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本文是《第7届ACCP抗栓和溶栓治疗会议:循证指南》的一部分,阐述卒中的预防和治疗。1级推荐最强,表示益处确实超过(或不超过)风险、负担和花费。2级推荐提示对个体化患者的评价可能导致选择差异(阅读Guyatt等的推荐等级说明有助于充分理解)。以下为本文包括的关键推荐:对于急性缺血性卒中(AIS)患者,如果是在确定的发病3h内,推荐给予静脉注射(IV)组织型纤溶酶原激活剂(tPA)治疗(1A级)。对于CT存在广泛而清晰可辨的低密度灶的患者,推荐不采用溶栓治疗(1B级)。对于未经选择的发病3~6h的AIS患者,推荐临床医生不采用IVtPA治疗(2A级)。对于AIS患者,推荐不使用链激酶治疗(1A级),同时推荐临床医生不要应用IV或皮下注射肝素或类肝素进行足量抗凝治疗(2B级)。对于那些未接受溶栓治疗的AIS患者,推荐早期应用阿司匹林治疗,剂量为160~325mg,1次/d(1A级)。对于活动受限的AIS患者,推荐预防性皮下注射小剂量肝素、低分子肝素或类肝素(1A级);而对于那些存在抗凝禁忌证的患者,推荐使用间歇性充气加压装置或弹力长袜(1C级)。对于急性脑内血肿患者,推荐开始应用间歇性充气加压装置(1C+级)。对于非心源性栓塞性卒中或短暂性脑缺血发作(TIA)[即动脉粥样硬化性血栓形成、腔隙性或原因不明性卒中]患者,推荐使用抗血小板药(1A级),包括阿司匹林50~325mg,1次/d;阿司匹林+缓释型双嘧达莫联合应用,25mg/200mg,2次/d;或氯吡格雷75mg,1次/d。对于这些患者,推荐阿司匹林+缓释型双嘧达莫联合应用25mg/200mg,2次/d,效果优于阿司匹林(2A级);氯吡格雷优于阿司匹林(2B级)。对于阿司匹林过敏者,推荐应用氯吡格雷(1C+级)。对于最近发生过卒中或TIA的心房颤动患者,推荐长期口服抗凝药治疗(目标国际标准化比率2·5,范围2·0~3·0)(1A级)。对于静脉窦血栓形成患者,推荐在急性期应用普通肝素(1B级)或低分子肝素(1B级),效果优于非抗凝疗法。
This article is part of the Seventh ACCP Antithrombotic and Thrombolytic Therapy Meeting: Evidence-based Guidance, describing stroke prevention and treatment. Level 1 is the most recommended, meaning that the benefits do exceed (or exceed) the risks, burdens and costs. Level 2 Recommendations Hints on individualized patients may lead to differences in selections (reading Guyatt’s recommendation for rating helps to fully understand). The following is a summary of the key recommendations included in this article: Intravenous (IV) Tissue Plasminogen Activator (tPA) is recommended for patients with acute ischemic stroke (AIS) within 3 hours of established onset (Grade 1A ). Thrombolytic therapy (Grade 1B) is not recommended for patients with extensive and legible low-density CT lesions. For unselected patients with AIS 3 to 6 hours after onset, it is recommended that clinicians not use IVtPA (Grade 2A). For patients with AIS, it is not recommended to use streptokinase (Grade 1A) and clinicians are advised not to use adequate IV or subcutaneous heparin or heparin for adequate anticoagulation (Grade 2B). For patients with AIS who have not received thrombolytic therapy, early aspirin use is recommended at a dose of 160-325 mg once daily (Grade 1A). Prophylactic subcutaneous injections of low-dose heparin, low molecular weight heparins or heparinoid (Grade 1A) prophylactic subcutaneous injections are recommended for patients with limited mobility, whereas intermittent inflatable compression devices or elastic-length devices are recommended for those with anticoagulation contraindications Socks (1C level). For patients with acute intracerebral hematoma, it is recommended to start using an intermittent inflatable device (1C + level). For patients with non-cardioembolic stroke or transient ischemic attack (TIA) [ie, atherothrombotic, lacunar, or unexplained stroke], antiplatelet agents (Grade 1A) are recommended, including Aspirin 50 ~ 325mg, 1 / d; aspirin + sustained release dipyridamole combination, 25mg / 200mg, 2 times / d; or clopidogrel 75mg, 1 / d. For these patients, aspirin + sustained-release dipyridamole is recommended in combination with 25 mg / 200 mg twice daily, which is superior to aspirin (Grade 2A) and clopidogrel is superior to aspirin (Grade 2B). For aspirin allergy, clopidogrel (1C + grade) is recommended. Long-term oral anticoagulant therapy is recommended for patients with recent stroke or TIA atrial fibrillation (target international standardization ratio of 2.5, range 2.0-3.0) (Grade 1A). For patients with sinus venous thrombosis, unfractionated heparin (Grade 1B) or low molecular weight heparin (Grade 1B) is recommended for use in the acute phase and is preferred over non-anticoagulant therapy.