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黄立安教授缺血性脑卒中诊治进展课件

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黄立安教授缺血性脑卒中诊治进展 缺血性脑卒中 治疗缺血性脑卒中
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The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 缺血性卒中的防治进展 暨南大学附属第 一医院 神经内 科 黄立安 1 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 1.脑梗死是综合征 • 脑梗死--是一组突然起 病的脑血液循环障碍 性疾病,表现为急性 起病、迅速出现局限 性神经功能缺失症状 和体征,甚至伴发意 识障碍。 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 脑梗死是综合征 • 一组疾病共同的临床病理状态 • 多种病因:高血压、动脉硬化、心脏病、 糖尿病、动脉炎 ┄ • 不同发病机制:栓塞、血栓形成、低灌注┄ • 众多临床征象组合的综合征:受累血管及梗塞 的部位、大小、侧支循环病变出现偏瘫、失语 、偏身感觉障碍、吞咽困难、抽搐、昏迷、、 、 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 脑梗死是综合征 病因繁多 2. 心脏病43(2):154-160 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 概述 • 脑梗死二级预防的关键在于对脑梗死病因的诊断 及危险因素的认识,医生应充分利用现有的有循 证医学证据的检查手段,对患者进行全面的风险 评估及病因诊断,针对不同病因,并根据危险因 素的多寡和严重程度,对不同复发风险的患者进 行分层,制定出具有针对性的个体化的治疗方案 。 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 二级预防—策略及六要素 • 策略 – 寻找和去除危险因素 – 抗栓治疗(心源性:抗凝剂;非心源性:抗血 小板) • 六要素 – 三大基石:抗血小板、他汀、降压 – 三个理念:分层、长期、依从指南 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 缺血性梗死/TIA二级预防策略-抗栓治疗 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 二级预防-抗栓治疗(非心源性) The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 抗血小板药物的选择 基于危险因素的风险分层评估: Essen评分 1. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events Lancet 1996;348:1329-1339 3分可作为更高危 的分界线 其他评分系统 二级预防 抗栓治疗 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. Diener HC, et al. Clopidogrel for the secondary prevention of stroke. Expert Opin Pharmacother, 2005,6(5):755-764. ESSEN3分的高危患者, 预防梗死再发,波立维优于阿司匹林 CAPRIE :缺血性梗死患者的ESSEN分析 基于CAPRIE亚组6431位梗死患者,ESSEN评分6的梗死极高危患者比例较低(仅96位患者,占1.4%),未纳入★ 12 10 8 6 4 2 0 0 123 456 ESSEN 波立维 75mg 阿司匹林 325mg 波立维优于阿司匹林 梗 死 事 件 率/ 年 (% ) The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 2010中国缺血性梗死/TIA二级预防指南推荐意见 IA 对于非心源性栓塞性缺血性梗死或TIA患者,除少数情况需要抗凝治疗,大多 数情况均建议给予抗血小板药物预防缺血性梗死/TIA复发 抗血小板药物的选择以单药治疗为主,氯吡格雷(75 mg/d)、阿司匹林(50~ 325 mg/d)都可以做为首选药物 有证据表明氯吡格雷优于阿司匹林,尤其对于高危患者获益更显著 不推荐常规应用双重抗血小板药物。但对于有急性冠状动脉疾病(例如不稳定 型心绞痛,无Q波心肌梗死)或近期有支架成形术的患者,推荐联合应用氯吡 格雷+阿司匹林 IA IA 非心源性缺血性梗死/TIA的抗栓治疗 中华医学会神经病学分会脑血管病学组指南写作组,2010中国缺血性梗死/短暂性脑 缺血发作二级预防指南,中华神经病学杂志 2010;43(2):1-7 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 二级预防-血压 • 推荐意见: • (1)对于缺血性脑梗死和TIA,建议进行抗高血压治疗,以 降低脑梗死和其他血管事件复发的风险(I级推荐,A级证 据)。