脑梗死静脉溶栓后24 h内选择性双联
抗血小板治疗的安全性观察

摘要/Abstract

摘要：

目的探讨阿替普酶（alteplase，rt-PA）静脉溶栓治疗缺血性卒中后1 h内选择性早期使用口服抗血小板药物治疗的安全性。方法本研究为前瞻性研究，通过多模影像和溶栓后出血风险（hemorrhage after thrombolysis， HAT）评分连续入选了第三军医大学第三附属医院神经内科2011年1月～2014年4月期间出血性转化（hemorrhagic transformation，HT）风险较低（HAT评分≤2分或者HAT评分3～5分但多模影像提示侧支循环良好）的急性脑梗死静脉溶栓住院病例（n =112）。根据患者或家属是否同意早期使用口服抗血小板药物（阿司匹林100 mg联合氯吡格雷75 mg）治疗分为溶栓后1 h内的早期使用治疗组（n =66）和溶栓24 h后的标准治疗组（n =46）；观察溶栓后1 d内的再闭塞发生率、3 d内颅内及其他部位出血的发生率、溶栓7 d后的美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分和死亡率。结果两组的性别构成、年龄分布、高血压病史、2型糖尿病病史、高胆固醇血症病史、冠状动脉粥样硬化性心脏病病史、短暂性脑缺血发作病史、心脏瓣膜病史、心房颤动病史、收缩压、舒张压、血糖、溶栓前NIHSS评分、发病到溶栓时间、HAT评分、责任血管的构成比等基线情况比较差异无显著性（P＞ 0.05）；早期使用治疗组的HT发生率与标准治疗组比较差异无显著性（7.6% vs 6.5%，P =1.000）；两组的症状性脑出血（symptomatic intracerebral hemorrhage，sICH）和死亡数均为0；早期使用治疗组再闭塞发生率有低于标准治疗组的趋势，但差异无显著性（4.5% vs 15.2%，P =0.107）；早期使用治疗组溶栓7 d后NIHSS评分也有低于标准治疗组的趋势，但差异也无显著性（NIHSS=6 vs NIHSS=7，P =0.143）。结论通过多模影像和HAT评分选择HT风险较低的rt-PA静脉溶栓患者在溶栓后1 h内使用口服抗血小板药物治疗并不增加溶栓后出血风险。

文章导读： 本文通过多模影像和HAT评分选择HT风险较低的rt-PA静脉溶栓患者在溶栓后1 h内给予联合口服
抗血小板治疗，结果发现不增加溶栓后出血风险。

关键词: 急性脑梗死; 静脉溶栓; 抗血小板治疗; 出血性转化

Abstract:

Objective To evaluate the safety of selectively early administration of oral antiplatelet therapy within 1 hour after recombinant tissue type plasminogen activator (rt-PA) treatment in patients with acute ischemic stroke. Methods A total of 112 acute ischemic stroke patients with relatively low hemorrhagic transformation (HT) risk according to multimode imaging and hemorrhage after thrombolysis (HAT) score were selected for this clinical trial from Department of Neurology of The Third Affiliated Hospital of Third Military Medical University, from January 2011 to April 2014. Sixty-six patients were treated with oral 100 mg aspirin and 75 mg clopidogrel within 1 hour after the intravenous rt-PA administration with the informed consent from the patients or their legal representatives. In the other 46 patients, oral antiplatelet therapy started 24 hours after rt-PA treatment according to the will of the patients or their family, who preferred to follow the current guidelines. The primary safety endpoint was the reocclusion in 1 d after the thrombolysis, HT in 3 d, the score of National Institutes of Health Stroke Scale (NIHSS) in 7 d, and the death of the patients. Results There was no significant difference in the baseline (including gender, age, level of blood pressure, blood glucose and cholesterin before thrombolysis, the history of transient ischemic attack or cardiac valvular disease, etc.) between two groups. Importantly, no significant difference was found in HT (7.6% vs 6.5%, P =1.000), while the number of symptomatic intracerebral hemorrhage and death in both groups were zero. We even found decreasing tendency of NIHSS score at 7 d after the thrombolysis (NIHSS=6 vs NIHSS=7, P =0.143) and the frequency of reocclusion (4.5% vs 15.2 %, P =0.107) in early antiplatelet administration group was reduced although no significance was achieved. Conclusion Administration of oral antiplatelet therapy within 1 hour after patients with acute ischemic stroke treated with rt-PA does not increase the risk of HT in the patients screened by multimode imaging and HAT score

Key words: Acute cerebral infarction; Intravenous thrombolysis; Antiplatelet therapy; Hemorrhagic transformation

王欢，李玮，刘承春，吴娅，易旭，张志宏，李小树，张猛. 脑梗死静脉溶栓后24 h内选择性双联
抗血小板治疗的安全性观察[J]. 中国卒中杂志, 2014, 9(10): 831-836.

WANG Huan,LI Wei, LIU Cheng-Chun, WU Ya, YI Xu, ZHANG Zhi-Hong, LI Xiao-Shu, ZHANG Meng.. Assessing the Safety of Selectively Early Administration of Dual Antiplatelet Therapy
in Patients with Cerebral Infarction after Intravenous Thrombolysis[J]. Chinese Journal of Stroke, 2014, 9(10): 831-836.

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