中风二级预防更新课件

UpdateofsecondarystrokepreventionUpdateofsecondarystrokepre1Introduction

Secondaryprevention：preventingastrokeafteratransientischaemicattack(TIA)orarecurrentstrokeafterafirststroke.卒中二级预防概念：在发生TIA或初次中风后预防中风发生或再次发生。

IntroductionSecondaryprev28to15%strokeorTIApatientssufferarecurrentstrokeinthefirstyear.Therecurrenceriskishighestinthefirstfewweeksanddeclinesovertime.有8~15%的中风或TIA患者会在第一年内再次中风或发生中风。且风险在最初的几周是最高的，随时间的延长而下降。So,ImmediateevaluationofpatientswithastrokeorTIA,identificationofthepathophysiologyandinitiationofsecondarypreventionareofgreatimportance因此，发生TIA或中风后立即进行评估，了解其病理生理学情况积极启动二级预防措施是非常重要的。8to15%strokeorTIAp3Hypertension1.HOPE:

Ameta-analysiscomprisedsevenstudiesin15527patientswithTIA,ischaemicorhaemorrhagicstroke.荟萃分析7项研究涉及15527个TIA、缺血性或出血性中风患者。

Followedupperiod:2–5y.随访周期：2~5年

Hypertension1.HOPE:4Result:

(1)Treatmentwithantihypertensivesreducedtheriskofstrokeby24%,riskofnon-fatalstrokeby21%,riskofmyocardialinfarction(MI)by21%andtheriskofallvasculareventsby21%.

服用控制高血压药物的卒中复发风险降低了24%,非致死性的卒中风险降低了21%,心肌梗塞风险降低了21%，所有的血管性事件降低了21%。

Result:5(2)thecombinationofanACEIwithadiureticwasmoreeffective(45%riskreduction)thanadiureticasmonotherapy(32%),monotherapywithanACEI(7%)orabeta-blocker(7%).

ACEI与利尿剂联用更有效，优于利尿剂、ACEI、β受体阻滞剂各自单用。

(2)thecombinationofan62.PROGRESS：

thefirstlarge-scaletrialspecificallyperformedinpatientsafterstroke.第一个针对中风后病人实施的大型临床试验。Method:Atotalof6105patientsweretreatedwithperindoprilasmonotherapyorincombinationwithindapamideorplacebo.

6105例中风后病人或培哚普利单用或与吲哒帕胺、安慰剂联用Followedupperiod:4y.

随访周期：4年2.PROGRESS：7Result:

1)Theabsoluteriskreductionforrecurrentstrokewas4%,andtherelativeriskreduction(RRR)was28%.卒中复发的绝对危险度下降了4%，相对危险度下降了28%.

Result:8

2)MonotherapywiththeACEinhibitorwasnotonlysuperiortoplacebobutalsodidnotachievethesamelevelofbloodpressureloweringthanthecombinationtherapy.TheRRRforcombinationtherapywas43%.

单用ACEI类不仅二级预防效果优于安慰剂组，且与联用相比不致于使血压降得过低。联用降低中风复发的相对危险度较高：43%.

2)MonotherapywiththeACE93.MOSES:Method:1352patientswithhypertensionwhohadsufferedastrokeinthelast24monthsweretreatedeitherwitheprosartan依普罗沙坦(600mg)orwithnitrendipin(10mg).

1352例在24个月内发生过中风的高血压病人或用依普罗沙坦(600mg)治疗或用尼群地平（10mg）治疗。3.MOSES:10Result:1)Foranidenticaldropinbloodpressure,eprosartanwassuperiortonitrendipintopreventrecurrentvascularevents(21%RRR).

具有基本相同的降压效果，但在防止血管事件复发方面依普罗沙坦优于尼群地平治疗。2)TheoptimalsystolicbloodpressureintheMOSEStrialwas120–140mmHg.

MOSES的研究提示中风后最佳收缩压应控制在120-140mmHg。

Result:1)Foranidenticaldro114.PRoFESS:Method:randomized20332patientswitharecentischaemicstroketoreceivetelmisartan替米沙坦at80mg/dayorplacebo.随机将新近发生过中风的20332名病人分为替米沙坦80mg/d和安慰剂组。Followedupperiod:2.4years.随访周期：2.4年。4.PRoFESS:12Result:Themeanbloodpressureoverthetrialperiodwaslowerinthetelmisartangroupby3.8/2.0mmHg.Recurrentstrokesoccurredin8.7%inthetelmisartangroupcomparedto9.2%intheplacebogroup,whichwasnotsignificant.

