Stroke:替格瑞洛-阿司匹林联用治疗卒中,利大于弊

2021-09-07 Freeman MedSci原创

在轻中度缺血性卒中或高危TIA患者中,使用ticagrelor-aspirin进行30天治疗的缺血益处超过了出血风险。

抗血小板药物和抗凝剂已被证明可以在各种临床环境中减少缺血事件,包括在缺血性中风或短暂性脑缺血发作(TIA)患者的特定人群中。这种好处,也伴随着出血风险的增加。

主要疗效结果(Primary efficacy outcomes )包括安全因素,如出血性事件,由于个别事件包括在疗效和安全终点中,因此往往掩盖了对效益与风险关系的理解。

如果在不同的试验中对结果进行比较,这个问题就更严重了。虽然可以利用包含风险和益处的单一综合结果指标,来避免在权衡风险和益处时的混乱,但这种综合指标掩盖了固有风险治疗的实际权衡。

用替格瑞洛和阿司匹林预防中风和死亡的急性中风或短暂性缺血发作试验(Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and Aspirin for Prevention of Stroke and Death;THALES)表明了这个问题。在11016名急性轻度至中度缺血性中风或TIA患者中,随机接受了替格瑞洛联合阿司匹林(替格瑞洛-阿司匹林)或单独阿司匹林的30天治疗,替格瑞洛-阿司匹林减少了中风或死亡(主要疗效结果),但在绝对程度上,严重出血(主要安全结果)增加。

其主要疗效结果,即中风或死亡,包括出血事件,也被计入主要安全结果。因此,权衡这些结果,对风险和益处的评估不准确。这会掩盖对可能经历不成比例的益处或损害的亚组的检测。此外,最初发表的THALES结果侧重于相对风险,而绝对风险提供了一个更有用的风险和效益的比较。

为了更清楚地评估使用ticagrelor-aspirin治疗的益处和风险,美国德克萨斯大学的S. Claiborne Johnston等人, 重新定义了疗效和安全结果,使其具有独特性,并与类似的长期影响相关。最后,重新分析了THALES试验的结果。他们评估了呈现的特征、人口统计学和其他与绝对风险和获益不成比例相关的因素。

在THALES中,患者在症状发生后24小时内被随机分配到30天的替卡格雷加阿司匹林方案或匹配的安慰剂加阿司匹林方案。在目前的分析中,他们将疗效结果(主要缺血事件)定义为缺血性卒中或非出血性死亡的综合( composite of ischemic stroke or non-hemorrhagic death),并将安全结果(主要出血)定义为颅内出血或出血性死亡。净临床影响(Net clinical impact )被定义为这两个终点的组合。

在11016名患者中(5523名替格瑞洛-阿司匹林和5493名阿司匹林),替卡格雷-阿司匹林组的294名患者(5.3%)和阿司匹林组的359名患者(6.5%)发生主要缺血事件(绝对风险降低1.19%,95%CI 0.31%-2.07%)。

替格瑞洛-阿司匹林组有22名患者(0.4%)发生大出血,阿司匹林组有6名患者(0.1%)(绝对风险增加0.29%,95%CI,0.10-0.48%)。

净临床影响有利于替格瑞洛-阿司匹林(绝对风险降低0.97%,95%CI,0.08%-1.87%)。当采用不同的残疾阈值时(thresholds for disability ),以及在一系列预定的亚组中,研究结果是相似的。

这个研究的重要意义在于发现了:在轻中度缺血性卒中或高危TIA患者中,使用ticagrelor-aspirin进行30天治疗的缺血益处超过了出血风险。

原文出处:
Johnston SC, Amarenco P, Aunes M, et al. Ischemic Benefit and Hemorrhage Risk Of Ticagrelor-Aspirin Versus Aspirin In Patients With Acute Ischemic Stroke Or TIA. Stroke. Published online September 3, 2021:STROKEAHA.121.035555. doi:10.1161/STROKEAHA.121.035555

