急性脑梗死课件

急性脑梗死急性脑梗死优选急性脑梗死21优选急性脑梗死21第一节急性脑梗死的概述是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。占脑卒中的85%。85%预后是好的，15%的缺血脑卒中预后差，死亡率高。31第一节急性脑梗死的概述是由于局部脑血流中断引起,时间超过第二节急性脑梗死的病因脑动脉粥样硬化：高血压、高血脂、吸烟小血管玻璃样变：高血压、糖尿病低灌注性脑梗死：动脉狭窄心源性脑栓塞：冠心病、风心病血管炎：SLE、结核、螺旋体动脉炎其它：避孕药。41第二节急性脑梗死的病因脑动脉粥样硬化：高血压、高血脂、吸第三节急性脑梗死的分类OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死ASCO：A-动脉硬化，S-小血管，C-心源性，O-其它51第三节急性脑梗死的分类OCSP：按临床症状分：完全前循环第四节急性脑梗死的诊断血脂、糖代谢、HCY心脏、血管彩超头颅CT及CTA头颅MRI及MRADSA61第四节急性脑梗死的诊断血脂、糖代谢、HCY617171pravastatin40Within24hoursEffectsincriticallyillpatientsDurationforbetween3and5days中山大学附属第三医院神经病学科Grayetal.Drugs2003;63:625-636超早期溶栓治疗AmJCardiol.是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。pleiotropiceffectsbeyondtheireffectsoncholesterollevelsOCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死follow-up：>or=1year>or=2medicationswithdifferentmechanismsofactionwillbenecessaryPreventstrokeandimproveoutcomeBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)腔隙性脑梗死：21型，常见有5型。Secondarystrokepreventionofantithrombotics完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）Stroke2004;35:122OCSP完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）部分前循环：皮层枝或深穿支完全后循环：四肢瘫痪、眩晕、意识障碍腔隙性脑梗死：21型，常见有5型。81pravastatin40OCSP完全前循环：意识障碍、眼球

急性脑梗死的治疗陆正齐中山大学附属第三医院神经病学科

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急性脑梗死的治疗91脑梗死的急性期治疗超早期溶栓治疗抗栓治疗他汀类药物抗高血压药物控制高血糖抗炎神经保护剂脱水问题101脑梗死的急性期治疗超早期溶栓治疗101超早期溶栓治疗111超早期溶栓治疗111抗栓治疗TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.121抗栓治疗Theannualizedrates

Design13studiesfollow-up：>or=1yeartocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)

131Design13studies131Totalbleedingrate4.8%-aspirin(<or=325mg/day)2.9%-clopidogrel3.6%-aspirinplusER-DP10.1%-aspirinplusclopidogrel16.8%-anticoagulation141Totalbleedingrate4.8%-aspiriMajorbleedingrate1%-aspirin(<or=325mg/day)0.85%-clopidogrel0.93%-aspirinplusER-DP1.7%-aspirinplusclopidogrel2.5%-anticoagulation

151Majorbleedingrate1%-aspiriConclusionThecombinationofaspirinandclopidogrelisassociatedwithsignificantlygreaterbleedingthaneitheraspirin(<or=325mg/day)orclopidogrelalone.AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alone

161ConclusionThecombinationofaProton-pumpinhibitors(PPIs)andclopidogrel

13,608patients33%(n=4529)ofpatientswereonaPPIatrandomisationNoassociationexistedbetweenPPIuseandriskoftheprimaryendpointThecurrentfindingsdonotsupporttheneedtoavoidconcomitantuseofPPIs

Lancet.2009Sep19;374(9694):989-97.Epub2009Aug31171Proton-pumpinhibitors(PPIs)181181

