Chong Ji Y, Mohr Jay P
Doris and Stanley Tananbaum Stroke Center, Neurological Institute, New York Presbyterian Hospital, New York, NY 10032, USA.
Curr Opin Neurol. 2005 Feb;18(1):53-7. doi: 10.1097/00019052-200502000-00011.
The results of recent large clinical trials have modified treatment plans formerly based on inferred mechanisms of ischemic stroke and hazards of certain forms of therapy.
Strong data have emerged to support anticoagulation with warfarin for stroke associated with inferred embolism in a setting of atrial fibrillation. No clear advantage for warfarin over aspirin exists for ischemic stroke in a setting of intracranial atheroma, patent cardiac foramen ovale, or elevated levels of antiphospholipid antibody. Among antiplatelet agents, aspirin and clopidogrel have a similar recurrent stroke risk. Combination therapies with aspirin and warfarin show no additional benefits with regard to stroke prevention and carry higher risks of hemorrhage. Treatment with aspirin combined with specially formulated long-acting dipyridamole carries a lower risk of stroke than aspirin alone and does not increase the risk of hemorrhage significantly. The combination of aspirin and clopidogrel does not reduce the risk of stroke over clopidogrel alone and carries a greater risk of bleeding than clopidogrel alone.
Choice of antithrombotic therapy depends on the etiology of the stroke. Oral anticoagulation treatment is the preferred choice for inferred cardioembolism in the setting of atrial fibrillation, while the varying rates of hemorrhage with oral anticoagulants continue to favor antiplatelet therapy in other settings of inferred etiology. Combinations of antithrombotic therapy vary in their lowering of stroke rate, and some raise the risk of hemorrhage. Insufficient data exist to determine whether antithrombotic therapy combined with antihypertensives, statins or other agents will further reduce the risk of stroke in synergistic or supplemental fashion, or give no additional benefit.
近期大型临床试验的结果改变了以往基于缺血性中风的推测机制和某些治疗方式风险的治疗方案。
已有强有力的数据支持在房颤情况下，使用华法林进行抗凝治疗以预防推测为栓塞性的中风。在颅内动脉粥样硬化、心脏卵圆孔未闭或抗磷脂抗体水平升高的情况下，华法林相对于阿司匹林在预防缺血性中风方面并无明显优势。在抗血小板药物中，阿司匹林和氯吡格雷的复发性中风风险相似。阿司匹林和华法林联合治疗在预防中风方面并无额外益处，且出血风险更高。阿司匹林与特制长效双嘧达莫联合治疗的中风风险低于单用阿司匹林，且不会显著增加出血风险。阿司匹林和氯吡格雷联合治疗在降低中风风险方面并不优于单用氯吡格雷，且出血风险高于单用氯吡格雷。
抗血栓治疗的选择取决于中风的病因。在房颤情况下，口服抗凝治疗是推测为心源性栓塞性中风的首选，而口服抗凝剂不同的出血发生率使抗血小板治疗在其他推测病因的情况下更受青睐。抗血栓联合治疗在降低中风发生率方面各有不同，且有些会增加出血风险。目前尚无足够数据确定抗血栓治疗与抗高血压药、他汀类药物或其他药物联合使用是否会以协同或补充方式进一步降低中风风险，或者是否并无额外益处。
