急性腦梗死課件

急性腦梗死急性腦梗死優(yōu)選急性腦梗死21優(yōu)選急性腦梗死21第一節(jié)急性腦梗死的概述是由于局部腦血流中斷引起,時(shí)間超過2小時(shí)，DWI上有表現(xiàn)。占腦卒中的85%。85%預(yù)后是好的，15%的缺血腦卒中預(yù)后差，死亡率高。31第一節(jié)急性腦梗死的概述是由于局部腦血流中斷引起,時(shí)間超過第二節(jié)急性腦梗死的病因腦動脈粥樣硬化：高血壓、高血脂、吸煙小血管玻璃樣變：高血壓、糖尿病低灌注性腦梗死：動脈狹窄心源性腦栓塞：冠心病、風(fēng)心病血管炎：SLE、結(jié)核、螺旋體動脈炎其它：避孕藥。41第二節(jié)急性腦梗死的病因腦動脈粥樣硬化：高血壓、高血脂、吸第三節(jié)急性腦梗死的分類OCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死ASCO：A-動脈硬化，S-小血管，C-心源性，O-其它51第三節(jié)急性腦梗死的分類OCSP：按臨床癥狀分：完全前循環(huán)第四節(jié)急性腦梗死的診斷血脂、糖代謝、HCY心臟、血管彩超頭顱CT及CTA頭顱MRI及MRADSA61第四節(jié)急性腦梗死的診斷血脂、糖代謝、HCY617171pravastatin40Within24hoursEffectsincriticallyillpatientsDurationforbetween3and5days中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科Grayetal.Drugs2003;63:625-636超早期溶栓治療AmJCardiol.是由于局部腦血流中斷引起,時(shí)間超過2小時(shí)，DWI上有表現(xiàn)。pleiotropiceffectsbeyondtheireffectsoncholesterollevelsOCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死follow-up：>or=1year>or=2medicationswithdifferentmechanismsofactionwillbenecessaryPreventstrokeandimproveoutcomeBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)腔隙性腦梗死：21型，常見有5型。Secondarystrokepreventionofantithrombotics完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）Stroke2004;35:122OCSP完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）部分前循環(huán)：皮層枝或深穿支完全后循環(huán)：四肢癱瘓、眩暈、意識障礙腔隙性腦梗死：21型，常見有5型。81pravastatin40OCSP完全前循環(huán)：意識障礙、眼球

急性腦梗死的治療陸正齊中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科

91

急性腦梗死的治療91腦梗死的急性期治療超早期溶栓治療抗栓治療他汀類藥物抗高血壓藥物控制高血糖抗炎神經(jīng)保護(hù)劑脫水問題101腦梗死的急性期治療超早期溶栓治療101超早期溶栓治療111超早期溶栓治療111抗栓治療TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.121抗栓治療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?腎病血透病人及腎移植病人?出血性卒中?大劑量與標(biāo)準(zhǔn)劑量?191StatinsforstrokePleiotrpleiotropiceffectsofstatinspleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities201pleiotropiceffectsofstatinsPreventstrokeandimproveoutcomestatinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality211Preventstrokeandimproveout33%(n=4529)ofpatientswereonaPPIatrandomisationDrugs2003;63:625-636Grayetal.MesottenD,VandenBergheG.血管炎：SLE、結(jié)核、螺旋體動脈炎statinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheevent93%-aspirinplusER-DPsimvastatin89Proton-pumpinhibitors(PPIs)andclopidogrelAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce04vsplacebo)andtotalstroke(24%,P=.Baselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)atorvastatin10statinsreducetheriskofmyocardialinfarctionandstrokePreventstrokeandimproveoutcome68687/68721OCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alonePreventiveantibioticsinpatientswithacutestrokeEffectsincriticallyillpatientsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockersEffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins22133%(n=4529)ofpatientswere研究名稱出版時(shí)間處理因素mg對照因素mg平均隨訪時(shí)間（年）病例數(shù)(I/C)平均年齡(歲)男性比例（%）基礎(chǔ)LDHMg/dl卒中病例數(shù)(I/C)致死卒中(I/C)腦出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰劑3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰劑510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰劑3.35168/5137638113389/121....ALERT2003fluvastatin40安慰劑5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰劑3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰劑22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰劑4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰劑4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰劑41211/1199616611334/38....MEGA2006simvastatin87飲食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰劑2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰劑1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰劑3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合計(jì)......4.168687/6872164691242226/2604354/385186/166231研究名稱出版時(shí)間處理因素對照因素平均隨訪時(shí)間（年）病例數(shù)(I他汀與安慰劑或空白對照比較對所有卒中預(yù)防的meta分析