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1807745, encodeId=4aa4180e745c7, content=<a href='/topic/show?id=3fe480e46e5' target=_blank style='color:#2F92EE;'>#联用治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80746, encryptionId=3fe480e46e5, topicName=联用治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1777154, createdName=chenhongpeng, createdTime=Sun Aug 14 19:50:36 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1200354, encodeId=e40e120035418, content=这个双抗策略有没有氯吡格雷双抗好, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=af2c5726846, createdName=ms3000001643437590, createdTime=Mon Mar 07 21:08:52 CST 2022, time=2022-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1015904, encodeId=414b101590474, content=新的双抗策略, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=df324723890, createdName=452946589, createdTime=Wed Sep 08 23:35:14 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026955, encodeId=90631026955ab, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1052594, encodeId=ef62105259420, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1807745, encodeId=4aa4180e745c7, content=<a href='/topic/show?id=3fe480e46e5' target=_blank style='color:#2F92EE;'>#联用治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80746, encryptionId=3fe480e46e5, topicName=联用治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1777154, createdName=chenhongpeng, createdTime=Sun Aug 14 19:50:36 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1200354, encodeId=e40e120035418, content=这个双抗策略有没有氯吡格雷双抗好, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=af2c5726846, createdName=ms3000001643437590, createdTime=Mon Mar 07 21:08:52 CST 2022, time=2022-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1015904, encodeId=414b101590474, content=新的双抗策略, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=df324723890, createdName=452946589, createdTime=Wed Sep 08 23:35:14 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026955, encodeId=90631026955ab, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1052594, encodeId=ef62105259420, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=)]
    2022-03-07 ms3000001643437590

    这个双抗策略有没有氯吡格雷双抗好

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1807745, encodeId=4aa4180e745c7, content=<a href='/topic/show?id=3fe480e46e5' target=_blank style='color:#2F92EE;'>#联用治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80746, encryptionId=3fe480e46e5, topicName=联用治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1777154, createdName=chenhongpeng, createdTime=Sun Aug 14 19:50:36 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1200354, encodeId=e40e120035418, content=这个双抗策略有没有氯吡格雷双抗好, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=af2c5726846, createdName=ms3000001643437590, createdTime=Mon Mar 07 21:08:52 CST 2022, time=2022-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1015904, encodeId=414b101590474, content=新的双抗策略, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=df324723890, createdName=452946589, createdTime=Wed Sep 08 23:35:14 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026955, encodeId=90631026955ab, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1052594, encodeId=ef62105259420, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=)]
    2021-09-08 452946589

    新的双抗策略

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1807745, encodeId=4aa4180e745c7, content=<a href='/topic/show?id=3fe480e46e5' target=_blank style='color:#2F92EE;'>#联用治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80746, encryptionId=3fe480e46e5, topicName=联用治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1777154, createdName=chenhongpeng, createdTime=Sun Aug 14 19:50:36 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1200354, encodeId=e40e120035418, content=这个双抗策略有没有氯吡格雷双抗好, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=af2c5726846, createdName=ms3000001643437590, createdTime=Mon Mar 07 21:08:52 CST 2022, time=2022-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1015904, encodeId=414b101590474, content=新的双抗策略, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=df324723890, createdName=452946589, createdTime=Wed Sep 08 23:35:14 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026955, encodeId=90631026955ab, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1052594, encodeId=ef62105259420, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=)]
    2021-09-08 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1807745, encodeId=4aa4180e745c7, content=<a href='/topic/show?id=3fe480e46e5' target=_blank style='color:#2F92EE;'>#联用治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80746, encryptionId=3fe480e46e5, topicName=联用治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1777154, createdName=chenhongpeng, createdTime=Sun Aug 14 19:50:36 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1200354, encodeId=e40e120035418, content=这个双抗策略有没有氯吡格雷双抗好, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=af2c5726846, createdName=ms3000001643437590, createdTime=Mon Mar 07 21:08:52 CST 2022, time=2022-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1015904, encodeId=414b101590474, content=新的双抗策略, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=df324723890, createdName=452946589, createdTime=Wed Sep 08 23:35:14 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026955, encodeId=90631026955ab, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1052594, encodeId=ef62105259420, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Wed Sep 08 08:50:36 CST 2021, time=2021-09-08, status=1, ipAttribution=)]
    2021-09-08 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

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