在试验期间替米沙坦组血压比安慰剂组平均低3.8/2.0mmHg.其中风复发率为8.7%，安慰剂组中风复发率为9.2%，两组间没有显著性差异。Result:Themeanbloodpressur13Conclusion:initiationoftelmisartanearlyafterastroke,didnotsignificantlylowertherateofrecurrentstrokes,othermajorvasculareventsornewdiabetes。

中风后早期服用替米沙坦并不能显著的阻止中风复发，及其他血管事件和新法糖尿病。Conclusion:initiationoftelm14Highcholesterol1.HeartProtectionStudy(HPS)Total20536high-riskpatients,3280patientshadTIAorstrokeand1820ofthemwithoutconcomitantCHD.共20536高危病人，其中3280具有TIA或卒中病史，1820没有伴随心脏疾病。TheRRRachievedbysimvastatingivenfor5yearsforvasculareventswas20%andtheabsoluteriskreduction5.1%.给予辛伐他汀组（连续5年）血管事件相对危险度下降了20%，绝对危险度下降了5.1%.Highcholesterol1.HeartProtec152.SPARCL

(StrokePreventionbyAggressiveReductioninCholesterolLevels)Method:4731patientswithTIAorstrokewithoutCHDandLDLcholesterollevelsbetween100and190mg/dl.Thepatientsreceivedeither80mgatorvastatinorplacebo.

4731个具有TIA或中风病史排除心脏病且LDL在100~190mg/dl被分为80mg阿托伐他汀组和安慰剂组.

Followedupperiod:averageof4.9y.Result:theprimaryendpoint(stroke)wasreducedby16%relativeand2.2%absolute.第一终点事件卒中发生率下降的相对值和绝对值分别为16%和2.2%2.SPARCL(StrokePreventionby16HPSVSSPARCLTherateofischaemicstrokewasreduced(218versus274)whereashaemorrhagicstrokesweremorefrequentwithatorvastatin(55versus33).这两个临床试验相比，阿托伐他汀组的卒中发生下降了相对要高一点，但发生出血性卒中的数目确相对多一点。HPSVSSPARC17TherapywithastatinshouldbeinitiatedearlyafteranischaemicstrokeorTIA.Thesuddendiscontinuationofastatininpatientswithastrokeoracutecoronarysyndromemightbeassociatedwithhighermorbidityandmortality.

Discontinuationofstatintreatmentinstrokepatients.Stroke2006在初发中风后对具有血脂异常者应尽早开始服用他汀类调脂。具有中风或冠心病的患者突然停用他汀类会出现比较高的复发率和致死率。

Therapywithastatinshou18Diabetes

mellitusRandomizedcontrolledstudieswereunabletoshowaneffectofglitazones列酮类onvasculareventsinstrokepatientswithdiabetesmellitusEffectsofpioglitazoneGlitazonesinpatientswithtype2diabeteswithorwithoutpreviousstroke:resultsfromPROACTIVE.Stroke2007;38

一随机对照研究未能发现服用列酮类降糖药能明显降低具有糖尿病的中风患者的血管事件的发生率。Aggressiveloweringofbloodglucosedoesnotreducetheriskofstrokeandmightevenincreasemortality.Intensivebloodglucosecontrolandvascularoutcomesinpatientswithtype2diabetes.NEnglJMed2008;358

过分降糖不但不会降低卒中的风险反而会增加恶性事件。DiabetesmellitusRandomize19SupplementationofvitaminsTheVISPstudywasunabletoshowabenefitofthetreatmentofhighhomocysteineinstrokepatientswithBvitaminsandfolicacid.

VISP的研究表明具有高同型半胱氨酸的中风患者服用维生素B和叶酸未能额外获益。TheHOPE-2studyalsofailedtodemonstratebenefit.

TheHeartOutcomesPreventionEvaluation(HOPE)2Investigators.HomocysteineloweringwithfolicacidandBvitaminsinvasculardisease.NEnglJMed2006;354

HOPE-2研究也得出与VISP基本相同的结论。Supplementationofvitamins20EffectoffolicacidandBvitaminsonriskofcardiovasculareventsandtotalmortalityamongwomenathighriskforcardiovasculardisease:arandomizedtrial.

