最新 脑梗死急性期的早期治疗(北京) 董强.ppt

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1、脑梗死急性期的早期治疗措施超早期脑梗死的溶栓治疗静脉溶栓治疗tPANINDSECASSI&II,ATLANTISStreptokinaseMAST-I,MAST-E,ASK动脉溶栓治疗前循环:MCA（PROACTII）后循环:BasilararteryNINDSrt-PA试验设计Part1Part2ExclusioncriteriaInclusioncriteriaPart1RandomizationPart2RandomizationrtPA(144)rtPA(168)Placebo(147)Placebo(165)Primaryoutcome:≥4-po

2、intimprovementonNIHSSorcompleteresolutionat24hrsPrimaryoutcome:globalteststatisticforfavorableoutcome(minimalornodisabilityat3monthsusing4scales)NINDSrt-PA试验：Part1PrimaryOutcome（24hrs）NS%patients≥4ptimprovementinNIHSS39%47%NEJM1995;333:1581-1587NINDSrt-PA试验：Part2PrimaryOutcome（3mos

3、）%patientswithlittleornodisabilityGlobalcomparisonofallscalescombined(Waldtest),p<0.0131%20%26%39%38%50%32%44%NEJM1995;333:1581-1587NINDSrt-PA试验：ICHwithin36hrsofRx%patientswithICH6.4%0.6%4.5%2.9%NEJM1995;333:1581-1587NINDSrt-PA试验：死亡率DaysafterRandomizationDeath(#ofpatients)NEJM1995;

4、333:1581-1587NINDSrt-PA试验：Whodevelopedhemorrhage?SymptomaticHemorrhageGoodRankin0-1PoorRankin2-5DeadOutcomeat3Monthsin624PatientsNINDSrt-PA试验：Longtermoutcome（1year）ECASSI：620病人rt-PA(1.1mg/kg)vs.安慰剂治疗窗<6hours90daysBarthelIndex和改良RankinScalert-PA和安慰剂组间无差异ECASSII：800病人rt-PA(0.9mg/kg)v

5、s.安慰剂治疗窗<6hours90days改良RankinScale<1rt-PA和安慰剂组间无差异ATLANTIS：613病人rt-PA(0.9mg/kg)vs.安慰剂治疗窗：3-5hours90daysNIHSS<1rt-PA和安慰剂组间无差异rt-PA治疗剂量和时间窗：Hackeetal.,JAMA.1995;274:1017-1025Hackeetal.,Lancet.1998;352:1245-1251Clarketal.,JAMA.1999;282:2019-2026InternationalStrokeTrial(IST)>Lancet1997

6、;349:1569-1581HongKongNadroparinTrial(HK)>NewEnglandJournalofMedicine1995;333:1588-1593TrialofORG10172inAcuteStrokeTreatment(TOAST)>JournaloftheAmericanMedicalAssociation1998;279:1588-1593上海低分子肝素治疗急性脑梗死临床试验(SH)>中国临床神经科学2003抗凝治疗急性脑梗死的临床试验上海低分子肝素治疗试验设计急性脑梗塞，<48小时内856例完全随机分组治疗组443例对照组

7、413例治疗组114例对照组99例研究终点：治疗后21天随访：治疗后3月（24.9%）痊愈+显进进步无变化恶化+死亡治疗组53.27%*29.8%16.25%2.49%对照组45.76%26.39%25.42%5.08%*p<0.05临床神经功能评分的疗效情况各个抗凝治疗临床试验的比较ISTFISS（HK）TOASTSHEntry<48hrs<48hrs<24hrs<48hrsEndpointDead/DependentDead/DependentGoodGoodDuration6months6months3months3monthsDrugHeparinN

8、adroparinORG10172Nadropari