1、缺血性脑卒中脑出血转化缺血性脑卒中脑出血转化 HI 出血性梗死：HI1 小点状出血HI2 多个融合的点状出血 PH 脑实质出血PH1 30%梗死灶有轻微占位效应出血PH2 30%梗死灶有明显占位效应出血或远离梗死灶出血缺血性脑卒中出血转化的抗栓治疗缺血性脑卒中出血转化的抗栓治疗2010 中国卒中急性期指南缺血性脑卒中出血转化的抗栓治疗缺血性脑卒中出血转化的抗栓治疗3.对于出血性脑梗死患者，根据患者的临床情况（无症状和出对于出血性脑梗死患者，根据患者的临床情况（无症状和出血量少）及抗凝适应症时，可以考虑继续抗凝。血量少）及抗凝适应症时，可以考虑继续抗凝。Class IIb;Level of Ev
2、idence CGuidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke.published online May 1,2014特殊情况的抗栓治疗特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗1.脑出血后重新开始抗栓治疗的决策制定，依赖于脑出血后重新开始抗栓治疗的决策制定，依赖于随后的动脉随后的动脉或静脉血栓栓塞的风险大小、脑出血再发的风险、病人的全或静脉血栓栓塞的风险大小、脑出血再发的风险、病人的全身情况身情
3、况，所以对每个病人必须制定个体化的方案。，所以对每个病人必须制定个体化的方案。*脑梗死风险脑梗死风险相对较低相对较低病人（如房颤但没有缺血性脑卒中史）病人（如房颤但没有缺血性脑卒中史）和脑出血再发和脑出血再发风险较高风险较高（如高龄的脑叶出血或可疑淀粉样脑（如高龄的脑叶出血或可疑淀粉样脑血管病患者）或者整个神经系统功能很差，可以考虑应用血管病患者）或者整个神经系统功能很差，可以考虑应用抗抗血小板药物血小板药物来预防缺血性脑卒中。来预防缺血性脑卒中。颅内出血后的抗凝治疗颅内出血后的抗凝治疗Class IIb;Level of Evidence BGuidelines for the Preven
4、tion of Stroke in Patients With Stroke and Transient Ischemic Stroke.published online May 1,20142.对于急性脑出血、蛛网膜下腔出血或硬脑膜下出血后，何时对于急性脑出血、蛛网膜下腔出血或硬脑膜下出血后，何时恢复或开始抗凝治疗，最佳时机尚无定论。大多数病人来说，恢复或开始抗凝治疗，最佳时机尚无定论。大多数病人来说，发病至少发病至少1周以上较为合理周以上较为合理颅内出血后的抗凝治疗颅内出血后的抗凝治疗:Class IIb;Level of Evidence BGuidelines for the Prev
5、ention of Stroke in Patients With Stroke and Transient IschemicStroke.published online May 1,2014特殊情况的抗栓治疗特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗For patients with AF and stable coronary artery disease(eg,no acute coronary syndrome within the previous year)who choose oral anticoagulation
6、suggest adjusted-dose VKA therapy alone(target INR range,2.0-3.0)rather than the combination of adjusted-dose VKA therapy and aspirin (Grade 2C)Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Base
7、d Clinical Practice Guidelines For patients with AF at intermediate to high risk of stroke(eg,CHADS2 score 1)who experience an acute coronary syndrome and do not undergo intracoronary stent placement suggest for the first 12 monthsadjusted-dose VKA therapy(INR 2.0-3.0)plus single antiplatelet therap
8、y rather than dual antiplatelet therapy(eg,aspirin and clopidogrel)or triple therapy(eg,warfarin,aspirin,and clopidogrel)(Grade 2C).Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Based Clinical P
9、ractice Guidelines For patients with AF at intermediate to high risk of stroke After the first 12 monthsantithrombotic therapy is suggested as for patients with AF and stable coronary artery diseaseAntithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th
10、 ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with AF at high risk of stroke(eg,CHADS2 score 2)during the first month after placement of a bare-metal stent or the first 3 to 6 months after placement of a drug-eluting stent suggest triple therapy(eg
11、,VKA therapy,aspirin,and lopid-ogrel)rather than dual antiplatelet therapy(eg,aspirin and clopidogrel)(Grade 2C)Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines F
