Department of Neurology, Froedtert Hospital and Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA,
Curr Treat Options Neurol. 2009 Nov;11(6):452-9. doi: 10.1007/s11940-009-0049-x.
Stroke is a common public health problem. About 25% of strokes are recurrent ones. Stroke subtype should be defined to determine the best evidence-based antithrombotic treatment option for preventing recurrent stroke. When choosing an antiplatelet agent for this purpose, clinicians should take into account cost, side effect profile, medical comorbidity, and patient preference.To prevent recurrent stroke, aspirin alone (50-325 mg/d), a combination of aspirin (25 mg) plus extended-release dipyridamole (200 mg), given twice daily, or clopidogrel (75 mg/d) may be used as initial treatment. Aspirin is an efficacious, relatively safe, widely available, inexpensive, and easy-to-use antiplatelet agent. Current evidence suggests that administration of low-dose aspirin (< 325 mg/d or < 100 mg/d in various studies) is at least as efficacious as higher-dose aspirin (eg, > 325 mg/d) but is safer. The combination of aspirin plus extended-release dipyridamole is more efficacious than low-dose aspirin alone (eg, 50 or 75 mg/d) in preventing recurrent stroke.Clopidogrel (75 mg/d) may be more efficacious than aspirin alone (325 mg/d) for prevention of recurrent stroke. Clopidogrel is a prodrug that must be converted in the liver to its active metabolite by cytochrome P450 enzymes. Certain polymorphisms (eg, CYP2C19) may prevent this conversion and lead to failure of clopidogrel to prevent major cardiovascular events.In patients with well-controlled or treated cardiovascular risk factors, aspirin plus extended-release dipyridamole and clopidogrel may provide similar results in preventing recurrent stroke, but aspirin plus extended-release dipyridamole may be associated with a slightly higher risk of major hemorrhage. Careful control of vascular risk factors is an important strategy for prevention of recurrent stroke, and blood pressure control reduces the risk of both brain hemorrhage and infarction.Prasugrel, a new thienopyridine derivative, more quickly and consistently inhibits platelets than clopidogrel. In stroke patients, prasugrel may be associated with a higher risk of brain hemorrhage, so it may not be indicated when there is a history of cerebrovascular disease.
中风是一种常见的公共卫生问题。约 25%的中风是复发性中风。为了确定预防复发性中风的最佳循证抗血栓治疗选择，应明确中风亚型。在为此目的选择抗血小板药物时，临床医生应考虑成本、副作用谱、合并症和患者偏好。为了预防复发性中风，可单独使用阿司匹林（50-325mg/d）、阿司匹林（25mg）加缓释双嘧达莫（200mg），每日 2 次，或氯吡格雷（75mg/d）作为初始治疗。阿司匹林是一种有效、相对安全、广泛可用、廉价且易于使用的抗血小板药物。目前的证据表明，低剂量阿司匹林（<325mg/d 或在不同研究中<100mg/d）的给药至少与高剂量阿司匹林（如>325mg/d）一样有效，但更安全。阿司匹林加缓释双嘧达莫的联合使用比单独使用低剂量阿司匹林（如 50 或 75mg/d）更能有效预防复发性中风。氯吡格雷（75mg/d）在预防复发性中风方面可能比阿司匹林（325mg/d）更有效。氯吡格雷是一种前体药物，必须在肝脏中由细胞色素 P450 酶转化为其活性代谢物。某些多态性（如 CYP2C19）可能会阻止这种转化，导致氯吡格雷无法预防主要心血管事件。在心血管危险因素得到良好控制或治疗的患者中，阿司匹林加缓释双嘧达莫和氯吡格雷在预防复发性中风方面可能会产生相似的结果，但阿司匹林加缓释双嘧达莫可能与更高的大出血风险相关。仔细控制血管危险因素是预防复发性中风的重要策略，血压控制可降低脑出血和脑梗死的风险。普拉格雷是一种新型噻吩并吡啶衍生物，比氯吡格雷更快、更一致地抑制血小板。在中风患者中，普拉格雷可能与脑出血风险增加相关，因此当有脑血管疾病病史时，可能不适用。