241他汀與安慰劑或空白對照比較對所有卒中預(yù)防的meta分析244個(gè)研究大劑量與標(biāo)準(zhǔn)劑量他汀對所有卒中預(yù)防的meta分析

2514個(gè)研究大劑量與標(biāo)準(zhǔn)劑量他汀對所有卒中預(yù)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小血管玻璃樣變：高血壓、糖尿病MesottenD,VandenBergheG.Preventstrokeandimproveoutcome33%(n=4529)ofpatientswereonaPPIatrandomisationGrayetal.clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.ManagementofhyperglycemiaincriticallyillpatientsEpub2009Aug31Within24hoursMajorbleedingrateTheStudyonCognitionandPrognosisinEXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42腔隙性腦梗死：21型，常見有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、結(jié)核、螺旋體動脈炎Effectsincriticallyillpatients>or=2medicationswithdifferentmechanismsofactionwillbenecessaryTheStudyonCognitionandPrognosisinPreventstrokeandimproveoutcomestemcell-regulatingcapacities完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）pravastatin40第一節(jié)急性腦梗死的概述IntravenousinsulinisfeasibleandachieveseuglycemiainstrokeGrayetal.Stroke2004;35:122Brunoetal.Neurology2004;62:1441351therapyonCVeventsinelderlGlucose-Potassium-Insulininfusioninthemanagementofpoststrokehyperglycemia:theUKGlucoseInsulininStrokeTrial(GIST-UK).

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

361Glucose-Potassium-Insulininf神經(jīng)保護(hù)劑古老的神經(jīng)保護(hù)劑新型神經(jīng)保護(hù)劑371神經(jīng)保護(hù)劑古老的神經(jīng)保護(hù)劑371古老的神經(jīng)保護(hù)劑胞二磷膽堿依達(dá)拉奉381古老的神經(jīng)保護(hù)劑胞二磷膽堿381新型神經(jīng)保護(hù)劑激肽系統(tǒng)RhoproteinsEPO、CEPOG-csf391新型神經(jīng)保護(hù)劑激肽系統(tǒng)391第四節(jié)急性腦梗死的診斷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中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.低灌注性腦梗死：動脈狹窄tocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)第一節(jié)急性腦梗死的概述Neurology2004;62:1441stemcell-regulatingcapacitiessimvastatin90PRoFESStriallimitationsSecondarystrokepreventionofantithrombotics腎病血透病人及腎移植病人?脫水問題一般不脫。401第四節(jié)急性腦梗死的診斷Effectsincritic急性腦梗死急性腦梗死優(yōu)選急性腦梗死421優(yōu)選急性腦梗死21第一節(jié)急性腦梗死的概述是由于局部腦血流中斷引起,時(shí)間超過2小時(shí)，DWI上有表現(xiàn)。占腦卒中的85%。85%預(yù)后是好的，15%的缺血腦卒中預(yù)后差，死亡率高。431第一節(jié)急性腦梗死的概述是由于局部腦血流中斷引起,時(shí)間超過第二節(jié)急性腦梗死的病因腦動脈粥樣硬化：高血壓、高血脂、吸煙小血管玻璃樣變：高血壓、糖尿病低灌注性腦梗死：動脈狹窄心源性腦栓塞：冠心病、風(fēng)心病血管炎：SLE、結(jié)核、螺旋體動脈炎其它：避孕藥。441第二節(jié)急性腦梗死的病因腦動脈粥樣硬化：高血壓、高血脂、吸第三節(jié)急性腦梗死的分類OCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死ASCO：A-動脈硬化，S-小血管，C-心源性，O-其它451第三節(jié)急性腦梗死的分類OCSP：按臨床癥狀分：完全前循環(huán)第四節(jié)急性腦梗死的診斷血脂、糖代謝、HCY心臟、血管彩超頭顱CT及CTA頭顱MRI及MRADSA461第四節(jié)急性腦梗死的診斷血脂、糖代謝、HCY6147171pravastatin40Within24hoursEffectsincriticallyillpatientsDurationforbetween3and5days中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科Grayetal.Drugs2003;63:625-636超早期溶栓治療AmJCardiol.是由于局部腦血流中斷引起,時(shí)間超過2小時(shí)，DWI上有表現(xiàn)。pleiotropiceffectsbeyondtheireffectsoncholesterollevelsOCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死follow-up：>or=1year>or=2medicationswithdifferentmechanismsofactionwillbenecessaryPreventstrokeandimproveoutcomeBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)腔隙性腦梗死：21型，常見有5型。Secondarystrokepreventionofantithrombotics完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）Stroke2004;35:122OCSP完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）部分前循環(huán)：皮層枝或深穿支完全后循環(huán)：四肢癱瘓、眩暈、意識障礙腔隙性腦梗死：21型，常見有5型。481pravastatin40OCSP完全前循環(huán)：意識障礙、眼球

