Cheng Suk F, Brown Martin M
UCL Division of Surgery and Interventional Science, University College London, UK.
UCL Stroke Research Centre, UCL Institute of Neurology, University College London, The National Hospital for Neurology and Neurosurgery, Box 6, Queen Square, London WC1N 3BG, UK.
Semin Vasc Surg. 2017 Mar;30(1):8-16. doi: 10.1053/j.semvascsurg.2017.04.005. Epub 2017 Apr 27.
Contemporary medical therapy consists of identification and treatment of all patient-modifiable vascular risk factors. Specific atherosclerotic disease therapies are designed to reduce the risk of thrombosis, and the disease progression in order to reduce the risk of future cardiovascular events. Contemporary medical management emphasizes the need to support the patient in achieving lifestyle modifications and to adjust medication to achieve individualized target values for specific quantifiable risk factors. Antiplatelet therapy in the form of aspirin or clopidogrel is routinely used for the prevention of ischemic stroke in patients who have had a transient ischemic attack or stroke. There is evidence from a recent trial that the use of combination antiplatelet therapy with aspirin and clopidogrel started within 24 hours of minor stroke or transient ischemic attack reduces the risk of recurrent stroke compared to the use of aspirin alone, and therefore we use aspirin plus clopidogrel in recently symptomatic patients with carotid stenosis pending carotid revascularization. Anticoagulation with heparins or vitamin K antagonist is not recommended except in patients at risk for cardio-embolic events. Lowering blood pressure to target levels has been shown to slow down the progression of carotid artery stenosis and reduces the intima-media thickness of the carotid plaque, while lowering lipid levels with statins has become an essential element in the medical therapy of carotid artery stenosis. Diabetes management should be optimized. Lifestyle choices, including tobacco smoking, physical inactivity, unhealthy diet, obesity, and excessive alcohol intake, are all important modifiable vascular risk factors. The combination of dietary modification, physical exercise, and use of aspirin, a statin, and an antihypertensive agent can be expected to give a cumulative relative stroke risk reduction of 80%. The evidence suggests that intensive medical therapy is so effective that carotid revascularization may no longer be necessary in many of the patients in whom carotid surgery or stenting is currently performed. Two large ongoing trials are therefore comparing the risks and benefits of carotid revascularization versus intensive medical therapy alone.
当代医学治疗包括识别和治疗所有患者可改变的血管危险因素。特定的动脉粥样硬化疾病治疗旨在降低血栓形成风险和疾病进展，以降低未来心血管事件的风险。当代医学管理强调需要帮助患者实现生活方式的改变，并调整药物以达到特定可量化危险因素的个体化目标值。阿司匹林或氯吡格雷形式的抗血小板治疗通常用于预防短暂性脑缺血发作或中风患者的缺血性中风。最近一项试验的证据表明，在轻度中风或短暂性脑缺血发作后24小时内开始使用阿司匹林和氯吡格雷联合抗血小板治疗，与单独使用阿司匹林相比，可降低复发性中风的风险，因此我们在近期有症状的颈动脉狭窄患者等待颈动脉血运重建时使用阿司匹林加氯吡格雷。除有心脏栓塞事件风险的患者外，不建议使用肝素或维生素K拮抗剂进行抗凝。将血压降至目标水平已被证明可减缓颈动脉狭窄的进展，并减少颈动脉斑块的内膜中层厚度，而使用他汀类药物降低血脂水平已成为颈动脉狭窄医学治疗的重要组成部分。糖尿病管理应得到优化。生活方式的选择，包括吸烟、缺乏运动、不健康饮食、肥胖和过量饮酒，都是重要的可改变的血管危险因素。饮食调整、体育锻炼以及使用阿司匹林、他汀类药物和抗高血压药物相结合，预计可使中风累积相对风险降低80%。证据表明，强化医学治疗非常有效，以至于在目前进行颈动脉手术或支架置入术的许多患者中，可能不再需要进行颈动脉血运重建。因此，两项正在进行的大型试验正在比较颈动脉血运重建与单纯强化医学治疗的风险和益处。