StatinsforstrokePleiotropiceffectsPreventORtreatment?criticallyillpatients?肾病血透病人及肾移植病人?出血性卒中?大剂量与标准剂量?191StatinsforstrokePleiotrpleiotropiceffectsofstatinspleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities201pleiotropiceffectsofstatinsPreventstrokeandimproveoutcomestatinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality211Preventstrokeandimproveout33%(n=4529)ofpatientswereonaPPIatrandomisationDrugs2003;63:625-636Grayetal.MesottenD,VandenBergheG.血管炎：SLE、结核、螺旋体动脉炎statinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheevent93%-aspirinplusER-DPsimvastatin89Proton-pumpinhibitors(PPIs)andclopidogrelAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce04vsplacebo)andtotalstroke(24%,P=.Baselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)atorvastatin10statinsreducetheriskofmyocardialinfarctionandstrokePreventstrokeandimproveoutcome68687/68721OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alonePreventiveantibioticsinpatientswithacutestrokeEffectsincriticallyillpatientsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockersEffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins22133%(n=4529)ofpatientswere研究名称出版时间处理因素mg对照因素mg平均随访时间（年）病例数(I/C)平均年龄(岁)男性比例（%）基础LDHMg/dl卒中病例数(I/C)致死卒中(I/C)脑出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰剂3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰剂510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰剂3.35168/5137638113389/121....ALERT2003fluvastatin40安慰剂5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰剂3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰剂22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰剂4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰剂4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰剂41211/1199616611334/38....MEGA2006simvastatin87饮食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰剂2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰剂1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰剂3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合计......4.168687/6872164691242226/2604354/385186/166231研究名称出版时间处理因素对照因素平均随访时间（年）病例数(I他汀与安慰剂或空白对照比较对所有卒中预防的meta分析

241他汀与安慰剂或空白对照比较对所有卒中预防的meta分析244个研究大剂量与标准剂量他汀对所有卒中预防的meta分析

2514个研究大剂量与标准剂量他汀对所有卒中预防的meta分析2ControllingBPforstroke>or=2medicationswithdifferentmechanismsofactionwillbenecessaryRAAShaveproventobeexcellenttherapeutictargetsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockerscombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsAmHeartJ.2009Jun;157(6Suppl):S24-30261ControllingBPforstroke>orCumulativeproportionsofpatientsprescribednewmedicationnewstatin(adding)clopidogrelnewBPloweringmed.2newBPloweringmed.EXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42271Cumulativeproportionsofpati

ACEIsclinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.281ACEIsclinicalevidencesuIVformulationofHydrophilicstatins小血管玻璃样变：高血压、糖尿病MesottenD,VandenBergheG.Preventstrokeandimproveoutcome33%(n=4529)ofpatientswereonaPPIatrandomisationGrayetal.clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.ManagementofhyperglycemiaincriticallyillpatientsEpub2009Aug31Within24hoursMajorbleedingrateTheStudyonCognitionandPrognosisinEXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42腔隙性脑梗死：21型，常见有5型。1mmol/L[80‑110mg/dL])simvastatin402009Sep;66(9):1076-81Combinationtherapyresultedina2.Grayetal.9%-clopidogrelARBs

andischemicstrokepreventionTheStudyonCognitionandPrognosisintheElderly(SCOPE)assessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.SCOPEtrialassessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.Activetreatmentwasassociatedwithasignificantreductioninnonfatalstroke(28%,P=.04vsplacebo)andtotalstroke(24%,P=.056vsplacebo).291IVformulationofHydrophilicPRoFESStriallimitationsDiastolicBP(<80mmHg)inthefirstmonthpost-strokemayhavebeentoolowinatleastonethirdofthepopulationBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)301PRoFESStriallimitations301CombinationACEI/ARBtherapyCombinationtherapyresultedina2.4/1.4-mmHggreaterdecreaseinBPcomparedwithramiprilaloneAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce311CombinationACEI/ARBtherapyCoMeta-analysis4randomizedclinicaltrialsincluding426patients.94%hadischemicstrokeFluoroquinolonesin2andtetracyclineoracombinationofbeta-lactamantibioticwithbeta-lactamaseinhibitorin1Within24hoursDurationforbetween3and5daysArchNeurol.2009Sep;66(9):1076-81Preventiveantibioticsinpatientswithacutestroke321Meta-analysisArchNeurol.2009控制高血糖331控制高血糖331ManagementofhyperglycemiaincriticallyillpatientsAbetterlong-termoutcomewasshowninpatientswhosufferedfromMIandwhounderwentmeticulousbloodglucosecontrol1,548surgicalintensivecarepatientshadbeenrandomlyallocatedtoeithertheconventionalapproach(insulininfusionstartedonlywhenbloodglucoselevelsexceeded12mmol/L)orintensiveinsulintherapy(insulininfusedtomaintainbloodglucoseatalevelof4.5-6.1mmol/L[80‑110mg/dL])Intensiveinsulintherapyreducedintensivecaremortalitybymorethan40%

