把握缺血性卒中患者的抗栓新.ppt

CHANCE研究的讨论 仅观察双抗21天结果，若单用阿司匹林90天，是否出现同样结果？ 仅纳入小卒中和TIA，且24小时内用药，能否广泛应用？ AHA/ASA指南：卒中发生24-48小时内，推荐服用初始计量325mg的阿司匹林（ⅠA），氯吡格雷对急性缺血卒中治疗有效证据不足（Ⅱb；C）。 为何临床阿司匹林的不良反应似乎看起来不少？ 使用率高是临床上医生直觉认为阿司匹林出血风险高的原因 阿司匹林和氯吡格雷的上消化道出血风险相似，但阿司匹林的使用率明显高于氯吡格雷，导致研究人群中因阿司匹林导致的出血发病数（631例）明显高于氯吡格雷（68例） 。 阿司匹林和氯吡格雷出血风险相似 出血风险RR 使用率% 阿司匹林使用率明显高于氯吡格雷 Circulation 2011, 123:1108-1115 阿司匹林 氯吡格雷 阿司匹林 氯吡格雷 使用率高导致阿司匹林引起的出血患者例数增加 在临床中，应该如何选择阿司匹林的剂型？ 阿司匹林肠溶片剂型较普通剂型显著降低胃部损害 Aliment Pharmacol Ther 1999; 13: 1109-1114 41例志愿者随机分至阿司匹林肠溶片100mg或普通阿司匹林100mg。结果显示，与普通阿司匹林相比，阿司匹林肠溶片100mg/d对胃肠道损害明显减少 专家推荐阿司匹林肠溶片降低胃肠道损伤 李晓鹰教授对阿司匹林在动脉硬化性心血管疾病中的临床应用专家共识进行解读时指出，精确阿司匹林肠溶片仅在碱性肠液中释放并缓慢吸收，可减轻胃及十二指肠的刺激症状达60%以上，因此建议选用精确阿司匹林肠溶片以预防或减轻阿司匹林副作用 中国实用乡村医生杂志 2007 年第3 期（第14 卷） * * * * * * * * * * * * * * * * * In conclusion, our study shows that among patients with high-risk TIA or minor ischemic stroke who are initially seen within 24 hours after symptom onset, treatment with clopidogrel plus aspirin for 21 days, followed by clopidogrel alone for a total of 90 days, is superior to aspirin alone in reducing the risk of subsequent stroke events. The combination of clopidogrel with aspirin did not cause more hemorrhagic events in this patient population than aspirin alone. In this large-scale trial involving patients with high-risk TIA or minor ischemic stroke, we found that the addition of clopidogrel to aspirin within 24 hours after symptom onset reduced the risk of subsequent stroke by 32.0%, as compared with aspirin alone. Event rates during this early period were very high, and clopidogrel was associated with an absolute risk reduction of 3.5 percentage points, equivalent to a number needed to treat of 29 patients to prevent one stroke over a period of 90 days. Combination therapy with clopidogrel and aspirin, as compared with aspirin alone, was not associated with an increased incidence of hemorrhage, although there was a worrisome trend in overall bleeding toward more events with the combination therapy. * * * Users of NA-NSAIDs