急性腦梗死的治療陸正齊中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科

491

急性腦梗死的治療91腦梗死的急性期治療超早期溶栓治療抗栓治療他汀類藥物抗高血壓藥物控制高血糖抗炎神經(jīng)保護(hù)劑脫水問題501腦梗死的急性期治療超早期溶栓治療101超早期溶栓治療511超早期溶栓治療111抗栓治療TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.521抗栓治療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?腎病血透病人及腎移植病人?出血性卒中?大劑量與標(biāo)準(zhǔn)劑量?591StatinsforstrokePleiotrpleiotropiceffectsofstatinspleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities601pleiotropiceffectsofstatinsPreventstrokeandimproveoutcomestatinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality611Preventstrokeandimproveout33%(n=4529)ofpatientswereonaPPIatrandomisationDrugs2003;63:625-636Grayetal.MesottenD,VandenBergheG.血管炎：SLE、結(jié)核、螺旋體動脈炎statinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheevent93%-aspirinplusER-DPsimvastatin89Proton-pumpinhibitors(PPIs)andclopidogrelAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce04vsplacebo)andtotalstroke(24%,P=.Baselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)atorvastatin10statinsreducetheriskofmyocardialinfarctionandstrokePreventstrokeandimproveoutcome68687/68721OCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alonePreventiveantibioticsinpatientswithacutestrokeEffectsincriticallyillpatientsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockersEffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins62133%(n=4529)ofpatientswere研究名稱出版時(shí)間處理因素mg對照因素mg平均隨訪時(shí)間（年）病例數(shù)(I/C)平均年齡(歲)男性比例（%）基礎(chǔ)LDHMg/dl卒中病例數(shù)(I/C)致死卒中(I/C)腦出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰劑3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰劑510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰劑3.35168/5137638113389/121....ALERT2003fluvastatin40安慰劑5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰劑3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰劑22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰劑4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰劑4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰劑41211/1199616611334/38....MEGA2006simvastatin87飲食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰劑2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰劑1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰劑3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合計(jì)......4.168687/6872164691242226/2604354/385186/166631研究名稱出版時(shí)間處理因素對照因素平均隨訪時(shí)間（年）病例數(shù)(I他汀與安慰劑或空白對照比較對所有卒中預(yù)防的meta分析

641他汀與安慰劑或空白對照比較對所有卒中預(yù)防的meta分析244個(gè)研究大劑量與標(biāo)準(zhǔn)劑量他汀對所有卒中預(yù)防的meta分析

6514個(gè)研究大劑量與標(biāo)準(zhǔn)劑量他汀對所有卒中預(yù)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小血管玻璃樣變：高血壓、糖尿病MesottenD,VandenBergheG.Preventstrokeandimproveoutcome33%(n=4529)ofpatientswereonaPPIatrandomisationGrayetal.clinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.ManagementofhyperglycemiaincriticallyillpatientsEpub2009Aug31Within24hoursMajorbleedingrateTheStudyonCognitionandPrognosisinEXPRESSstudy,Rothwelletal,Lancet2007;370:1432-42腔隙性腦梗死：21型，常見有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