Weinberger Jesse
Neurovascular Laboratory, Department of Neurology, The Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1052, New York, NY 10029, USA.
Drugs. 2005;65(4):461-71. doi: 10.2165/00003495-200565040-00003.
Stroke is the third most common cause of death in the US. Primary prevention of stroke can be achieved by control of risk factors including hypertension, diabetes mellitus, elevated cholesterol levels and smoking. Approximately one-third of all ischaemic strokes occur in patients with a history of stroke or transient ischaemic attack (TIA). The mainstay of secondary prevention of ischaemic stroke is the addition of medical therapy with antithrombotic agents to control the risk factors for stroke. Antithrombotic therapy is associated with significant medical complications, particularly bleeding.Low-dose aspirin (acetylsalicylic acid) has been shown to be as effective as high-dose aspirin in the prevention of stroke, with fewer adverse bleeding events. Aspirin has been shown to be as effective as warfarin in the prevention of noncardioembolic ischaemic stroke, with significantly fewer bleeding complications. Ticlopidine may be more effective in preventing stroke than aspirin, but is associated with unacceptable haematological complications. Clopidogrel may have some benefit over aspirin in preventing myocardial infarction, but has not been shown to be superior to aspirin in the prevention of stroke. The combination of clopidogrel and aspirin may be more effective than aspirin alone in acute coronary syndromes, but the incidence of adverse bleeding is significantly higher. Furthermore, the combination of aspirin with clopidogrel has not been shown to be more effective for prevention of recurrent stroke than clopidogrel alone, while the rate of bleeding complications was significantly higher with combination therapy. The combination of aspirin and extended-release dipyridamole has been demonstrated to be more effective than aspirin alone, with the same rate of adverse bleeding complications as low-dose aspirin. When selecting the appropriate antithrombotic agent for secondary prevention of stroke, the adverse event profile of the drug must be taken into account when assessing the overall efficacy of the treatment plan.
中风是美国第三大常见死因。通过控制包括高血压、糖尿病、胆固醇水平升高和吸烟在内的风险因素，可以实现中风的一级预防。所有缺血性中风中约三分之一发生在有中风病史或短暂性脑缺血发作（TIA）的患者中。缺血性中风二级预防的主要方法是加用抗血栓药物进行药物治疗，以控制中风的风险因素。抗血栓治疗会伴有严重的医学并发症，尤其是出血。低剂量阿司匹林（乙酰水杨酸）已被证明在预防中风方面与高剂量阿司匹林效果相同，但不良出血事件较少。阿司匹林在预防非心源性栓塞性缺血性中风方面已被证明与华法林效果相同，且出血并发症明显较少。噻氯匹定在预防中风方面可能比阿司匹林更有效，但会伴有难以接受的血液学并发症。氯吡格雷在预防心肌梗死方面可能比阿司匹林有一定优势，但在预防中风方面尚未被证明优于阿司匹林。氯吡格雷和阿司匹林联合使用在急性冠状动脉综合征中可能比单独使用阿司匹林更有效，但不良出血的发生率明显更高。此外，阿司匹林与氯吡格雷联合使用在预防复发性中风方面并未被证明比单独使用氯吡格雷更有效，而联合治疗的出血并发症发生率明显更高。阿司匹林与缓释双嘧达莫联合使用已被证明比单独使用阿司匹林更有效，且不良出血并发症的发生率与低剂量阿司匹林相同。在为中风二级预防选择合适的抗血栓药物时，在评估治疗方案的总体疗效时必须考虑药物的不良事件情况。
