Ruland Sean
Section of Cerebrovascular Disease and Neurologic Critical Care, Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
Drug Saf. 2008;31(6):449-58. doi: 10.2165/00002018-200831060-00001.
Antiplatelet therapy is universally recommended for the prevention of recurrent events in patients with noncardioembolic ischaemic stroke or transient ischaemic attack (TIA), acute and chronic coronary artery disease, or peripheral arterial disease. However, choosing which antiplatelet agents to use in these situations remains controversial. The use of aspirin, aspirin plus extended-release dipyridamole, or clopidogrel is recommended as initial therapy in patients with noncardioembolic ischaemic stroke or TIA to reduce the risk of recurrent stroke and other cardiovascular events. Based on the results of the MATCH trial, combination therapy with aspirin plus clopidogrel is not recommended for patients with ischaemic stroke or TIA due to the increased risk of haemorrhage. The results of the CHARISMA trial support this recommendation; despite previous data demonstrating a favourable benefit-risk profile of aspirin plus clopidogrel in patients with acute coronary syndrome, this combination should not be used in patients at high risk for atherothrombosis and those with previous stroke or TIA. In these patients, the CHARISMA trial demonstrated a lack of significant clinical efficacy and an increased risk of bleeding with clopidogrel plus aspirin compared with aspirin alone. Further research is needed to assess the benefit-risk ratio of clopidogrel plus aspirin in specific subpopulations of patients at high risk for atherothrombotic events, and to determine the role of clopidogrel plus aspirin in preventing cardioembolic stroke or early recurrent stroke after symptomatic large-vessel atherostenosis. Recent and ongoing studies are seeking to better define the roles of different antiplatelet regimens in preventing recurrent stroke.
对于非心源性缺血性卒中或短暂性脑缺血发作（TIA）、急慢性冠状动脉疾病或外周动脉疾病患者，普遍推荐使用抗血小板治疗来预防复发事件。然而，在这些情况下选择使用哪种抗血小板药物仍存在争议。对于非心源性缺血性卒中或TIA患者，推荐使用阿司匹林、阿司匹林加缓释双嘧达莫或氯吡格雷作为初始治疗，以降低复发性卒中及其他心血管事件的风险。基于MATCH试验的结果，由于出血风险增加，不推荐阿司匹林加氯吡格雷联合治疗缺血性卒中和TIA患者。CHARISMA试验的结果支持这一推荐；尽管先前的数据表明阿司匹林加氯吡格雷在急性冠状动脉综合征患者中具有良好的效益风险比，但这种联合用药不应在动脉粥样硬化血栓形成高危患者以及既往有卒中或TIA的患者中使用。在这些患者中，CHARISMA试验表明，与单独使用阿司匹林相比，氯吡格雷加阿司匹林缺乏显著的临床疗效且出血风险增加。需要进一步研究来评估氯吡格雷加阿司匹林在动脉粥样硬化血栓形成事件高危特定亚组患者中的效益风险比，并确定氯吡格雷加阿司匹林在预防心源性栓塞性卒中或症状性大血管动脉粥样硬化狭窄后早期复发性卒中中的作用。近期和正在进行的研究正在寻求更好地界定不同抗血小板治疗方案在预防复发性卒中中的作用。