12、or patients with AF at high risk of stroke After this initial period of triple therapy suggest a VKA(INR 2.0-3.0)plus a single antiplatelet drug rather than VKA alone (Grade 2C).12 months after intracoronary stent placement antithrombotic therapy is suggested as for patients with AF and stable coron
13、ary artery diseaseAntithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines patients with nonvalvular AFpatients with nonvalvular AF CHA2DS2-VASc score is recommended for
14、assessment of stroke risk(Level of Evidence:B)high risk of stroke with prior stroke,transient ischemic attack(TIA)or a CHA2DS2-VASc score of 2 or greater2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial FibrillationFor patients with nonvalvular AFFor patients with nonvalvular AF
15、oral anticoagulants are recommended Options include:warfarin(INR 2.0 to 3.0)(Level of Evidence:A)dabigatran(Level of Evidence:B),rivaroxaban(Level of Evidence:B)apixaban(Level of Evidence:B)2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation如暂停口服抗凝药，需要过渡性治疗吗？warfarin(I
16、NR 2.Class IIb;Level of Evidence B(Level of Evidence:A)Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Stroke.2个一级证据、1个二级证据、1个三级证据的临床研究，肝素过渡性治疗可增加出血风险暂停抗凝药物所致血栓栓塞风险停药所致的血栓栓塞风险没有足够证据支持眼科手术时需停用华法林(Level U).(Grade 2C).肌电图、前列腺手术、腹股沟疝修补术、大隐静脉消融手术Summary of evidence-
17、based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80
18、 May 28,2013虽然出血性不良事件罕见PH2 30%梗死灶有明显占位效应出血或远离梗死灶出血patients with AF undergoing percutaneous patients with AF undergoing percutaneous coronary interventioncoronary intervention bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy Following coronary revascu
19、larization(percutaneous or surgical)in patients with AF and a CHA2DS2-VASc score of 2 or greater,it may be reasonable to use clopidogrel(75 mg once daily)concurrently with oral anticoagulants but without aspirin(Level of Evidence:B)2014 AHA/ACC/HRS Guideline for the Management of Patients With Atria
20、l FibrillationWOESTWOEST试验试验 比较了华法林、氯吡格雷加或不加阿司匹林的双联与三联治疗 结果显示华法林加氯吡格雷的双联治疗 出血风险更低（p0.001），1年次要临床终点（包括死亡、心肌梗死、卒中）发生率降低（p=0.025）血栓栓塞风险并不增加 指南对这种抗栓方案更为推崇2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation特殊情况的抗栓治疗特殊情况的抗栓治疗缺血性脑卒中脑出血转化颅内出血房颤合并冠心病围手术期管理缺血性脑血管疾病患者抗栓治疗缺血性脑血管疾病
21、患者抗栓治疗缺血性脑血管疾病患者抗栓治疗围手术期管理围手术期管理 围手术期的抗血栓形成治疗必须评估继续用药所致的出血风险停药所致的血栓栓塞风险Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013缺血性脑血管疾病患者抗栓治疗缺血性脑血管疾病患者抗栓治疗围手术期管理围手术期管理 暂停抗栓药物的血栓栓塞风险？继续使用抗栓药物
22、的围手术期出血风险？如暂停口服抗凝药，需要过渡性治疗吗？如果停用抗栓药物，该停多长时间？Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013暂停抗血小板药物暂停抗血小板药物所致血栓栓塞的风险所致血栓栓塞的风险 one Class I study1 and 2 Class II studies 暂停阿司匹林很可能增加脑卒
23、中或短暂性脑缺血发作风险发生脑卒中风险与阿司匹林停止时间长短相关停药2周的相对危险度（RR）为1.97停药4周的比值比（OR）为3.4停药5月的相对危险度（RR）为1.40Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013暂停抗凝药物所致血栓栓塞风险暂停抗凝药物所致血栓栓塞风险 不同抗凝适应症，停用抗凝药所致血栓栓塞
24、风险各异。继续使用华法林和停用华法林（有或没有围手术期肝素过渡性治疗）条件下血栓栓塞的风险，尚缺乏大样本的研究。停用华法林超过7天，导致血栓栓塞的风险高达(RR 5.5)(one Class I study)Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中华心
25、血管病杂志,2013.183-194.如暂停口服抗凝药，需要过渡性治疗吗？如暂停口服抗凝药，需要过渡性治疗吗？没有足够证据肝素过渡性治疗减少血栓栓塞事件没有足够证据肝素过渡性治疗减少血栓栓塞事件 大多数研究提示肝素过渡性治疗可能大多数研究提示肝素过渡性治疗可能增加围手术期出血风险增加围手术期出血风险。2个一级证据、个一级证据、1个二级证据、个二级证据、1个三级证据的临床研究，肝素过渡性治疗个三级证据的临床研究，肝素过渡性治疗可增加出血风险可增加出血风险另另1个一级证据的临床研究，没有实质性地增加风险。个一级证据的临床研究，没有实质性地增加风险。也没有足够证据发现也没有足够证据发现“继续服用口服