JAMA2008;299:2027–2036

叶酸和维生素B在具有高风险心血管疾病女性受试者中对心血管事件和总致死率的效果included5522patientsaged>55yearsandavasculareventordiabetesmellitus包含5522例具有血管事件或糖尿病年龄大于55岁的女性受试者treatedthemfor5yearswitheitherplaceboor2.5mgfolicacid,50mgvitaminB6and1mgvitaminB12.对照组服用安慰剂，治疗组服用2.5mg叶酸,50mg维生素B6and1mg维生素B12.resultedinasignificantreductioninhomocysteinelevelsbutnotinvascularevents.

结果：同型半胱氨酸水平下降但血管事件未明显下降。EffectoffolicacidandBvit21Hormonereplacementtherapyaftermenopause

关于女性中风患者的一项随机安慰剂对照研究提示，绝经后采取激素替代疗法疗法会增加中风的死亡率，并给非致死性卒中带来较差的预后。Hormonereplacementtherapyaf22Antiplatelet

therapy1.TheMATCHstudy:Object:high-riskpatientswithTIAorischaemicstrokeAim:clopidogrel75mg+ASA75mgPKclopidogrel75Result:combinationtherapyfailedtoshowsuperiorityonendpointvascularevent.

联合用药组未能体现在降低血管性终点事件中的优势。反而出血性并发症的发生率较高。Reverselyresultedinasignificantincreaseinbleedingcomplications.-------notrecommended.Antiplatelettherapy1.TheMATC232.CHARISMA

(ClopidogrelforHighAtherothromboticRiskandIschemicStabilization,ManagementandAvoidance)

atrialcombinedprimaryandsecondarypreventionAim:clopidogrel+ASAPKASAResult:Combinationtherapyfailedtoshowabenefitanddisplayedahigherbleedingrate.联合用药治疗未能明显获益。出血性并发症的发生率较高。Symptomaticpatientsshowedatrendtowardsabenefitforcombinationantiplatelettherapy.

但在症状性中风患者表现出一定的优势。2.CHARISMA(ClopidogrelforHi243.ESPS2(thesecondEuropeanstrokepreventionstudy)Method:6602patientswithTIAorstrokewererandomizedtoASA(25mgbid),ER-DP(200mgbid),ASA+ER-DPorplacebo.

6602例TIA或中风病人随机分为ASA组，ER-DP组、二者联用组及安慰剂组。Result:Fortheprimaryendpointstroke,ASA+ER-DPwassuperiortoASAandplacebo

对第一终点事件卒中来说，联用效优。ASAloweredtheriskofstrokeby18%anddipyridamolemonotherapyby16%.BleedingcomplicationswereseenmorefrequentlywithASAandtheASA+ER-DP,DPhadasimilarbleedingrateasplacebo

ASA及联用组出血性并发症较高，DP较低。3.ESPS2(thesecondEuropeans254.Ahead-toheadcomparisonofclopidogrelwithASA+ER-DP

(performedinthePRoFESSstudy)Method:Randomized20332patientswithischaemicstrokeandfollowedforameanperiodof2.4y.Result:Therewasnodifferenceinefficacyacrossallendpointsandvarioussubgroupsofpatients.

在所有终点事件的发生发面两者之间没有明显差异。ASA+ER-DPresultedinmoreintracranialbleedingsandahigherdropoutrateduetoheadachecomparedwithclopidogrel(5.9%versus0.9%).

与clopidogrel相比ASA+ER-DP的颅内出血率和因于头疼的脱落率较高。4.Ahead-toheadcomparisonof261.EuropeanAtrialFibrillationtrial

(randomizedplacebo-controlledtrial)Numbersneededtotreat(NNT)are12/year.Result:

warfarin:RRR68%V300mgASA:RRR19%Anticoagulationincerebralischaemiaduetocardiacembolism

抗凝剂在心源性栓塞缺血性卒中患者中的应用1.EuropeanAtrialFibrillation272.TheACTIVEstudyMethod:

RandomizedpatientswithAFintoASA+clopidogrelandwarfaringroups.

