Antiplatelet therapy for noncardiac stroke stroke

Since entering the door of neurology, the most commonly exposed disease is stroke, the most commonly contacted drugs are antiplatelet drugs, although the variety is small, the combination is more, to a stroke patient, how to administer?

Antiplatelet therapy for noncardiac stroke stroke

Let's explain this picture

Three concepts

Acute phase of cerebral infarction

The temporal division of the acute phase is not uniform, generally referred to as within 2 weeks after the onset of illness, 1 week in mild cases, and 1 month in
severe cases.

Transient ischemic attack (TIA)[1]

TIA is a sudden, focal neurological function (brain, spinal cord, or retina) disorder due to vascular causes that lasts < 24 hours
.

According to the histological definition, TIA is a transient neurological disorder caused by ischemia of the brain, spinal cord, or retina without acute infarction
.

light stroke [2]

Its definition has been controversial, and there are currently the following types:

1) NIHSS each item must be 0 or 1, and the consciousness must be 0;

2) Lam-like syndrome (occlusion of small blood vessels);

3) only movement disorders (including dysarthria or ataxia), with or without sensory impairment;

4) Baseline NIHSS minimum score per item (total score of ≤ 9), no aphasia, neglect or any impairment of level of consciousness;

5) Baseline NIHSS has the lowest score for each item, with a total score of ≤ 9 points;

6) Baseline NIHSS ≤ 3 points;

Definition 1) and Definition 6) The patient's short-term (patient discharged home) and mid-term (improved Rankin scale score ≤ 2 points) at 3 months have the best outcome, so Definition 1) and Definition 6) may be closest to the nature of mild stroke, which may be why the world-renowned CHANCE study chose NIHSS ≤ 3

Three scoring scales

NIHSS scoring scale

Providing a sensitive tool for monitoring neurological changes in patients, NIHSS scores can predict the clinical prognosis of stroke 7d and 90d, thereby guiding patients to develop long-term rehabilitation and prevention plans
.

ABCD2 scoring scale

A commonly used TIA early stroke risk stratification tool for predicting the risk of stroke within 2 days of TIA, we call it a high risk of stroke recurrence when the ABCD2 score is ≥ 4 [3].

ESSEN scale

Clinically used to determine the recurrence rate of ischemic stroke, suggesting that patients with ischemic stroke should be concerned about a variety of risk factors, particularly diabetes mellitus, multivascular bed lesions, previous TIA, or ischemic stroke
.

The ESSEN scale ≥ 3 in patients at high risk of recurrence, and clopidogrel is superior to aspirin [4].

Antiplatelet drug therapy

Take a look at the guide recommendations first

1.

Clopidogrel plus aspirin therapy should be given as early as possible for 21 days (clopidogrel first day load 300 mg).

However, the following conditions should be excluded: (1) patients with cardiac causes requiring anticoagulation; (2) thrombolysis; (3) Patients with moderate to severe (NIHSS ≥ 3 points) ischemic stroke with the risk of bleeding transformation; (4) For patients with simple sensory, visual or vertigo symptoms or ABCD2 score of <4 with a low risk of stroke recurrence;

2.

3.

4.

Clinical application

For a newly admitted patient, it is difficult to immediately evaluate the blood vessel in terms of the current medical conditions, so the dosing regimen
should be developed according to the most convenient scoring system before evaluating the blood vessel.

The CHANCE study used aspirin 75 mg/day, and the most reasonable dose for aspirin is currently considered to be 75-150 mg/day
.

Antiplatelet and anticoagulant therapy for stroke

Clinicians will divide patients into hemorrhagic stroke and ischemic stroke according to their different status, and be divided into acute and chronic stages according to the different periods of the patient's
onset.

Antiplatelet and anticoagulant therapy for noncardiac stroke

Antiplatelet and anticoagulant therapy in patients with non-cardiac stroke is mainly for ischemic stroke, and the treatment of patients with non-cardiac ischemic stroke should be dominated by antiplatelet therapy, and clinical antiplatelet therapy usually prefers aspirin
.

In 2011, the Chinese Cerebrovascular Prevention and Control Expert Group agreed to recommend the use of aspirin for cerebrovascular disease prevention (I, A) in high-risk groups (over 50 years old, hypertension, DM, hyperlipidemia, carotid plaque formation, smoking, and obesity)
when the risk of stroke is sufficiently high (10-year cerebrovascular time risk is 6% to 10%) 。 Secondary prevention after stroke is divided into acute phase and chronic phase, and the 2010 Chinese guidelines for the treatment of acute phase of ischemic stroke recommend that aspirin is preferred for patients in acute phase, and administered as soon as possible after 48 hours of onset when there is no significant bleeding contraindication (150-300 mg qd, changed to 50-150 mg qd after 2-4 weeks) (I, A); Clopidogrel (III, C) can be selected for aspirin intolerance, and patients with thrombolytic therapy are given aspirin (I, B) after 24 hours; Dual antiplatelet therapy is not recommended in the acute phase, and anticoagulation therapy is not recommended (in the absence of atrial fibrillation and other diseases
).

