最新卒中再发的风险与处理幻灯片.ppt

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1、2022-7-52卒中的概念与分类 概念：急性起病的血供异常导致的脑或脊髓损伤称为卒中。 分类：2022-7-59美国胸科医师协会心房颤动风险专家共识美国胸科医师协会心房颤动风险专家共识 年龄年龄75岁岁 既往卒中病史、既往卒中病史、TIA 或系统性栓塞病史或系统性栓塞病史 高血压病史高血压病史 糖尿病糖尿病 左室功能异常左室功能异常 风湿性心脏病风湿性心脏病 瓣膜修复术瓣膜修复术1、高度风险高度风险:存在一种或以存在一种或以上危险因素上危险因素 ；应予华法林；应予华法林抗凝抗凝 (INR2.03.0)2、中度风险中度风险:年龄年龄6575之之间，无任一危险因间，无任一危险因 素；由素；由医师

2、决定医师决定 抗凝或抗血小板抗凝或抗血小板治疗治疗3、低度风险低度风险:年龄年龄6ESSENESSEN3 30%ESSEN 3 70%事事件件率率/年年%2022-7-519SCALA：近60%的患者处于高复发风险Weimar C. Rother J. et al. J Neurol, 2007, 254 (11).1562-1568Essen卒中风险评分卒中风险评分 0 1 2 3 4 5 6 7 8 9 高危高危 58.3 % 低危低危41.7%患者(%)4.61621.223.516.310.30.61.95.702030nSCALA研究（前瞻性观察队列），85家卒中单元，德国，852例

3、，急性缺血性卒中/TIA，不予干预，平均随访17.5个月2022-7-520ESSEN评分的应用氯吡格雷75mg/d阿司匹林50-325mg/d2022-7-521AHA卒中二级预防指南颅内大动脉狭窄50%99%For patients with stroke or TIA due to 50% to 99% stenosis of a major intracranial artery, aspirin is recommended in preference to warfarin (Class I; Level of Evidence B). Patients in the WASID

4、trial were treated with aspirin 1300 mg/d, but the optimal dose of aspirin in this population has not been determined. On the basis of the data on general safety and efficacy, aspirin doses of 50 mg to 325 mg of aspirin daily are recommended (Class I; Level of Evidence B).推荐阿司匹林(I，B)。剂量50mg325mg/天。（

5、I，B） For patients with stroke or TIA due to 50% to 99% stenosis of a major intracranial artery, long-term maintenance of BP 140/90 mm Hg and total cholesterol level 200 mg/dL may be reasonable (Class IIb; Level of Evidence B). 目标血压140/90 mm Hg ，胆固醇200 mg/dL （IIb，B）For patients with stroke or TIA due

6、 to 50% to 99% stenosis of a major intracranial artery, the usefulness of angioplasty and/or stent placement is unknown and is considered investigational (Class IIb; Level of Evidence C). 血管成形术/支架置入术的作用未知，可以开展研究（IIb , C）For patients with stroke or TIA due to 50% to 99% stenosis of a major intracrani

7、al artery, EC-IC bypass surgery is not recommended (Class III; Level of Evidence B). 不推荐颅内外血管搭桥术（III，B）2022-7-522AHA卒中二级预防指南颅外段颈动脉疾病的外科治疗For patients with recent TIA or ischemic stroke within the past 6 months and ipsilateral severe (70% to 99%) carotid artery stenosis, CEA is recommended if the per

8、ioperative morbidity and mortality risk is estimated to be 6% (Class I; Level of Evidence A).颈动脉重度狭窄（70%99%）且过去的6个月内造成缺血性卒中或TIA，如围手术期死亡风险低于6%推荐CEA（I，A）For patients with recent TIA or ischemic stroke and ipsilateral moderate (50% to 69%) carotid stenosis, CEA is recommended depending on patient-speci

9、fic factors, such as age, sex, and comorbidities , if the perioperative morbidity and mortality risk is estimated to be 6% (Class I; Level of Evidence B).颈动脉中度狭窄（50%69%）且近期发生缺血性卒中或TIA，根据患者的年龄、性别及并发症情况选择性行CEA，要求围手术期死亡风险低于6%（I，B）When the degree of stenosis is 50%, there is no indication for carotid re

10、vascularization by either CEA or CAS (Class III; Level of Evidence A).颈动脉狭窄is 70% by noninvasive imaging or 50% by catheter angiography (Class I; Level of Evidence B).CAS可以作为CEA的替代方案（I,B）Among patients with symptomatic severe stenosis (70%) in whom the stenosis is difficult to access surgically, med

11、ical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist, such as radiation induced stenosis or restenosis after CEA, CAS may be considered (Class IIb; Level of Evidence B).外科手术难以到达、风险过大、或其他特殊情况（射线导致的狭窄、CEA后再狭窄）时可考虑CAS（II b ，B）2022-7-523AHA卒中

12、二级预防指南颅外段椎动脉疾病的治疗Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with vertebral artery stenosis and a TIA or stroke as outlined elsewhere in this guideline (Class I; Level of Evidence B). 最佳的内科治疗（抗血小板治疗

13、、他汀治疗、控制危险因素）Endovascular and surgical treatment of patients with extracranial vertebral stenosis may be considered when patients are having symptoms despite optimal medical treatment (including antithrombotics, statins, and relevant risk factor control) (Class IIb; Level of Evidence C) 最佳内科治疗不能控制发作时应考虑血管内治疗或外科手术治疗（IIb,C）2022-7-524小结 房颤患者卒中风险评估及治疗 CHADS2评分、不同风险的治疗 非房颤患者卒中风险评估及治疗 专家共识、AHA指南