将受试的具有房颤卒中病人随机分为ASA+clopidogrel和华法令组Result:

terminatedprematurelyduetoasignificantreductionofstrokeandsystemicembolisminfavourofwarfarin.

由于华法令在降低中风发生和系统性栓塞方面表现出明显的显著性差异而提前终止。rateofbleedingcomplicationswasnotdifferentbetweenthetworegimens.

在出血性并发症方面两者无明显差异。2.TheACTIVEstudy28Cryptogenic（隐源性）strokeandpatentforamenovale(PFO)ProspectivecohortstudieshaveshownthattreatmentwithaspirinorwarfarinreducestheriskofrecurrentstrokeintheaveragepatientwithPFOtothesameriskasinpatientswithoutPFO.一项前瞻性队列研究显示：阿司匹林或华法令可将具有PFO的病人中风复发的危险性降至非PFO病人同等水平。Suggest:Aspirinwasaseffectiveasanticoagulationandthereforeshouldbegiven

建议：在防止PFO病人中风复方方面阿司匹林具有与抗凝剂同等效果，PFO病人应该服用。Cryptogenic（隐源性）strokeandpa29Anticoagulationincerebralischaemiaofnon-cardiacorigin1.ESPIRIT(TheStrokePreventioninReversibleIschemiatrial)Aim:studiedoralanticoagulationwithanINRbetween3.0and4.5versusASA30mginpatientswithTIAorminorstrokewithoutcardiacsourceofembolism.

研究在非心源性栓塞的TIA和中风病人中，比较将INR控制在3~4.5的情况下服用抗凝剂和服用阿司匹林30mg的效果优劣。Anticoagulationincerebralis30Result:terminatedduetoasignificantlyincreasedbleedingriskwithanticoagulation.因抗凝剂明显增加出血性风险而中止。、lowerrateofischaemiceventswithanticoagulationcounterbalancedbyanincreasedriskofintracranialbleedings.

抗凝剂降低缺血性卒中时间的比率被其增加率内出血的风险所抵消。Result:terminatedduetoasi312.WARSS(TheWarfarinAspirinRecurrentStrokeStudy)

showedasimilarrateofischaemiceventsandbleedingcomplications:warfarin(INR1.4–2.8)VSASA(instrokepatientswithoutcardiacsourceofembolism)

在非心源性栓塞的卒中病人中华法令（INR1.4–2.8）与阿司匹林的卒中再发及出血并发症事件方面大致相似。2.WARSS(TheWarfarinAspirin32CarotidendarterectomyandstentingwithballoonangioplastyNASCETandESC

(Twolargerandomizedtrials)Result:clearbenefitofcarotidsurgerythanmedicaltreatmentinpatientswithhigh-degreestenosis.在颈动脉高度狭窄的病人中，血管内膜切除术明显优于单纯药物治疗。Takentogether,thetrialsfoundanabsoluteriskreductionof13.5%over5yearsforthecombinedendpointofstrokeanddeathinfavourofcarotidendarterectomy.总体而言，在5年随访期内，颈动脉血管内膜切除术在降低卒中及死亡等终点事件方面的绝对危险性下降13.5%，具有一定优势。

Carotidendarterectomyandste33Theriskreductionisevenhigherinstenosis>90%.当颈动脉狭窄程度>90%时手术可将风险降得更低。Patientswith<50%ICAstenosisdonotbenefitfromcarotidendarterectomy.当颈内动脉狭窄程度<50%时，颈动脉内膜切除术不能明显获益。Theriskreductionisevenhig34Theshort-termcomplicationrates(strokeanddeath)were6.2%forstenosis>70%and8.4%for50–69%stenosis.ASAshouldbegivenpriorto,duringandaftercarotidsurgery.颈动脉狭窄程度>70%和狭窄程度在50–69%者手术后短期内复发和死亡的风险分别是6.2%和8.4%。阿司匹林在手术前后及手术期间都应给服。Theshort-termcomplicationra35Thatisall,Thanksforyourattendance!Thatisall,Thanksforyourat36UpdateofsecondarystrokepreventionUpdateofsecondarystrokepre37Introduction

Secondaryprevention：preventingastrokeafteratransientischaemicattack(TIA)orarecurrentstrokeafterafirststroke.卒中二级预防概念：在发生TIA或初次中风后预防中风发生或再次发生。