MesottenD,VandenBergheG.Clinicalpotentialofinsulintherapyincriticallyillpatients.Drugs2003;63:625-636

341ManagementofhyperglycemiaintherapyonCVeventsinelderlypatients.immunomodulationandantiinflammationsimvastatin20PleiotropiceffectsArchNeurol.newBPloweringmed.simvastatin872007May;6(5):397-406.combinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrials33%(n=4529)ofpatientswereonaPPIatrandomisation6%-aspirinplusER-DP血管炎：SLE、结核、螺旋体动脉炎Effectsincriticallyillpatients>or=2medicationswithdifferentmechanismsofactionwillbenecessaryTheStudyonCognitionandPrognosisinPreventstrokeandimproveoutcomestemcell-regulatingcapacities完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）pravastatin40第一节急性脑梗死的概述IntravenousinsulinisfeasibleandachieveseuglycemiainstrokeGrayetal.Stroke2004;35:122Brunoetal.Neurology2004;62:1441351therapyonCVeventsinelderlGlucose-Potassium-Insulininfusioninthemanagementofpoststrokehyperglycemia:theUKGlucoseInsulininStrokeTrial(GIST-UK).

LancetNeurol.2007May;6(5):397-406.

361Glucose-Potassium-Insulininf神经保护剂古老的神经保护剂新型神经保护剂371神经保护剂古老的神经保护剂371古老的神经保护剂胞二磷胆碱依达拉奉381古老的神经保护剂胞二磷胆碱381新型神经保护剂激肽系统RhoproteinsEPO、CEPOG-csf391新型神经保护剂激肽系统391第四节急性脑梗死的诊断Baselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)10269/10267simvastatin89MajorbleedingrateProton-pumpinhibitors(PPIs)andclopidogrelimmunomodulationandantiinflammationSecondarystrokepreventionofantithromboticsDurationforbetween3and5daysBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)SecondarystrokepreventionofantithromboticsTheStudyonCognitionandPrognosisin9%-clopidogrel93%-aspirinplusER-DP5%-anticoagulationsimvastatin86pleiotropiceffectsbeyondtheireffectsoncholesterollevelsantioxidantEpub2009Aug31PRoFESStriallimitations2009Sep;66(9):1076-81Effectsincriticallyillpatientssimvastatin81EffectsincriticallyillpatientsMesottenD,VandenBergheG.SecondarystrokepreventionofantithromboticsAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreducecombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsstemcell-regulatingcapacities(adding)clopidogrel中山大学附属第三医院神经病学科clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.低灌注性脑梗死：动脉狭窄tocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)第一节急性脑梗死的概述Neurology2004;62:1441stemcell-regulatingcapacitiessimvastatin90PRoFESStriallimitationsSecondarystrokepreventionofantithrombotics肾病血透病人及肾移植病人?脱水问题一般不脱。401第四节急性脑梗死的诊断Effectsincritic急性脑梗死急性脑梗死优选急性脑梗死421优选急性脑梗死21第一节急性脑梗死的概述是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。占脑卒中的85%。85%预后是好的，15%的缺血脑卒中预后差，死亡率高。431第一节急性脑梗死的概述是由于局部脑血流中断引起,时间超过第二节急性脑梗死的病因脑动脉粥样硬化：高血压、高血脂、吸烟小血管玻璃样变：高血压、糖尿病低灌注性脑梗死：动脉狭窄心源性脑栓塞：冠心病、风心病血管炎：SLE、结核、螺旋体动脉炎其它：避孕药。441第二节急性脑梗死的病因脑动脉粥样硬化：高血压、高血脂、吸第三节急性脑梗死的分类OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死ASCO：A-动脉硬化，S-小血管，C-心源性，O-其它451第三节急性脑梗死的分类OCSP：按临床症状分：完全前循环第四节急性脑梗死的诊断血脂、糖代谢、HCY心脏、血管彩超头颅CT及CTA头颅MRI及MRADSA461第四节急性脑梗死的诊断血脂、糖代谢、HCY6147171pravastatin40Within24hoursEffectsincriticallyillpatientsDurationforbetween3and5days中山大学附属第三医院神经病学科Grayetal.Drugs2003;63:625-636超早期溶栓治疗AmJCardiol.是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。pleiotropiceffectsbeyondtheireffectsoncholesterollevelsOCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死follow-up：>or=1year>or=2medicationswithdifferentmechanismsofactionwillbenecessaryPreventstrokeandimproveoutcomeBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)腔隙性脑梗死：21型，常见有5型。Secondarystrokepreventionofantithrombotics完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）Stroke2004;35:122OCSP完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）部分前循环：皮层枝或深穿支完全后循环：四肢瘫痪、眩晕、意识障碍腔隙性脑梗死：21型，常见有5型。481pravastatin40OCSP完全前循环：意识障碍、眼球