26、抗凝药与肝素过渡性治疗间血栓栓塞风继续服用口服抗凝药与肝素过渡性治疗间血栓栓塞风险差别险差别”另有另有1个一级证据临床研究发现，牙科手术，使用低分子肝素过渡性治疗与继个一级证据临床研究发现，牙科手术，使用低分子肝素过渡性治疗与继续服用抗凝药相比，出血风险很可能相似。续服用抗凝药相比，出血风险很可能相似。Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurol
27、ogy 80 May 28,2013Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013如果停用抗栓药物，该停多长时间？也有很多回顾性分析，提示停药时间可更短。缺血性脑卒中患者接受牙科手术时应常规地继续服用阿司匹林(Level A)。published online May 1,2014继续使用阿司匹林可能（proba
28、bly）不增加临床意义的出血性并发症Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic(Level of Evidence:B),逆转抗栓作用时间，一般推荐也有很多回顾性分析，提示停药时间可更短。Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemicwith prior stroke,transient ischemic attack(TIA)缺血性脑卒中脑
29、出血转化继续使用阿司匹林可能（probably）不增加临床意义的出血性并发症经尿道前列腺切除术，继续使用阿司匹林增加临床意义出血风险没有达统计学差异(Level U).one Class I study1 and 2 Class II studies1年次要临床终点（包括死亡、心肌梗死、卒中）发生率降低（p=0.Class IIb;Level of Evidence CClass IIb;Level of Evidence C缺血性脑卒中脑出血转化12 months after intracoronary stent placementGuidelines for the Prevention
30、 of Stroke in Patients With Stroke and Transient Ischemic Stroke.暂停抗血小板药物所致血栓栓塞的风险经尿道前列腺切除术，继续使用阿司匹林增加临床意义出血风险没有达统计学差异(Level U).0)plus single antiplatelet therapy rather than dual antiplatelet therapy(eg,aspirin and clopidogrel)or triple therapy(eg,warfarin,aspirin,and clopidogrel)PH2 30%梗死灶有明显占位效应出
31、血或远离梗死灶出血Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013比较了华法林、氯吡格雷加或不加阿司匹林的双联与三联治疗尚无足够的证据支持任何明确的结论PH1 30%梗死灶有轻微占位效应出血如果停用抗栓药物，该停多长时间？如果停用抗栓药物，该停多长时间？尚无足够的证据支持任何明确的结论 抗栓作用时间阿司匹林和氯吡格
32、雷预计可达7天单次量的华法林作用时间预计为2-5天 逆转抗栓作用时间，一般推荐抗血小板药物停止7-10天华法林停止5天也有很多回顾性分析，提示停药时间可更短。Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推 荐 牙科操作，继续使用阿司匹林，很可能（highly unlikely）不增加临床意义的出血性并发症。缺血
33、性脑卒中患者接受牙科手术时应常规地继续服用阿司匹林(Level A)。Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013 推 荐 继续使用阿司匹林可能（probably）不增加临床意义的出血性并发症 眼部麻醉、白内障手术、皮肤科小手术和操作、经直肠超声引导下前列腺穿刺、腰穿/硬膜外操作、腕管手术(Level B)鉴于
34、很小临床意义出血风险 脑卒中患者接受上述操作时也许应该继续使用阿司匹林(Level B)。Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推荐 继续使用阿司匹林可能（might）不增加临床意义出血并发症 玻璃体视网膜手术、肌电图、经支气管镜肺活检、肠镜检查、息肉切除术、胃镜检查和活检、括约肌切开术、腹部超声引导下活
35、检 较弱证据支持较小临床意义出血风险 高危血栓栓塞风险脑卒中病人接受上述操作时可能应该继续使用阿司匹林(Level C)。Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013 推 荐 虽然出血性不良事件罕见 经尿道前列腺切除术，继续使用阿司匹林增加临床意义出血风险没有达统计学差异(Level U).Summary of
36、 evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推 荐 髋部骨科手术 继续服用阿司匹林很可能（probably）增加出血风险(Level B).Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in p
37、atients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推 荐 牙科操作，继续使用华法林很可能（highly unlikely）不增加临床意义的出血性并发症(Level A).鉴于出血风险小 缺血性脑卒中病人接受牙科操作时应常规继续使用华法林(Level A).Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrova
38、scular disease,Neurology 80 May 28,2013推 荐 皮肤科操作，继续使用华法林仅轻微(1.2%)增加出血风险(Level B)皮肤科皮肤操作，也许应继续使用华法林(Level B).Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推 荐 眼科麻醉，继续使用华法林很可能（probab
