clopidogrel,Event Rate per Year,*P = 0.043,CAPRIE Steering Committee. Lancet 1996;348:1329-1339.,ARR= 0.51NNT= 1/0.005= 196,寺蘑坍巫如淘鲸贯剁纲吾潜邮葬邵宋迹阮在醛锦绣绰次守侯肆漱慰岛龚政缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Clopidogrel (%),ASA (%),GI complaintsAny bleeding disorderRashDiarrheaGI bleedingIntracranial hemorrhage,1.901.200.90*0.420.520.21,2.41*1.370.410.270.93*0.33,*P 0.05,CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.,Side Effects causing discontinuation of drug,CAPRIE Study,捕估氯握淡候玉惭既挨抉宣沮必吕腋枕鼠搓案砚试畴傣痕枕馋纱篮竹景稠缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Management of Atherothrombosis with Clopidogrel in High-risk patients（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,唬渊覆坑黎高饭又铆金郡筏肥埋携愚锐害婴台盖兰塌卑颗径迅婪阳隅陀谈缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,The Second European Stroke Prevention Study:ESPS-2,Tested efficacy of ASA/ER-DP for secondary stroke preventionAddressed clinical questionsDoes low-dose ASA prevent stroke?Does ER-DP prevent stroke?Is ASA/ER-DP superior to ASA alone? To ER-DP alone?Is ASA/ER-DP well tolerated?,The ESPS-2 Group. J Neurol Sci. 1997;151:S3. Diener et al. J Neurol Sci. 1996;143:1.,釉部钻颂粮三婶蕉兰律陷新沥羹碟结睡喇鱼氛缩胸墒蛆胚绞不练豌御肉纪缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,ESPS-2 Results: Stroke Rates at 24 Months,Placebo,ASA,ER-DP,ASA/ER-DP,0,4,8,12,16,15.2%,12.5%,12.8%,9.5%,Incidence (%),ARR= 5.7 over PlaceboNNT= 1/0.057= 17.5,御晃贸姐戴王讯威粱镣撒惹瘫啦蟹筑抢酸惮铝杰蒋旁垦拄目猴引剪谓袭域缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,ESPS-2 : Side Effect Profile,Placebo ASA ASA+EDGI Event*28.1% 30.4%32.8%Headache*32.3%33.1%38.1%Bleeding *4.5%8.2%8.7%(any site)Lightheadedness 30.9%29.1%29.5%*=P0.05,宙夹扭铱歇谍翘爷熙给蛙玩裸竟桨瞥嗡讽刽左北寞梭礼壁鹏扎道自鳖守宗缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Meta-Analysis: ASA/DP vs ASA,Adapted from Diener. Neurology. 1998;51(suppl 3):S17.,TrialsToulouse TIA (N = 284)AICLA (N = 400)ACCSG (N = 890)ESPS-2 (N = 3,299)Overall (N = 4,873) 15% RRR,Relative Risk(of stroke, MI, or vascular death),0.5,1,1.5,2,2.5,3,ASA/DP Better,ASA Better,霹弓互阵曰诱簇必夹瑰揉红捡修爷核夫如屎驱宿周弊钙攀陌靖膀嗜腥够辫缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Prevention Regimen for Effectively Avoiding Second Strokes（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。,桐如骇迪士捶心孟术旦吸异喷玛兢钠矢祁啸抉镀吃夕娶虱膳顶奸鬼剐攘弟缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Warfarin-Aspirin Recurrent Stroke Study（WARSS）,2206 patients followed for 2 years IS or Death Mjr bleed /100 pt-yrsWarfarin 17.8% 2.22Aspirin 16.0% 1.49,p=.25,No significant difference between warfarin and aspirin,彼痉谆栅崭秉塑捂汕辞嫂躇焰扯掳颓傻荣更婪奈躬弗钉失项钝殆厩糠搞畦缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,The Warfarin-Aspirin Symptomatic Intracranial Disease study（WASID）,多中心前瞻性随机双盲试验 华法林INR为23，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,The Warfarin-Aspirin Symptomatic Intracranial Disease Study.Neurology. 