急性脑梗死的治疗陆正齐中山大学附属第三医院神经病学科

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急性脑梗死的治疗91脑梗死的急性期治疗超早期溶栓治疗抗栓治疗他汀类药物抗高血压药物控制高血糖抗炎神经保护剂脱水问题501脑梗死的急性期治疗超早期溶栓治疗101超早期溶栓治疗511超早期溶栓治疗111抗栓治疗TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.521抗栓治疗Theannualizedrates

Design13studiesfollow-up：>or=1yeartocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)

531Design13studies131Totalbleedingrate4.8%-aspirin(<or=325mg/day)2.9%-clopidogrel3.6%-aspirinplusER-DP10.1%-aspirinplusclopidogrel16.8%-anticoagulation541Totalbleedingrate4.8%-aspiriMajorbleedingrate1%-aspirin(<or=325mg/day)0.85%-clopidogrel0.93%-aspirinplusER-DP1.7%-aspirinplusclopidogrel2.5%-anticoagulation

551Majorbleedingrate1%-aspiriConclusionThecombinationofaspirinandclopidogrelisassociatedwithsignificantlygreaterbleedingthaneitheraspirin(<or=325mg/day)orclopidogrelalone.AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alone

561ConclusionThecombinationofaProton-pumpinhibitors(PPIs)andclopidogrel

13,608patients33%(n=4529)ofpatientswereonaPPIatrandomisationNoassociationexistedbetweenPPIuseandriskoftheprimaryendpointThecurrentfindingsdonotsupporttheneedtoavoidconcomitantuseofPPIs

Lancet.2009Sep19;374(9694):989-97.Epub2009Aug31571Proton-pumpinhibitors(PPIs)581181

StatinsforstrokePleiotropiceffectsPreventORtreatment?criticallyillpatients?肾病血透病人及肾移植病人?出血性卒中?大剂量与标准剂量?591StatinsforstrokePleiotrpleiotropiceffectsofstatinspleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities601pleiotropiceffectsofstatinsPreventstrokeandimproveoutcomestatinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality611Preventstrokeandimproveout33%(n=4529)ofpatientswereonaPPIatrandomisationDrugs2003;63:625-636Grayetal.MesottenD,VandenBergheG.血管炎：SLE、结核、螺旋体动脉炎statinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheevent93%-aspirinplusER-DPsimvastatin89Proton-pumpinhibitors(PPIs)andclopidogrelAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce04vsplacebo)andtotalstroke(24%,P=.Baselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)atorvastatin10statinsreducetheriskofmyocardialinfarctionandstrokePreventstrokeandimproveoutcome68687/68721OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alonePreventiveantibioticsinpatientswithacutestrokeEffectsincriticallyillpatientsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockersEffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins62133%(n=4529)ofpatientswere研究名称出版时间处理因素mg对照因素mg平均随访时间（年）病例数(I/C)平均年龄(岁)男性比例（%）基础LDHMg/dl卒中病例数(I/C)致死卒中(I/C)脑出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰剂3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰剂510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰剂3.35168/5137638113389/121....ALERT2003fluvastatin40安慰剂5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰剂3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰剂22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰剂4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰剂4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰剂41211/1199616611334/38....MEGA2006simvastatin87饮食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰剂2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰剂1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰剂3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合计......4.168687/6872164691242226/2604354/385186/166631研究名称出版时间处理因素对照因素平均随访时间（年）病例数(I他汀与安慰剂或空白对照比较对所有卒中预防的meta分析

