克里斯蒂萨·埃米尔·奎·阿尔拜
近年来，双重抗血小板治疗对卒中二级预防的有效性和安全性有了新的证据。进行了一项最新的荟萃分析，以确定各种双重抗血小板治疗（包括替格瑞洛和西洛他唑）与单独使用阿司匹林对缺血性卒中复发率、心血管发病率和死亡率的影响，以及通过大出血报告的安全性。
介绍：
缺血性中风是最常见的中风类型，约占所有中风的 80-90%。根据世界卫生组织 (WHO) 的数据，脑血管意外或中风是第二大死亡原因和第三大发病原因。这是一种大脑区域缺血的疾病，导致脑细胞缺氧，进而导致细胞死亡，从而导致局部神经功能缺损（具体取决于损伤区域）。另一方面，短暂性脑缺血发作与缺血性中风类似，但没有留下组织受损的迹象。血流暂时受损，无需干预即可自行逆转。
中风是导致长期残疾的唯一主要原因。除了最初的损伤外，局部缺陷的进展还会导致不良后果。在过去的几十年里，人们研究了强化治疗和介入策略，以减少中风的致残率和复发率。根据 Aoki 等人的研究，静脉溶栓、血管内治疗和阿司匹林在减少中风复发方面发挥了关键作用。根据几项前瞻性随机对照试验，如“机会”试验和点试验。在阿司匹林中添加氯吡格雷可显著降低急性非心源性缺血性中风患者的神经系统恶化。其他双重抗血小板疗法也显示出积极的影响。缺血性中风的管理引起了对这些药物的几项系统评价和荟萃分析。然而，随后的试点研究涉及小规模人群，涉及抗血小板药物，如替格瑞洛和西洛他唑。与阿司匹林联合使用时尚未确认急性中风患者的临床结果是否会改善。
Two recent randomized control trials were published on the use of Cilostazol with Aspirin and Ticagrelor with Aspirin vs. Aspirin alone which were not included in the meta-analysis by Yang Y, et al., on Dual vs. Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke. These two additional randomized controlled trials provided the data that was used to update the current management of secondary prevention of acute ischemic stroke. Hence, the aim of this study was to present an updated systematic review involving several antiplatelets that are combined with aspirin as a dual therapy vs. aspirin alone in its effect to a recurrence of stroke in patients who have suffered from acute stroke composite events such cardiovascular morbidity and mortality. Safety as measured through major bleeding, among patients who have suffered from an acute non cardioembolic stroke.
Objectives:
The general objective of this study was to determine the effect of the various dual antiplatelets that including ticagrelor and cilostazol vs. aspirin alone on recurrence rate of ischemic stroke. Composite events like cardiovascular morbidity – acute coronary syndrome, and mortality, and its safety profile as reported through the major bleeding. In this study all randomized trials used had an acute stroke or transient ischemic attack time frame of less than 72 hours.
Methods:
PubMed, Cochrane and Science Direct data bases were utilized, RCTs evaluating dual antiplatelet vs mono antiplatelet therapy for acute ischemic stroke or transient ischemic attack within < 72 hours from ictus were searched up to July 2019. Risk ratio at 95% confidence intervals was calculated to evaluate stroke recurrence, cardiac events and mortality, and major bleeding.
Results:
Sixteen studies in the previous meta-analysis were included. Those excluded were trials where in the monotherapy treatment was not aspirin for uniformity of the control drug. Based on the relevant studies from January 2016 to June 2019. The data base searching and citation tracking of references identified 53,082, by using Boolean function. 44 trials were excluded and 6 randomized control trials were reviewed by full text for details and 4 of which were excluded due to the missing data wherein all channels to retrieve it were exhausted. Therefore 2 eligible randomized controlled trial were identified. Both of which compared its efficacy and safety versus aspirin in patients with acute non-cardioembolic ischemic stroke or transient ischemic attack.
Conclusion:
对于急性非心源性栓塞性缺血性中风或曾遭受短暂性脑缺血发作的患者，双重抗血小板疗法与中风复发和复合心脏事件的疗效相关，且大出血风险不显著。在发作后 72 小时内患有急性非心源性栓塞性缺血性中风或短暂性脑缺血发作的患者中。与单一疗法相比，双重抗血小板疗法与中风复发和复合事件（例如急性冠状动脉综合征和心脏相关死亡）的减少有关。但是，由于可能存在大出血事件，双重抗血小板疗法的安全性降低。虽然本研究观察到的大出血事件在统计学上并不显著。可能导致大出血风险增加的因素包括治疗剂量和治疗持续时间。总之，目前的数据表明，在缺血性中风或短暂性脑缺血发作的急性期进行短期双重抗血小板治疗是有效且相对安全的，其中西洛他唑与阿司匹林可以成为标准治疗的潜力，因为它有证据表明可以减少中风复发，并且是最具成本效益的组合，尽管出血风险在统计学上并不显着。