Kirshner H S
Department of Neurology and Vanderbilt Stroke Center, Nashville, TN 37232-2551, USA.
Int J Clin Pract. 2007 Oct;61(10):1739-48. doi: 10.1111/j.1742-1241.2007.01515.x.
Stroke risk is heightened among patients who have had a primary stroke or transient ischaemic attack (TIA). The primary care physician is in the best position to monitor these patients for stroke recurrence. Because stroke recurrence can occur shortly after the primary event, guidelines recommend initiating antiplatelet therapy as soon as possible. Aspirin, with or without extended-release dipyridamole (ER-DP), and clopidogrel are options for such patients. Low-dose aspirin (75-150 mg/day) has the same efficacy as higher doses but with less gastrointestinal bleeding. Clopidogrel remains an option for prevention of secondary events and may benefit patients with symptomatic atherothrombosis, but its combined use with aspirin can harm patients with multiple risk factors and no history of symptomatic cerebrovascular, cardiovascular or peripheral vascular disease.
Low dose aspirin is effective in secondary stroke prevention. Trials assessing aspirin plus ER-DP have shown that the combination is more effective than aspirin monotherapy in preventing stroke, with efficacy increasing among higher risk patients, notably those with prior stroke/TIA. Clopidogrel does not appear to have as much advantage over aspirin in secondary stroke prevention as aspirin plus ER-DP. Smoking cessation and cholesterol, blood glucose and blood pressure control are also important concerns in preventing recurrent stroke. In choosing pharmacological therapy, the physician must consider the individual patient's risk factors and tolerance, as well as other issues, such as use of aspirin among patients with ulcers.
Antiplatelet therapy is effective in secondary stroke prevention. Low dose aspirin can be used first-line, but aspirin plus ER-DP improves efficacy. Clopidogrel is another option in secondary stroke prevention, especially for aspirin-intolerant patients, but it appears to have less advantage over aspirin than aspirin plus ER-DP, and its combined use with aspirin has only marginally better efficacy and increased bleeding risk.
曾发生过原发性卒中或短暂性脑缺血发作（TIA）的患者中风风险会升高。基层医疗医生最适合对这些患者进行中风复发监测。由于中风复发可能在原发性事件后不久就会发生，指南建议尽快开始抗血小板治疗。阿司匹林（无论是否联用缓释双嘧达莫[ER-DP]）和氯吡格雷都是这类患者的选择。低剂量阿司匹林（75 - 150毫克/天）与高剂量阿司匹林疗效相同，但胃肠道出血较少。氯吡格雷仍是预防继发性事件的一种选择，可能对有症状性动脉粥样硬化血栓形成的患者有益，但它与阿司匹林联合使用可能会对有多种风险因素且无有症状性脑血管、心血管或外周血管疾病病史的患者造成伤害。
低剂量阿司匹林在二级预防中风方面有效。评估阿司匹林加ER-DP的试验表明，该组合在预防中风方面比单用阿司匹林更有效，在高危患者中疗效更高，尤其是那些既往有中风/TIA的患者。在二级预防中风方面，氯吡格雷似乎没有阿司匹林加ER-DP相对于阿司匹林那样有优势。戒烟以及控制胆固醇、血糖和血压也是预防中风复发的重要关注点。在选择药物治疗时，医生必须考虑个体患者的风险因素和耐受性，以及其他问题，如溃疡患者使用阿司匹林的情况。
抗血小板治疗在二级预防中风方面有效。低剂量阿司匹林可作为一线用药，但阿司匹林加ER-DP可提高疗效。氯吡格雷是二级预防中风的另一种选择，特别是对于不耐受阿司匹林的患者，但它相对于阿司匹林加ER-DP似乎优势较小，其与阿司匹林联合使用仅在疗效上略有提高，且出血风险增加。