641他汀与安慰剂或空白对照比较对所有卒中预防的meta分析244个研究大剂量与标准剂量他汀对所有卒中预防的meta分析

6514个研究大剂量与标准剂量他汀对所有卒中预防的meta分析2ControllingBPforstroke>or=2medicationswithdifferentmechanismsofactionwillbenecessaryRAAShaveproventobeexcellenttherapeutictargetsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockerscombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsAmHeartJ.2009Jun;157(6Suppl):S24-30661ControllingBPforstroke>orCumulativeproportionsofpatientsprescribednewmedicationnewstatin(adding)clopidogrelnewBPloweringmed.2newBPloweringmed.EXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42671Cumulativeproportionsofpati

ACEIsclinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.681ACEIsclinicalevidencesuIVformulationofHydrophilicstatins小血管玻璃样变：高血压、糖尿病MesottenD,VandenBergheG.Preventstrokeandimproveoutcome33%(n=4529)ofpatientswereonaPPIatrandomisationGrayetal.clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.ManagementofhyperglycemiaincriticallyillpatientsEpub2009Aug31Within24hoursMajorbleedingrateTheStudyonCognitionandPrognosisinEXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42腔隙性脑梗死：21型，常见有5型。1mmol/L[80‑110mg/dL])simvastatin402009Sep;66(9):1076-81Combinationtherapyresultedina2.Grayetal.9%-clopidogrelARBs

andischemicstrokepreventionTheStudyonCognitionandPrognosisintheElderly(SCOPE)assessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.SCOPEtrialassessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.Activetreatmentwasassociatedwithasignificantreductioninnonfatalstroke(28%,P=.04vsplacebo)andtotalstroke(24%,P=.056vsplacebo).691IVformulationofHydrophilicPRoFESStriallimitationsDiastolicBP(<80mmHg)inthefirstmonthpost-strokemayhavebeentoolowinatleastonethirdofthepopulationBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)701PRoFESStriallimitations301CombinationACEI/ARBtherapyCombinationtherapyresultedina2.4/1.4-mmHggreaterdecreaseinBPcomparedwithramiprilaloneAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce711CombinationACEI/ARBtherapyCoMeta-analysis4randomizedclinicaltrialsincluding426patients.94%hadischemicstrokeFluoroquinolonesin2andtetracyclineoracombinationofbeta-lactamantibioticwithbeta-lactamaseinhibitorin1Within24hoursDurationforbetween3and5daysArchNeurol.2009Sep;66(9):1076-81Preventiveantibioticsinpatientswithacutestroke721Meta-analysisArchNeurol.2009控制高血糖731控制高血糖331ManagementofhyperglycemiaincriticallyillpatientsAbetterlong-termoutcomewasshowninpatientswhosufferedfromMIandwhounderwentmeticulousbloodglucosecontrol1,548surgicalintensivecarepatientshadbeenrandomlyallocatedtoeithertheconventionalapproach(insulininfusionstartedonlywhenbloodglucoselevelsexceeded12mmol/L)orintensiveinsulintherapy(insulininfusedtomaintainbloodglucoseatalevelof4.5-6.1mmol/L[80‑110mg/dL])Intensiveinsulintherapyreducedintensivecaremortalitybymorethan40%

MesottenD,VandenBergheG.Clinicalpotentialofinsulintherapyincriticallyillpatients.Drugs2003;63:625-636

741ManagementofhyperglycemiaintherapyonCVeventsinelderlypatients.immunomodulationandantiinflammationsimvastatin20PleiotropiceffectsArchNeurol.newBPloweringmed.simvastatin872007May;6(5):397-406.combinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrials33%(n=4529)ofpat