Prevention of stroke recurrence also requires antiplatelet therapy, and antiplatelet prophylaxis in stroke patients is mainly monotherapy, such as clopidogrel (75 mg/day) or aspirin (50 to 325 mg/day) (I, A), and it is recommended that TIA repeat patients be treated with monotherapy (clopidogrel is better than aspirin).

Interventional therapy was initially used in the treatment of cardiac and peripheral vascular disease, but in recent years it has also been gradually used to treat cerebrovascular disease
.
Early guidelines suggest that patients with cerebral artery stents should receive clopidogrel plus aspirin for 30 days, and then switch to clopidogrel alone for 9 to 12 months
.

The 2015 Chinese guidelines for the endovascular treatment of acute ischemic stroke have been revised and improved according to the latest research results, and their contents have 4 key points: (1) the need for preoperative angiogenesis, clopidogrel 300 mg + aspirin 300 mg, postoperative clopidogrel 75 mg/day, aspirin 100 mg/day, clopidogrel for at least 3 months, aspirin for at least 6 months; (2) IIb/IIIa receptor antagonists need further clinical trial verification; (3) Cranial CT should be checked before antiplatelet therapy, and after mechanical thrombosis of vascular occlusion, routine antiplatelet therapy can be started after surgery; (4) Anticoagulation after thrombolysis or intravascular therapy is inconclusive, and early anticoagulation without choice is not recommended, and a small number of special patients choose carefully after careful assessment of the risk-benefit ratio
.

In patients with ischemic stroke, antiplatelet therapy appears to be treated with clopidogrel and aspirin, but in fact treatment decisions are based on risk stratification results
.
As early as 2010, the antiplatelet risk stratification strategy of ischemic stroke was agreed by Chinese experts to clearly stratify patients with ischemic stroke, and promote monotherapy for patients with medium and high risk and high risk, and only advocate dual antiplatelet therapy
for extremely high-risk patients.

In addition to the above two drugs, antiplatelet drugs include dipyridamole, which has less antiplatelet effect than aspirin and clopidogrel, PRoFESS study (n=22333) found that Aggrenox (a combination of dipyridamole and aspirin) has the same effect as clopidogrel in preventing stroke recurrence and major cardiovascular events, but increases the risk of
bleeding 。 In addition, cilotazole, the drug is mainly used for peripheral vascular diseases, cardiovascular disease treatment is less used, Peking University First Hospital research found that the drug has a basic clinical effect in the prevention of stroke, but also increases the risk of bleeding, which reminds us to pay attention to the risk
of bleeding when performing antiplatelet therapy for patients.

Antiplatelet and anticoagulant therapy for cardiogenic stroke

Cardiogenic stroke is more complex and therefore distinguishes from non-cardiac stroke
.
In addition to long-term rhythm testing can be used to distinguish between the two diseases, the 2010 ESC ultrasound ECG guidelines indicate that cardiogenic stroke often has the characteristics
of stroke onset, multiple spatials and time, associated with other system embolism, cortical infarction, MAC high-density shadow, and advanced age.
Cardiogenic stroke is identified not only because it is an important cause of stroke, but also because its treatment is not fully equivalent to non-cardiac treatment, and common causes of cardiac stroke include atrial fibrillation, myocardial infarction, and valvular disease
.

Antiplatelet therapy for stroke prevention and anticoagulation in patients with atrial fibrillation

After the occurrence of atrial fibrillation, the atrium changes from regular contractile movement to peristalsis, which is easy to form blood clots and easy to fall
off.
Atrial fibrillation is an age-increasing disease, with the intensification of social aging, the incidence of atrial fibrillation in China will inevitably increase, which in turn will lead to an increase in the incidence of stroke, because the risk of stroke in patients with atrial fibrillation is much higher than that of the general population
.
Stroke risk assessment is often required in patients with atrial fibrillation, and the CHADS2 score was used as a common risk assessment tool until 2014, when different guidelines began to recommend the use of CHA2DS2-VASC scores
.

The advantage of the CHA2DS2-VASC score over the CHADS2 score

The guidelines recommend that CHA2DS2-VASC score ≥2 must receive warfarin or NOAC anticoagulation therapy (unless there are contraindications), and the intensity of anticoagulation therapy for 0 to 1 points is not strict, aspirin (I, A) is applied to 0 points, aspirin or warfarin (IIa, B) is applied to 1 score, anticoagulation treatment does not need to distinguish between atrial fibrillation types, only according to the risk stratification of anticoagulation strategies can be formulated, and acute anticoagulation is paid attention to during the cardioversion
process.