39、ly）不增加临床意义出血风险(Level B),眼科麻醉后眼科手术，虽然出血性不良事件罕见 眼科手术出血风险研究仍得不出“华法林影响临床意义出血风险”的统计意义 没有足够证据支持眼科手术时需停用华法林(Level U).Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013推 荐 肌电图、前列腺手术、腹股沟疝修补术、大隐
40、静脉消融手术 华法林可能（might）不增加临床意义出血 接受上述手术或操作时可能应继续使用华法林(Level C).Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013(eg,CHADS2 score 1)who experience an acute coronary syndrome and do not und
41、ergo intracoronary stent placementwith prior stroke,transient ischemic attack(TIA)warfarin(INR 2.Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013继续使用阿司匹林可能（might）不增加临床意义出血并发症Guidelin
42、es for the Prevention of Stroke in Patients With Stroke and Transient Ischemic2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation也有很多回顾性分析，提示停药时间可更短。Class IIb;Level of Evidence C单次量的华法林作用时间预计为2-5天结果显示华法林加氯吡格雷的双联治疗结果显示华法林加氯吡格雷的双联治疗Antithrombotic Therapy for Atrial Fibri
43、llation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Based Clinical Practice GuidelinesAntithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-B
44、ased Clinical Practice Guidelines(Grade 2C).For patients with AF at high risk of stroke(eg,CHADS2 score 2)during the first month after placement of a bare-metal stent or the first 3 to 6 months after placement of a drug-eluting stent suggest triple therapy(eg,VKA therapy,aspirin,and lopid-ogrel)rath
45、er than dual antiplatelet therapy(eg,aspirin and clopidogrel)(Grade 2C)Antithrombotic Therapy for Atrial Fibrillation Antithrombotic Therapy and Prevention of Thrombosis,9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines For patients with nonvalvular AFFor patien
46、ts with nonvalvular AF oral anticoagulants are recommended Options include:warfarin(INR 2.0 to 3.0)(Level of Evidence:A)dabigatran(Level of Evidence:B),rivaroxaban(Level of Evidence:B)apixaban(Level of Evidence:B)2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial FibrillationWOEST
47、WOEST试验试验 比较了华法林、氯吡格雷加或不加阿司匹林的双联与三联治疗 结果显示华法林加氯吡格雷的双联治疗 出血风险更低（p0.001），1年次要临床终点（包括死亡、心肌梗死、卒中）发生率降低（p=0.025）血栓栓塞风险并不增加 指南对这种抗栓方案更为推崇2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial FibrillationSummary of evidence-based guideline:Periprocedural management of antithrombotic medicat
48、ions in patients with ischemic cerebrovascular disease,Neurology 80 May 28,2013published online May 1,2014CHA2DS2-VASc score is recommended for assessment of stroke risk缺血性脑血管疾病患者抗栓治疗(Level of Evidence:B)Class IIb;Level of Evidence C对于急性脑出血、蛛网膜下腔出血或硬脑膜下出血后，何时恢复或开始抗凝治疗，最佳时机尚无定论。bare-metal stents may
49、be considered to minimize the required duration of dual antiplatelet therapy12 months after intracoronary stent placementsuggest a VKA(INR 2.逆转抗栓作用时间，一般推荐缺血性脑卒中脑出血转化Class IIb;Level of Evidence CFor patients with AF at intermediate to high risk of stroke牙科操作，继续使用华法林很可能（highly unlikely）不增加临床意义的出血性并发症(
50、Level A).暂停抗血小板药物暂停抗血小板药物所致血栓栓塞的风险所致血栓栓塞的风险 one Class I study1 and 2 Class II studies 暂停阿司匹林很可能增加脑卒中或短暂性脑缺血发作风险发生脑卒中风险与阿司匹林停止时间长短相关停药2周的相对危险度（RR）为1.97停药4周的比值比（OR）为3.4停药5月的相对危险度（RR）为1.40Summary of evidence-based guideline:Periprocedural management of antithrombotic medications in patients with ischem