在参考高龄、基础血压、平时用药、可耐受性的情 况下,降压目标一般应该达到≤140mmHg,理想应达到 ≤130/80mm Hg(II级推荐,B级证据)。 • (2)降压治疗预防脑梗死和TIA复发的益处主要来自于降压 本身(I级推荐,A级证据)。建议选择单药或联合用药进行 抗高血压治疗(Ⅱ级推荐,B级证据)。具体药物的选择和 联合方案应个体化。 梗死和短暂性脑缺血发作二级预防指南 2010 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. l积极平稳控制过高的血压 l防止降压过低、过快 l严密监测血压变化,尤其在降压治疗过程中 l降压宜缓慢进行,避免导致脑缺血 l个体化治疗 l降压过程中注意心、脑、肾等靶器官的保护 l采用长效降压药物,既要有效、持久地降压,又不影响重 要器官的血流量 脑梗死患者血压调控的处理原则 中国脑血管病防治指南2007:61 29 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 梗死二梗死二级预级预级预级预 防中降防中降压药压药压药压药 物分物分层层层层 选择选择选择选择 严严重脑脑供血 动动脉狭窄 非低灌注 事件 低灌注 事件 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 其它缺血性梗死/TIA (除外心源性梗死) 缺血性梗死/TIA,伴以下任一 危险因素: •颅内外动脉粥样硬化 •糖尿病 •冠心病 •代谢综合征 •持续吸烟 缺血性梗死/TIA,属于以下 任一种情况: •有动脉-动脉栓塞证据 •有脑动脉粥样硬化易损斑块证据 临床描述 2.1mmol/L (80mg/dl) 强化 立即启动 标准 2.6mmol/L (100mg/dl) 高危 LDL-C 目标值 他汀 治疗方案 启动他汀 的LDL-C值 危险分层 极 高 危 (I) 极 高 危 (II) 高 危 40% 2010 中国《缺血性梗死和TIA二级预防指南》 血脂----分层诊治和目标 中华神经科杂志.2010;43(2):1-7. 动脉粥样 硬化人群 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. LDL-C100mg/dl者使用 具有强化降脂效果的他汀 LDL-C下降≥50% 或LDL-C70mg/dL 缺血性梗死 大动脉 粥样硬化 小动脉 闭塞 心源性 栓塞 其他原因或 原因不明 参照 ATPIII 有 2 是否有其 他AS证据 1 无 2011 AHA/ASA2011 AHA/ASA《《缺血性梗死和缺血性梗死和TIATIA二级预防指南二级预防指南》》 血脂血脂--------诊治标准和流程诊治标准和流程 Furie KL, et al. Stroke. 2011;42:00-00 首先进行分型 寻找其他 AS证据 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 二级预防—血糖 • 推荐意见: • (1)糖尿病血糖控制的靶目标为HbAc6.5%,但对于高 危2型糖尿病患者血糖过低可能带来危害(增加病死率,l级 推荐,A级证据)。 • (2)糖尿病合并高血压患者应严格控制血压在130/80 mmHg以下,糖尿病合并高血压时,降血压药物以血管紧 张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂类在降低心 脑血管事件方面获益明显(I级推荐,A级证据)。在严格控 制血糖、血压的基础上联合他汀类药物可以降低脑梗死的 风险(I级推荐,A级证据)。 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 二级预防-大动脉粥样硬化性脑梗死非药物治疗 颈动脉内膜剥脱术 颅内外动脉狭窄血管内治疗:颈动脉血管成形及支 架植入术 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 特殊情况下脑梗死二级预防治疗 • 动脉夹层 • 卵圆孔未闭 • 高同型半胱氨酸血症 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 世界梗死日宣言 2004年6月24日,温哥华 确保将现有的知识付诸实践 预防是最值得去做的,但是预防被极大地忽视了,尤其是在发展中国家 因此,我们需要: 1.鼓励健康的生活方式 2.使用一级预防和二级预防中的有效药物,可惜的是在发展中国家这些药物不能 得到或不能提供,在发达国家这些药物也不能合理应用 3.遏制未经证实的、高花费的或错误的做法,因为这些做法消耗了有限的资源 4.通过公共词汇、核心教程、在线资料、远程教育和临床观摩学习来全面教育健 康职业者 The guiding ideology should be guided by Deng Xiaoping's theory, the important thought of “three represents“ and the spirit of the 16th CPC National Congress and the third Plenary session of the 16th CPC Central Committee. 谢谢 谢谢 CV-1103-BE-0090 37
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