IntroductionSecondaryprev388to15%strokeorTIApatientssufferarecurrentstrokeinthefirstyear.Therecurrenceriskishighestinthefirstfewweeksanddeclinesovertime.有8~15%的中风或TIA患者会在第一年内再次中风或发生中风。且风险在最初的几周是最高的，随时间的延长而下降。So,ImmediateevaluationofpatientswithastrokeorTIA,identificationofthepathophysiologyandinitiationofsecondarypreventionareofgreatimportance因此，发生TIA或中风后立即进行评估，了解其病理生理学情况积极启动二级预防措施是非常重要的。8to15%strokeorTIAp39Hypertension1.HOPE:

Ameta-analysiscomprisedsevenstudiesin15527patientswithTIA,ischaemicorhaemorrhagicstroke.荟萃分析7项研究涉及15527个TIA、缺血性或出血性中风患者。

Followedupperiod:2–5y.随访周期：2~5年

Hypertension1.HOPE:40Result:

(1)Treatmentwithantihypertensivesreducedtheriskofstrokeby24%,riskofnon-fatalstrokeby21%,riskofmyocardialinfarction(MI)by21%andtheriskofallvasculareventsby21%.

服用控制高血压药物的卒中复发风险降低了24%,非致死性的卒中风险降低了21%,心肌梗塞风险降低了21%，所有的血管性事件降低了21%。

Result:41(2)thecombinationofanACEIwithadiureticwasmoreeffective(45%riskreduction)thanadiureticasmonotherapy(32%),monotherapywithanACEI(7%)orabeta-blocker(7%).

ACEI与利尿剂联用更有效，优于利尿剂、ACEI、β受体阻滞剂各自单用。

(2)thecombinationofan422.PROGRESS：

thefirstlarge-scaletrialspecificallyperformedinpatientsafterstroke.第一个针对中风后病人实施的大型临床试验。Method:Atotalof6105patientsweretreatedwithperindoprilasmonotherapyorincombinationwithindapamideorplacebo.

6105例中风后病人或培哚普利单用或与吲哒帕胺、安慰剂联用Followedupperiod:4y.

随访周期：4年2.PROGRESS：43Result:

1)Theabsoluteriskreductionforrecurrentstrokewas4%,andtherelativeriskreduction(RRR)was28%.卒中复发的绝对危险度下降了4%，相对危险度下降了28%.

Result:44

2)MonotherapywiththeACEinhibitorwasnotonlysuperiortoplacebobutalsodidnotachievethesamelevelofbloodpressureloweringthanthecombinationtherapy.TheRRRforcombinationtherapywas43%.

单用ACEI类不仅二级预防效果优于安慰剂组，且与联用相比不致于使血压降得过低。联用降低中风复发的相对危险度较高：43%.

2)MonotherapywiththeACE453.MOSES:Method:1352patientswithhypertensionwhohadsufferedastrokeinthelast24monthsweretreatedeitherwitheprosartan依普罗沙坦(600mg)orwithnitrendipin(10mg).

1352例在24个月内发生过中风的高血压病人或用依普罗沙坦(600mg)治疗或用尼群地平（10mg）治疗。3.MOSES:46Result:1)Foranidenticaldropinbloodpressure,eprosartanwassuperiortonitrendipintopreventrecurrentvascularevents(21%RRR).

具有基本相同的降压效果，但在防止血管事件复发方面依普罗沙坦优于尼群地平治疗。2)TheoptimalsystolicbloodpressureintheMOSEStrialwas120–140mmHg.

MOSES的研究提示中风后最佳收缩压应控制在120-140mmHg。

Result:1)Foranidenticaldro474.PRoFESS:Method:randomized20332patientswitharecentischaemicstroketoreceivetelmisartan替米沙坦at80mg/dayorplacebo.随机将新近发生过中风的20332名病人分为替米沙坦80mg/d和安慰剂组。Followedupperiod:2.4years.随访周期：2.4年。4.PRoFESS:48Result:Themeanbloodpressureoverthetrialperiodwaslowerinthetelmisartangroupby3.8/2.0mmHg.Recurrentstrokesoccurredin8.7%inthetelmisartangroupcomparedto9.2%intheplacebogroup,whichwasnotsignificant.

