Kapil Nikhil, Datta Yvonne H, Alakbarova Naila, Bershad Eric, Selim Magdy, Liebeskind David S, Bachour Ornina, Rao Gundu H R, Divani Afshin A
1 Department of Neurology, University of Minnesota, Minneapolis, MN, USA.
2 Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
Clin Appl Thromb Hemost. 2017 May;23(4):301-318. doi: 10.1177/1076029616660762. Epub 2016 Jul 26.
Ischemic stroke represents one of the leading causes of death and disability in both the United States and abroad, particularly for patients with prior ischemic stroke or transient ischemic attack (TIA). A quintessential aspect of secondary stroke prevention is the use of different pharmacological agents, mainly antiplatelets and anticoagulants. Antiplatelets and anticoagulants exhibit their effect by blocking the activation pathways of platelets and the coagulation cascade, respectively. Clinical trials have demonstrated the safety and efficacy of antiplatelets for noncardioembolic stroke prevention, while anticoagulants are more often used for cardioembolic stroke prevention. Commonly used antiplatelets include aspirin, clopidogrel, and aggrenox (aspirin plus extended-release dipyridamole). Furthermore, commonly used anticoagulants include warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban. Each of these drugs has a unique mechanism of action, and they share some common adverse events such as gastrointestinal bleeding and intracranial hemorrhage in more serious cases. Consequently, physicians should carefully assess the benefits and risks of using different antiplatelet or anticoagulant therapies when managing patients with previous ischemic stroke or TIA. This review discuses the published literature on major clinical trials assessing the efficacy of different antiplatelet and anticoagulant drugs under varying circumstances and the subsequent guidelines that have been developed by the American Heart Association/American Stroke Association. Additionally, the role of imaging in stroke prevention is discussed.
在美国及其他国家，缺血性中风都是导致死亡和残疾的主要原因之一，对于既往有缺血性中风或短暂性脑缺血发作（TIA）的患者而言尤其如此。二级中风预防的一个关键方面是使用不同的药物，主要是抗血小板药物和抗凝药物。抗血小板药物和抗凝药物分别通过阻断血小板的激活途径和凝血级联反应来发挥作用。临床试验已证明抗血小板药物在预防非心源性栓塞性中风方面的安全性和有效性，而抗凝药物则更常用于预防心源性栓塞性中风。常用的抗血小板药物包括阿司匹林、氯吡格雷和安步乐克（阿司匹林加缓释双嘧达莫）。此外，常用的抗凝药物包括华法林、达比加群、利伐沙班、阿哌沙班和依度沙班。这些药物中的每一种都有独特的作用机制，并且它们都有一些常见的不良事件，在更严重的情况下包括胃肠道出血和颅内出血。因此，医生在治疗既往有缺血性中风或TIA的患者时，应仔细评估使用不同抗血小板或抗凝治疗的益处和风险。本综述讨论了已发表的关于评估不同抗血小板和抗凝药物在不同情况下疗效的主要临床试验的文献，以及美国心脏协会/美国中风协会制定的后续指南。此外，还讨论了影像学在中风预防中的作用。
