ESSEN评分与脑卒中课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,掌握危险分层工具,(ESRS),识别卒中高危患者及长期预防,缺血性卒中,/TIA,复发的决定因素,缺血性卒中,TIA,复发,不复发,规范治疗,易损性,遗传背景,何人复发：卒中易损病人,卒中易损病人,危险因素,合并其他血管床病变,脑动脉狭窄率,脑储备能力,动脉粥样硬化斑块易损性,识别卒中易损病人的意义,卒中易损病人,危险因素,合并其他血管床病变,脑动脉狭窄率,脑储备能力,动脉粥样硬化斑块易损性,选择治疗,判定预后,选择预防,易损病人判定,二级预防分层用药依据,药物基因学,发病机制和药物作用靶点,危险因素,二级预防分层用药依据,药物基因学,发病机制和药物作用靶点,危险因素,缺血性卒中,TIA,二级预防中,抗血小板药物规范化应用的中国专家共识,氯吡格雷,(75mg/,日,),、阿司匹林,(50,325mg/,日,),、缓释双嘧达莫,(200mg),与阿司匹林（,25mg,）复方制剂（,2,次,/,日）都可作为首选的抗血小板药物（,I,类推荐，,A,级证据）。,依据各种抗血小板治疗药物的获益、相应风险及费用进行个体化治疗（,II,类推荐，,C,级证据）。,动脉粥样硬化性缺血性卒中,/TIA,以及既往有脑梗死病史、冠心病、糖尿病或周围血管病者优先考虑氯吡格雷,(75mg/,日,),（,I,类推荐，,B,级证据）。,一级预防,Framingham,SCORE,SPAF-III, CHADS2 index (,Atrial,Fibrillation),二级预防,Recurrent Stroke Risk Scores,High grade carotid,stenosis,危险分层概念,Framingham,卒中风险评估,(FSP),1,2,3,4,5,6,7,8,9,10,100,90,80,70,60,50,40,30,20,10,0,危险因素,值,年,累积风险,性别（,M/F),M,1,2.3%,年龄,(,岁）,64,2,4.9%,收缩压,(mmHg),186,3,7.6%,正在降压治疗,(Y=1 N=0),0,4,11.2%,糖尿病,(Y=1 N=0),0,5,15.1%,吸烟,(Y=1 N=0),1,6,16.6%,心血管疾病,(Y=1 N=0),0,7,23.5%,房颤,(Y=1 N=0),0,8,28.9%,左室肥厚,(Y=1 N=0),1,9,33.1%,10,年累积风险,10,36.3%,累计卒中风险,随访时间（年）,个体卒中风险（,10,年后）,0,身高,71.0,体重,190.0,26.5,体重指数,26.5,（超重）,注：,1,磅,=0.45392,公斤；,1,英尺,=2.54,厘米,DAgostino,RB et al. Stroke. 1994;25:40-43,已经验证的危险分层工具,Primary Secondary prevention,Titel,FraminghamSPI IIABCD,Essen,Prediction given10 years2 years7 days2 years,Index eventasymptomatic IS or TIA,TIA,IS or TIA,Range0-380-150-60-9,High-risk group 17742,Items,Age,age, 70 age 60 age 60 /75 diabetes,diabetes,arterialDiabetes,systolic RRprior strokehypertensionarterial,antihypertents,coronary heart,hemiaparesis,hypertension,smokingdiseaseaphasiaPrior MI,Cardiac diseasecardiac failureduration of Other cardio-,atrial,fibrillationstroke index eventsymptoms 10min /vascular disease,left ventricular(vs. TIA)1hPAD,hypertrophySmoking,prior IS / TIA,Reference,DAgostino,. Stroke,Kernan,Rothwell,. Lancet,Diener,. Exp,Opin,1994;25:40-32000;31:456-622005;366:29-36,Pharmacother,2005;6(5):755-764.,危险分层工具,寻找面临卒中复发的高危人群,基于,CAPRIE,试验卒中亚组分析开发的卒中风险预测工具,1,危险因素,分值,75,岁,2,高血压,1,糖尿病,1,既往,MI,1,其他心血管疾病（除外心房颤动和,MI,）,1,PAD,1,吸烟者,1,既往缺血性卒中,/TIA,史,1,最高分值,9,ESRS,: Essen,Stroke Risk Score Essen,卒中风险评分量表,1,1. CAPRIE Steering Committee. A,randomised, blinded, trial of,clopidogrel,versus aspirin in patients at risk of,ischaemic,events Lancet 1996;348:1329-1339,SCALA,：方法,验证,Essen,风险评分的前瞻性横断面研究,德国的,85,个卒中单元,852,名患者,在,2005,年,7,月到,10,月间入组患者,排除插管和颅内出血的患者,不干预,17.5,（,SD 0.88,）个月后以中心化随访为主,Weimar C.,Rother,J. et al.,J,Neurol, 2007, 254 (11).1562-1568,SCALA,：近,60%,的患者处于高复发风险,Weimar C.,Rother,J. et al.,J,Neurol, 2007, 254 (11).1562-1568,0 1 2 3 4 5 6 7 8 9,高危,58.3 %,低危,41.7%,Essen,卒中风险评分,患者,(%),4.6,16,21.2,23.5,16.3,10.3,0.6,1.9,5.7,0,10,20,30,J. Neurol. Neurosurg. Psychiatry 2008;79;1339-1343;,比值比,:,1.86, CI 0.91-3.80,Essen,卒中风险评分,3,与,3,患者的卒中再发事件比较,12.5,10.0,7.5,5.0,2.5,0.0,0,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,Months after admission,Essen Risk Score,3,3,%,ESRS,评分,3,患者的再发风险是,6,ESRS,ESRS6,的卒中极高危患者比例较低,(,仅,96,位患者，占,1.4%),，未纳入卒中高危：动脉粥样硬化性卒中以及既往有脑梗死病史、冠心病、糖尿病或周围血管病 易损斑块或动脉,-,动脉栓塞,12,10,8,6,4,2,0,0,1,2,3,4,5,6,ESRS,波立维,75mg,阿司匹林,325mg,波立维,优于阿司匹林,卒中事件率,/,年,(%),ESRS,3,分的高危患者，预防卒中再发，,氯吡格雷,优于阿司匹林,The REACH Registry,An International, Prospective Observational Study in Subjects at Risk of,Atherothrombotic,Events in an Outpatient Setting,GLB.CLO.06.02.06,Australia: 2,872,Latin America: 1,931,Brazil: 441,Chile: 253,Mexico: 899,Interlatina,: 338,Middle East: 846,Israel: 379,Kingdom of Saudi Arabia: 198,Lebanon: 120,United Arab Emirates: 149,Europe: 23,542,Austria: 1,588,Lithuania: 99,Belgium: 383,The Netherlands: 324,Bulgaria: 996,Portugal: 218,Denmark: 422,Romania: 2,009,Finland: 311,Russia: 999,France: 4,592,Spain: 2,515,Germany: 5,521,Switzerland: 695,Greece: 699,Ukraine: 596,Hungary: 957,United Kingdom: 618,North America: 27,746,Canada: 1,976,USA: 25,770,Thailand: 515,Taiwan: 1,057,South Korea: 505,Singapore: 880,Philippines: 1,039,Malaysia: 525,Indonesia: 499,Hong Kong: 175,China: 708,Asia: 10,951,Japan: 5,048,Interlatina,includes Panama, Costa Rica, Dominican Republic, Ecuador, Guatemala and Peru,A Large and Far-Reaching International Survey of Atherothrombosis*,1,*Data shown may differ slightly from published abstracts owing to a,subsequent database lock.,1. Bhatt DL et al, on behalf of the REACH Registry Investigators.,JAMA,2006; 295(2): 180-189.,一年致死性和非致死性卒中（白）以及联合心血管事件（斜纹）,Stroke. 2009;40:350-354.,Copyright 2008 BMJ Publishing Group Ltd.,Weimar, C et al. J,Neurol,Neurosurg,Psychiatry 2008;79:1339-1343,Survival free of recurrent stroke during follow-up in patients with an Essen Stroke Risk Score (ESRS) =3 (n = 700).,Copyright 2008 BMJ Publishing Group Ltd.,Weimar, C et al. J,Neurol,Neurosurg,Psychiatry 2008;79:1339-1343,Survival free of recurrent stroke during follow-up in patients with an Essen Stroke Risk Score (ESRS) =3 (n = 700).,Essen,卒中危险评分（,ESRS,）,危险因素或疾病,分数,年龄,65,75,岁,1,年龄,75,岁,2,高血压,1,糖尿病,1,既往心肌梗死,1,其他心血管病（除心肌梗死和房颤）,1,周围血管病,1,吸烟,1,除本次事件之外的既往,TIA,或缺血性卒中,1,JNNP 2008;(6),Essen,评分应用,0,1,2,3,4,5,6,7,8,9,极高危,高危：卒中危险,4,低危：卒中危险,4,JNNP 2008;(6),寻找面临卒中复发的高危人群,基于,CAPRIE,试验卒中亚组的卒中预测模型,1,危险因素,分值,75,岁,2,高血压,1,糖尿病,1,既往,MI,1,其他心血管疾病（除外心房颤动和,MI,）,1,PAD,1,吸烟者,1,既往缺血性卒中,/TIA,史,1,最高分值,9,1,. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:1329-1339,ESRS,:,E,ssen,Stroke Risk Score Essen,卒中风险量表,1,3,为高危患者，,卒中风险,4%/,年,需要更强的抗血小板药物,