Department of Neurology, UCSF, San Francisco, USA.
Int J Stroke. 2019 Apr;14(3):220-222. doi: 10.1177/1747493019828548. Epub 2019 Feb 6.
Stroke symptoms can be unsettling, even when symptoms resolve, but focusing on stroke prevention can be empowering provided that effective interventions for appropriate patient populations are available. Current options include interventions for symptomatic carotid artery stenosis, anticoagulation for atrial fibrillation, high-dose statins, new oral anticoagulants, new developments in atrial fibrillation detection, and new therapeutics are in development. For antiplatelet therapy, aspirin monotherapy is effective but dual antiplatelet therapy with the combination of aspirin and clopidogrel increases hemorrhage risks over the long term that outweigh potential benefits. In the short term though, both the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) and Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trials have shown a benefit of short-term dual-antiplatelet therapy, though the increased major hemorrhage risk seen in POINT could justify applying dual-antiplatelet therapy to just the first 21 days. Furthermore, since clopidogrel is a prodrug that must be metabolized to have antiplatelet activity, it is not surprising that the treatment effect in CHANCE was limited to patients who were not carriers of loss-of-function alleles for clopidogrel metabolism. Ticagrelor, an antiplatelet agent which failed to meet its primary endpoint as monotherapy compared to aspirin in the Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) trial, is currently being tested as combination therapy with aspirin compared to aspirin alone in Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death (THALES). These developments along with improvements to the infrastructure to perform rapid evaluations and to apply intensive secondary stroke prevention interventions hold continued promise for the future.
中风症状可能令人不安，即使症状已经缓解，但只要为合适的患者群体提供有效的干预措施，关注中风预防就可以赋予患者力量。目前的选择包括治疗症状性颈动脉狭窄的干预措施、房颤的抗凝治疗、大剂量他汀类药物、新型口服抗凝剂、房颤检测的新进展以及新的治疗方法正在开发中。对于抗血小板治疗，阿司匹林单药治疗有效，但阿司匹林和氯吡格雷联合的双联抗血小板治疗会增加长期出血风险，超过潜在益处。然而，在短期内，氯吡格雷用于急性非致残性脑血管事件高危患者（CHANCE）和血小板导向抑制新短暂性脑缺血发作和小卒中（POINT）试验都显示了短期双联抗血小板治疗的益处，尽管 POINT 中观察到的大出血风险增加可能证明将双联抗血小板治疗仅应用于前 21 天是合理的。此外，由于氯吡格雷是一种前体药物，必须代谢才有抗血小板活性，因此 CHANCE 中的治疗效果仅限于氯吡格雷代谢功能丧失等位基因的非携带者并不令人意外。替格瑞洛是一种抗血小板药物，与阿司匹林相比，在急性卒中和短暂性脑缺血发作的治疗中，替格瑞洛与阿司匹林或替格瑞洛和患者结局（SOCRATES）试验的疗效有限，与阿司匹林相比，替格瑞洛与阿司匹林联合治疗的疗效优于替格瑞洛单药治疗，目前正在作为急性卒中和短暂性脑缺血发作的联合治疗进行测试，与替格瑞洛和 ASA 治疗以预防卒中和死亡（THALES）。这些进展以及改进基础设施以进行快速评估和应用强化二级预防干预措施为未来提供了持续的希望。
