卒中发作及复发的风险评估与处理神经内科 马振兴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：2024/9/232 美国美国美国美国中国中国中国中国经年龄调整总的心血管疾病、冠心病、脑卒经年龄调整总的心血管疾病、冠心病、脑卒中死亡率的变化中死亡率的变化 1900-1996 美国美国标化死亡率标化死亡率(1/10万万)冠心病冠心病脑卒中脑卒中总的心血管疾病总的心血管疾病100200300400500019001920194019601990199603060901201501985 19901995 200020052010 (年年)脑卒中脑卒中冠心病冠心病2.MMWR Weekly August6, 1999 / 48(30);649-6561中国心血管病报告中国心血管病报告2005中国脑卒中和冠心病死亡率持续升高中国脑卒中和冠心病死亡率持续升高2024/9/233心房心房颤动患者卒中患者卒中风险评估及估及处理理2024/9/234年龄年龄并发症并发症危险度（无抗凝治疗的危险度（无抗凝治疗的1年危险度）年危险度）65岁无低（1%）65岁无中=75岁高血压或糖尿病高(8%)任何年龄TIA病史或脑血管病高(12%)任何年龄左房大;左室功能受损;心内血栓;瓣膜损伤;左房室瓣钙化高心房颤动患者的卒中风险心房颤动患者的卒中风险2024/9/235CHADS2评分项目项目表现表现评分评分心衰(CHF)病史无0有1高血压无0有1年龄=751糖尿病无0有1TIA或卒中病史无0有22024/9/236CHADS2评分的年卒中风险CHADS2评分评分卒中概率卒中概率(每每100患者年患者年)95%可信区间可信区间01.91.23.012.82.03.824.03.15.135.94.67.348.5 6.311.1512.5 8.217.5618.210.527.42024/9/237根据CHADS2评分及其风险程度选择治疗药物评分评分风险风险治疗药物治疗药物参考参考0低阿司匹林325mg或小一些的剂量1中阿司匹林或华法林取决于患者的意愿,INR2.03.02或以上中或高华法林INR2.03.0(无禁忌,如跌倒病史/明显的胃肠道出血/不能监测INR)2024/9/238美国胸科医美国胸科医师协会心房会心房颤动风险专家共家共识年年龄75岁既往卒中病史、既往卒中病史、TIA 或系或系统性栓塞病史性栓塞病史高血高血压病史病史糖尿病糖尿病左室功能异常左室功能异常风湿性心湿性心脏病病瓣膜修复瓣膜修复术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%2024/9/2318SCALA：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，急性缺血性卒中/TIA，不予干预，平均随访17.5个月2024/9/2319ESSEN评分的应用高危，卒中风险高危，卒中风险44中危，卒中风险中危，卒中风险44氯吡格雷75mg/d阿司匹林50-325mg/d2024/9/2320AHA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 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。（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 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 intracranial 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）2024/9/2321AHA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 perioperative 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-specific 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 revascularization 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, medical 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）2024/9/2322AHA卒中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、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）2024/9/2323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2024/9/2324