Annals of Neurology :房颤提前口服抗凝,有助于降低脑中风严重性,改善溶栓预后

2021-01-10 Freeman MedSci原创

房颤提前口服抗凝,有助于降低脑中风严重性,改善溶栓预后

 
口服抗凝,比如直接口服抗凝剂或维生素 K拮抗剂VKAs在预防急性缺血性脑卒中患者的房颤中非常有效。然而,每年使用抗凝药物的缺血性卒中发生率为2% ,在所有缺血性卒中患者中,有10% 的患者在卒中发病时已经接受抗凝治疗。先前的治疗性 VKA 和 DOAC 疗法与卒中严重程度的降低有关。
 
急性再通治疗(静脉溶栓[ IVT ]和机械取栓[ MT ])是急性卒中治疗的基石,能改善功能结局,预防卒中后严重残疾。根据美国心脏协会/美国卒中协会(AHA/ASA)的指南,提前抗凝治疗是 IVT 的相对用药禁忌,能否使用MT需要 做出风险-利益( risk–benefit )判断。观察性研究结果表明,选择服用 VKAs (INR ≤1.7)和 DOACs 的患者,IVT 和 MT 是安全的。
 
然而,提前抗凝治疗在超急性(hyperacute)场景中带来一个主要挑战——增加症状性颅内出血的风险。特别是,提前 DOAC 治疗可能是使用急性再通疗法的一个主要障碍,因为无法准确评估药效监测的不确定性。因此,由于不愿使用急性再通疗法,先前 DOAC 疗法对急性卒中特征的好处可能反过来被较差的长期功能结果所抵消。
 
基于以上问题,伯尔尼大学的Thomas R. Meinel等人,探究了房颤和急性缺血性卒中患者中,提前抗凝(VKA)或直接口服抗凝剂(DOACs)与卒中严重程度、静脉溶栓(IVT)使用情况、 IVT 安全性和3个月预后的关系。
 
他们纳入了2014-2019年连续接受抗凝治疗的患者与未接受抗凝治疗的患者,进行队列研究,探究提前抗凝和以下结局的关系:卒中严重程度、 IVT/机械性血栓切除率、症状性颅内出血(sICH)以及3个月时良好的预后(修改的 Rankin 评分0-2)。
 
共纳入了8179例患者(平均年龄为79.8岁,平均年龄为9.6岁,49% 为女性)中,1486例(18%)接受 VKA 治疗,1634例(20%)接受 DOAC 治疗,5059例对照。
 
相对于 VKA 和对照组,DOACs 患者的卒中严重程度较低。和对照组相比,VKA 和DOAC组患者的 IVT 发生率明显低于对照组(aOR=0.67 和aOR=0.06) 。IVT之后,各组的ICH发生率:对照组3.6%,VKA组4.6%,DOAC组3.1%。在对预后相关的混杂因素进行调整后,DOAC 提前抗凝与3个月的良好结果相关(aOR=1.24)。
 
这个研究的重要意义:房颤患者提前接受 DOAC 治疗与发病时入院脑卒中严重程度降低相关,而且和 IVT 发生率显著降低有关。总的来说,服用 DOAC 的患者在3个月后可能有更好的功能结果。当然需要进一步的研究来克服 DOACs 对 IVT 治疗的局限性。
 
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  1. [GetPortalCommentsPageByObjectIdResponse(id=2043728, encodeId=bb402043e288f, content=<a href='/topic/show?id=6dd7211832f' target=_blank style='color:#2F92EE;'>#严重性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=21183, encryptionId=6dd7211832f, topicName=严重性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Mon Dec 06 02:55:06 CST 2021, time=2021-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001195, encodeId=621420011959e, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Tue Mar 09 23:55:06 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915258, encodeId=19d491525881, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun Jan 10 14:53:38 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915207, encodeId=080c91520ee4, content=<a href='/topic/show?id=737a54248f5' target=_blank style='color:#2F92EE;'>#房颤#</a>&<a href='/topic/show?id=353b55219b8' target=_blank style='color:#2F92EE;'>#抗凝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=165, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54248, encryptionId=737a54248f5, topicName=房颤), TopicDto(id=55219, encryptionId=353b55219b8, topicName=抗凝)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun Jan 10 14:20:10 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915139, encodeId=39f0915139ba, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=347e5451464, createdName=ms4000001289472360, createdTime=Sun Jan 10 08:46:31 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915124, encodeId=19779151249c, content=内涵丰富,已学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201225/6e1ef4f864494d0284b9282bc4cafc19/f7f10a42767b46c9823f11c34f905873.jpg, createdBy=145f5447474, createdName=ms6000001700483633, createdTime=Sun Jan 10 07:20:00 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031339, encodeId=f5b0103133940, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Sun Jan 10 06:55:06 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046004, encodeId=ca8e104600462, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sun Jan 10 06:55:06 CST 2021, time=2021-01-10, status=1, ipAttribution=)]
    2021-12-06 xue8602
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    2021-03-09 yinhl1978
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    2021-01-10 zb1235672

    学习了

    0

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  5. [GetPortalCommentsPageByObjectIdResponse(id=2043728, encodeId=bb402043e288f, content=<a href='/topic/show?id=6dd7211832f' target=_blank style='color:#2F92EE;'>#严重性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=21183, encryptionId=6dd7211832f, topicName=严重性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Mon Dec 06 02:55:06 CST 2021, time=2021-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001195, encodeId=621420011959e, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Tue Mar 09 23:55:06 CST 2021, time=2021-03-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915258, encodeId=19d491525881, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun Jan 10 14:53:38 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915207, encodeId=080c91520ee4, content=<a href='/topic/show?id=737a54248f5' target=_blank style='color:#2F92EE;'>#房颤#</a>&<a href='/topic/show?id=353b55219b8' target=_blank style='color:#2F92EE;'>#抗凝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=165, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54248, encryptionId=737a54248f5, topicName=房颤), TopicDto(id=55219, encryptionId=353b55219b8, topicName=抗凝)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun Jan 10 14:20:10 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915139, encodeId=39f0915139ba, content=有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=347e5451464, createdName=ms4000001289472360, createdTime=Sun Jan 10 08:46:31 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=915124, encodeId=19779151249c, content=内涵丰富,已学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201225/6e1ef4f864494d0284b9282bc4cafc19/f7f10a42767b46c9823f11c34f905873.jpg, createdBy=145f5447474, createdName=ms6000001700483633, createdTime=Sun Jan 10 07:20:00 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031339, encodeId=f5b0103133940, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Sun Jan 10 06:55:06 CST 2021, time=2021-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046004, encodeId=ca8e104600462, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sun Jan 10 06:55:06 CST 2021, time=2021-01-10, status=1, ipAttribution=)]
    2021-01-10 ms4000001289472360

    有用

    0

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    2021-01-10 ms6000001700483633

    内涵丰富,已学习

    0

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    2021-01-10 心介

    房颤,临床上碰到很多哦

    0

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    2021-01-10 guging

    中风是俗称,应该称为缺血性卒中吧

    0

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