在试验期间替米沙坦组血压比安慰剂组平均低3.8/2.0mmHg.其中风复发率为8.7%，安慰剂组中风复发率为9.2%，两组间没有显著性差异。Result:Themeanbloodpressur49Conclusion:initiationoftelmisartanearlyafterastroke,didnotsignificantlylowertherateofrecurrentstrokes,othermajorvasculareventsornewdiabetes。

中风后早期服用替米沙坦并不能显著的阻止中风复发，及其他血管事件和新法糖尿病。Conclusion:initiationoftelm50Highcholesterol1.HeartProtectionStudy(HPS)Total20536high-riskpatients,3280patientshadTIAorstrokeand1820ofthemwithoutconcomitantCHD.共20536高危病人，其中3280具有TIA或卒中病史，1820没有伴随心脏疾病。TheRRRachievedbysimvastatingivenfor5yearsforvasculareventswas20%andtheabsoluteriskreduction5.1%.给予辛伐他汀组（连续5年）血管事件相对危险度下降了20%，绝对危险度下降了5.1%.Highcholesterol1.HeartProtec512.SPARCL

(StrokePreventionbyAggressiveReductioninCholesterolLevels)Method:4731patientswithTIAorstrokewithoutCHDandLDLcholesterollevelsbetween100and190mg/dl.Thepatientsreceivedeither80mgatorvastatinorplacebo.

4731个具有TIA或中风病史排除心脏病且LDL在100~190mg/dl被分为80mg阿托伐他汀组和安慰剂组.

Followedupperiod:averageof4.9y.Result:theprimaryendpoint(stroke)wasreducedby16%relativeand2.2%absolute.第一终点事件卒中发生率下降的相对值和绝对值分别为16%和2.2%2.SPARCL(StrokePreventionby52HPSVSSPARCLTherateofischaemicstrokewasreduced(218versus274)whereashaemorrhagicstrokesweremorefrequentwithatorvastatin(55versus33).这两个临床试验相比，阿托伐他汀组的卒中发生下降了相对要高一点，但发生出血性卒中的数目确相对多一点。HPSVSSPARC53TherapywithastatinshouldbeinitiatedearlyafteranischaemicstrokeorTIA.Thesuddendiscontinuationofastatininpatientswithastrokeoracutecoronarysyndromemightbeassociatedwithhighermorbidityandmortality.

Discontinuationofstatintreatmentinstrokepatients.Stroke2006在初发中风后对具有血脂异常者应尽早开始服用他汀类调脂。具有中风或冠心病的患者突然停用他汀类会出现比较高的复发率和致死率。

Therapywithastatinshou54Diabetes

mellitusRandomizedcontrolledstudieswereunabletoshowaneffectofglitazones列酮类onvasculareventsinstrokepatientswithdiabetesmellitusEffectsofpioglitazoneGlitazonesinpatientswithtype2diabeteswithorwithoutpreviousstroke:resultsfromPROACTIVE.Stroke2007;38

一随机对照研究未能发现服用列酮类降糖药能明显降低具有糖尿病的中风患者的血管事件的发生率。Aggressiveloweringofbloodglucosedoesnotreducetheriskofstrokeandmightevenincreasemortality.Intensivebloodglucosecontrolandvascularoutcomesinpatientswithtype2diabetes.NEnglJMed2008;358

过分降糖不但不会降低卒中的风险反而会增加恶性事件。DiabetesmellitusRandomize55SupplementationofvitaminsTheVISPstudywasunabletoshowabenefitofthetreatmentofhighhomocysteineinstrokepatientswithBvitaminsandfolicacid.

VISP的研究表明具有高同型半胱氨酸的中风患者服用维生素B和叶酸未能额外获益。TheHOPE-2studyalsofailedtodemonstratebenefit.

TheHeartOutcomesPreventionEvaluation(HOPE)2Investigators.HomocysteineloweringwithfolicacidandBvitaminsinvasculardisease.NEnglJMed2006;354

HOPE-2研究也得出与VISP基本相同的结论。Supplementationofvitamins56EffectoffolicacidandBvitaminsonriskofcardiovasculareventsandtotalmortalityamongwomenathighriskforcardiovasculardisease:arandomizedtrial.