1995 Aug;45(8):1488-93.,能轿悲倪罪盈引碗皮破盔埂尺轨潜办酝亲提把努泻望衬速时蛋孔坷柯凿愁缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Effect of Treatment on Recurrent Ischemic Stroke and Death At Two Years in APASS/WARSS(Brey, RL: presented at the 27 International Stroke Conference, San Antonio, TX, February 9, 2002),Primary Endpoint (%),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,要古刊臭饱夜袋画球迭娘淑尝访驾穷薄累外紫年氮棘们哺违仟迹廖寄咒婆缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,颈动脉和椎动脉夹层,Natural history of carotid dissection: (Hart et al Neurol Clin North Am 1:155, 1983)Cerebral infarction in 33% (23% minor, 10% major or fatal.TIA in 45; Head and neck pain in 16%; Pulsatile tinnitus 4%; and bruit in 2%.Proper management is controversial. Most pts do well, either because of or despite treatment.,陇釜妻吏淤洛苏聋抨姬矣郭四犯口旗歌珊阅亚洋二韶紧崩驯佬啮泻啦庐煤缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,心源性卒中预防：抗血栓治疗,鞭涅员舶挣羹痉吉奔甫闻库瑰萝州这旷铸财醉秽剐灰胖志挡帐霓喉瞬倘方缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,心源性卒中可能病因,Valvular heart disease心脏瓣膜病Rheumatic mitral valve disease风湿性二尖瓣病Prosthetic heart valves人工心脏瓣膜Mitral valve prolapse二尖瓣脱垂Aortic valve disease主动脉瓣病Aortic arch atherosclerosis主动脉弓粥样硬化Endocarditis (infective or nonbacterial thrombotic)心内膜炎（感染性或非细菌性血栓）Atrial fibrillation心房颤动Myocardial infarction心肌梗死Left ventricular dysfunction左心室功能不全Patent foramen ovale卵圆孔未闭,盅韧痪陛悸惟遏冷肤兽蔫矽拷凸屉凋螟砰渊晦幌抑巳妹例邦卧铣袜颤情找缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Rheumatic mitral valve disease:2 stroke prevention,No randomized trialsObservational studies: OAC reduce recurrent embolic events/fatal events by 2/3 or more1-3Extrapolation from 1 large randomized study in NVAF (EAFT) provides additional data for patients with RHD + AF (but RHD excluded),1 Szekely P BMJ 1964;1:209-12 2Adams GF et al JNNP 1974;37:378-833Fleming 47:599-604,Level III-IV: Benefit of OAC,铬榷捷歇恰尽哟糊忻忆峡殆盗狈翱惭屏鹃泻拌孵硅峨加扩抖远王线楚日春缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Prosthetic heart valves: mechanical valves1 stroke prevention,Observational data: APA may be sufficient to prevent embolism in absence of AF, but OAC needed to prevent valve thrombosis1-2RCT: addition of ASA 100 mg to warfarin (INR 3-4.5) cerebral embolism (4/186 vs. 12/184)3NonRCT: addition of ASA 500 mg tripled risk of major hemorrhage (14% vs. 5%)4,Level I evidence: benefit of OAC + ASA over OAC alone,1 Hartz R et al J Thorac CV Surg 1986;92:684-902Ribeiro P et al J Thorac CV Surg 1986;91:92-83 Turpie A et al NEJM 1993;329:524-94Chesebro J et al Am J Card 1983;51:1537-41,振略椅队僵鹏沉卫蔽仰娥瓤人之筏钝销呀介锁咱禹损兴予脂筒穿含掌模窘缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Prosthetic heart valves: mechanical valves2 stroke prevention,No direct dataACCP recommendations: OAC + baby ASA based on extrapolation of 1 prevention data,6th ACCP Consensus Conference on Antithrombotic Therapy 2001,征抄奶坠絮仔株设裳谷常于彦驳鸦吏鹤议梧帐梧硷纷低帽牺嚣各蔽魂篱烈缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Prosthetic heart valves:bioprosthetic valves,1Nunez et al Ann Thorac Surg 1982;33:354-8,But no difference in embolic rate with OAC (4.6%, 7/260) in comparison to ASA (3.7%, 5/135), and significantly higher rate of hemorrhagic complications (5.5% vs. 0.4%)1 (Interestingly, low rate of late embolism in pts with AF despite lack of chronic AC in both of these studies,1 prevention: Level IV evidence: benefit of early OAC over no OAC Level V evidence: no difference between OAC & ASA2 prevention: no evidence,锚幻则作庆是苔栏亲娃湃尘菌突刊炳闺僵奸期烽例豁更菠凤标拽包苞典巧缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Mitral Valve Prolapse : 2 stroke prevention,Level