JAMA2008;299:2027–2036

叶酸和维生素B在具有高风险心血管疾病女性受试者中对心血管事件和总致死率的效果included5522patientsaged>55yearsandavasculareventordiabetesmellitus包含5522例具有血管事件或糖尿病年龄大于55岁的女性受试者treatedthemfor5yearswitheitherplaceboor2.5mgfolicacid,50mgvitaminB6and1mgvitaminB12.对照组服用安慰剂，治疗组服用2.5mg叶酸,50mg维生素B6and1mg维生素B12.resultedinasignificantreductioninhomocysteinelevelsbutnotinvascularevents.

结果：同型半胱氨酸水平下降但血管事件未明显下降。EffectoffolicacidandBvit57Hormonereplacementtherapyaftermenopause

关于女性中风患者的一项随机安慰剂对照研究提示，绝经后采取激素替代疗法疗法会增加中风的死亡率，并给非致死性卒中带来较差的预后。Hormonereplacementtherapyaf58Antiplatelet

therapy1.TheMATCHstudy:Object:high-riskpatientswithTIAorischaemicstrokeAim:clopidogrel75mg+ASA75mgPKclopidogrel75Result:combinationtherapyfailedtoshowsuperiorityonendpointvascularevent.

联合用药组未能体现在降低血管性终点事件中的优势。反而出血性并发症的发生率较高。Reverselyresultedinasignificantincreaseinbleedingcomplications.-------notrecommended.Antiplatelettherapy1.TheMATC592.CHARISMA

(ClopidogrelforHighAtherothromboticRiskandIschemicStabilization,ManagementandAvoidance)

atrialcombinedprimaryandsecondarypreventionAim:clopidogrel+ASAPKASAResult:Combinationtherapyfailedtoshowabenefitanddisplayedahigherbleedingrate.联合用药治疗未能明显获益。出血性并发症的发生率较高。Symptomaticpatientsshowedatrendtowardsabenefitforcombinationantiplatelettherapy.

但在症状性中风患者表现出一定的优势。2.CHARISMA(ClopidogrelforHi603.ESPS2(thesecondEuropeanstrokepreventionstudy)Method:6602patientswithTIAorstrokewererandomizedtoASA(25mgbid),ER-DP(200mgbid),ASA+ER-DPorplacebo.

6602例TIA或中风病人随机分为ASA组，ER-DP组、二者联用组及安慰剂组。Result:Fortheprimaryendpointstroke,ASA+ER-DPwassuperiortoASAandplacebo

对第一终点事件卒中来说，联用效优。ASAloweredtheriskofstrokeby18%anddipyridamolemonotherapyby16%.BleedingcomplicationswereseenmorefrequentlywithASAandtheASA+ER-DP,DPhadasimilarbleedingrateasplacebo

ASA及联用组出血性并发症较高，DP较低。3.ESPS2(thesecondEuropeans614.Ahead-toheadcomparisonofclopidogrelwithASA+ER-DP

(performedinthePRoFESSstudy)Method:Randomized20332patientswithischaemicstrokeandfollowedforameanperiodof2.4y.Result:Therewasnodifferenceinefficacyacrossallendpointsandvarioussubgroupsofpatients.

在所有终点事件的发生发面两者之间没有明显差异。ASA+ER-DPresultedinmoreintracranialbleedingsandahigherdropoutrateduetoheadachecomparedwithclopidogrel(5.9%versus0.9%).

与clopidogrel相比ASA+ER-DP的颅内出血率和因于头疼的脱落率较高。4.Ahead-toheadcomparisonof621.EuropeanAtrialFibrillationtrial

(randomizedplacebo-controlledtrial)Numbersneededtotreat(NNT)are12/year.Result:

warfarin:RRR68%V300mgASA:RRR19%Anticoagulationincerebralischaemiaduetocardiacembolism

抗凝剂在心源性栓塞缺血性卒中患者中的应用1.EuropeanAtrialFibrillation632.TheACTIVEstudyMethod:

RandomizedpatientswithAFintoASA+clopidogrelandwarfaringroups.

将受试的具有房颤卒中病人随机分为ASA+clopidogrel和华法令组Result:

terminatedprematurelyduetoasignificantreductionofstrokeandsystemicembolisminfavourofwarfarin.

由于华法令在降低中风发生和系统性栓塞方面表现出明显的显著性差异而提前终止。rateofbleedingcomplicationswasnotdifferentbetweenthetworegimens.