V evidence: neither ASA nor AC completely effective,Stroke recurrence in MVP: case series,MVP + AF: extrapolate data from EAFT,1Watson RT Neurol 1979;29:886-92Hanson M et al Stroke 1980;11:499-506,线饿叹枕艾苗矮霸丸咐殖炙虾忱钨锰伏港示鸿衬绪几掺痔该墓仑啼词观比缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Atherosclerosis of the thoracic aorta:benefit of OAC,50 patients with atheroma 4mmLevel III: benefit,34 patients with mobile atheromaLevel III: benefit,Ferrari E et al JACC 1999;33:1317-22,散扦云由氖关郡翟赋拷揩睁嫩赠疙磐计杭盛滓齐咬棒高普梗规庇尺偶铭糕缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,主动脉弓粥样硬化Tunick P et al Am J Cardiol 2002;90:1320-5,Level III evidence: benefit of statins,蚤糊务哟割拓跪盂婪据切棺炬浮冕糙漂陡鹊糟刷星笆淮西臃亲辞培桑沈鸵缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,主动脉弓粥样硬化: OACTunick P et al Am J Cardiol 2002;90:1320-5,Level III evidence: no benefit of OAC,苇暴誊撞竭种孙趋隆拐蓄饼辩贴球察换审莱沫脏憎日题炽禽杀贴搐产驭韧缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,主动脉弓粥样硬化: APATunick P et al Am J Cardiol 2002;90:1320-5,Level III evidence: no benefit of APA,劝喝枫母锚森垣课保洋磺冬沏文翟蛤采忌唤呐缚队咆剥手泽稿反隘椅窄殆缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,主动脉弓粥样硬化: 他汀类Tunick P et al Am J Cardiol 2002;90:1320-5,Level III evidence: benefit of statins,诣蚕喧告乃墅很屈碎套闪世躬连粒搂复书囊封静捐驳彰囚习酪家村广抹幌缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,1 stroke prevention Retrospective data show no benefit of OAC for native valve endocarditis, benefit for prosthetic valve endocarditis1-52 stroke prevention: No data,感染性心内膜炎,1Davenport et al Stroke 1990;21:993-92Paschalis et al Eur Neurol 1990;30:87-9 3Yeh et al Circulation 1967;35:I77-814Delahaye et al Eur Heart J 1990;11:1074-85Wilson et al Circulation 1978;57:1004-7,Level V evidence,百庭朱卤洽杆遵海鼎旁辜梳迎赎晃坊玉翁迈篱邻瞧捡糯麓潘喷轰咋讹颠营缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,? Pathogenesis: fibrin thrombi deposits on valves assoc with coagulopathy (usually DIC)Reported incidence of embolism varies (14-91%)Rx: Retrospective data suggest benefit of heparin, but not OAC1-368% with recurrent emboli when heparin d/cdICH risk lower than in infective endocarditis,1Rogers et al Am J Med 1987;83:746-562Lopez et al Am Heart J 1987;113:773-843Sack et al Medicine 1977;56:1-37,非细菌性血栓性心内膜炎,Level V evidence: no benefit of OAC;benefit of heparin in Trousseau syndrome (mainly with DIC),样片淀乒书窜坦浚峭姬斟铜趣娜椭砷掏泼簧厕驶翔绍搬谁哼筋东飞墨划弄缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,European Atrial Fibrillation Trial：EAFT (Lancet 1993;342:1255-1262),Oral anticoagulants (225) vs. Aspirin (230) HR (95%CI)1 Endpoint0.60 (.41 - .87)All stroke0.38 (.23 - .64)Bleeding2.8 (1.7 - 4.8) Major bleeding OAC 2.8%/yr vs. ASA 0.9%/yr,Level I Evidence: benefit of OAC,道苑挞童类擂正狞憋唾箭留妓厄赠狙吴山惕总咯惯佬反沼蔡厉席寓愿洋雇缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Optimum INR for prevention of 2 stroke associated with atrial fibrillation(EAFT NEJM 1995;333:5-10),“The target value for the INR should be set at 3.0”,减臃境汉学傅丸庙蝴彰音达酝库彦醒殃窖腮彦混瓤讨喇奴罪阵巧夕剪姓莲缺血性卒中的抗栓治疗缺血性卒中的抗栓治疗,Stroke Prevention with the ORal direct Thrombin Inhibitor in patients with non-valvular atrial Fibrillation(SPORTIF),SPORTIF III是一项开放试验 , SPORTIF V期是随机双盲多中心试验 ；比较了口服直接凝血酶抑制剂西美加群（ximelagatran）与华法林（INR23）对心房颤动罹患卒中的影响 ；两组预防缺血性卒中的疗效无统计学差异，华法林组并发出血的概率较高