卒中后预防策略可使痴呆风险减半

伦敦——欧洲卒中大会上公布的一项探讨二级预防策略长期效果的研究显示，优化抗高血压、抗血栓和降脂药物治疗，可显著降低卒中后认知功能障碍(Stroke 2013;44:138-45)。

在这项研究中，伦敦国王学院的Abdel Douiri博士及其同事从基于人群的南伦敦卒中注册库中查找到4413例在1995年至2011年间发生首次卒中的患者。在卒中后3个月及此后每年使用简明智力测验或简易精神状态检查表评估患者的认知功能。患者的平均年龄为70岁，49%为女性，70.5%为白人，其余为黑人(21.2%)和其他种族。

结果显示，卒中后认知功能障碍发生率依研究存在差异，但随着时间推移呈相对一致，共累及1/4的患者。在最佳应用抗凝剂、双重抗高血压治疗、双重抗血小板治疗和降脂治疗的情况下，认知功能障碍相对危险度分别为0.8、0.9、0.9和0.9。联用抗高血压药、抗凝剂和降脂药可使认知功能障碍风险减半。该获益见于大部分卒中亚型，但未见于出血性卒中患者和房颤性卒中患者。

既往研究显示，约10%的卒中患者在首次卒中前发生认知功能障碍，10%在单次卒中后发生痴呆，30%在复发性卒中后发生痴呆(Lancet Neurol. 2009;8:1006-18)。目前预防卒中后认知功能障碍的治疗策略往往注重于降低复发性卒中或其他血管事件的风险，但目前为止大部分研究的随访时间较短或患者数量过少，仅少数患者的认知问题是由血管原因引起。

Douiri博士表示，在卒中后使用上述建议的治疗对认知功能具有保护作用。

不够理想的卒中后降脂疗效

虽然优化卒中后药物可改善认知转归，但这点在常规治疗中并不始终能够达到。另一项由都柏林Mater大学医院的Danielle Ní Chróinín医生及其同事进行的前瞻性人群研究显示，降脂目标并非始终可达到。

在这项研究中，Chróinín医生及其同事采用北都柏林人群卒中研究的数据，评估了患者的脂质情况和临床医生在卒中后或短暂性脑缺血发作(TIA)后依从循证指南应用降脂药物的情况。在为期1年的研究期间，共分析了428例缺血性卒中患者和188例TIA患者的病历。患者的平均年龄为71岁。

结果显示，在女性、老年、事件发生前改良Rankin评分较差、及国立卫生研究院卒中量表评分较高的患者中，就诊时测定脂质及出院时处方他汀类药物的比例较低。根据事件类型或患者是否需住院治疗来划分，未发现脂质测定或他汀类药物治疗的比例存在差异。

就诊时，仅33.7%的高危患者正在接受降脂药物治疗。虽然75.5%患者出院时处方他汀类药物，但1/4本应处方该药的患者出院时却未处方该药。

在接受降脂治疗的患者中，半数以下(44%-46%)达到美国或欧洲指南设定的推荐目标水平。在合并糖尿病或动脉粥样硬化性卒中患者中，出院时处方他汀类药物的比例较高。

Chróinín医生的研究获卫生研究委员会、爱尔兰心脏基金会及Mater大学研究生研究和教育补助金支持。Chróinín医生和Douiri博士声明无相关经济利益冲突。

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By: SARA FREEMAN, Cardiology News Digital Network

LONDON – Cognitive dysfunction following a stroke could be reduced significantly if treatment with antihypertensive, antithrombotic, and lipid-lowering drugs were optimized, according to a study looking at the long-term impact of secondary prevention strategies.

The relative risk for cognitive dysfunction was 0.8 with the optimal use of anticoagulants, and 0.9, 0.9, and 0.9 with the optimal use of dual antihypertensive therapy, dual antiplatelet therapy, and lipid-lowering treatment, respectively.

"The combination of antihypertensives, antithrombotics, and lipid-lowering drugs reduced the risk of cognitive impairment by about half," Abdel Douiri, Ph.D., said at the annual European Stroke Conference. The benefit was seen in most stroke subtypes, although not in those with hemorrhagic stroke or in patients with stroke due to atrial fibrillation.

Dr. Douri of King’s College London and coinvestigators looked at whether preventing vascular events could be associated with a protective effect on patients’ overall cognitive function after a stroke. They used the population-based South London Stroke Register to identify 4,413 patients who had experienced a first stroke between 1995 and 2011. Patients were assessed for cognitive function using the Abbreviated Mental Test or Mini-Mental State Examination at about 3 months after their stroke and annually thereafter.

The mean age of patients was 70 years, 49% of the cohort were female, and 70.5% were white. Blacks (21.2%) and other ethnicities made up the remainder of the patient population.

Cognitive impairment rates after stroke vary by study, but have been shown to be relatively consistent over time, affecting up to a quarter of patients overall, Dr. Douri noted (Stroke 2013;44:138-45). Approximately 10% of stroke patients have cognitive impairment prior to their first stroke, 10% develop dementia after a single stroke, and 30% develop dementia after recurrent strokes (Lancet Neurol. 2009;8:1006-18).

Current treatment strategies for preventing cognitive impairment after stroke tend to focus on reducing the risk of recurrent stroke or other vascular events, although most studies to date have had short follow-up or too few patients, with only a small number of these having vascular causes for their cognitive problems.

"The use of recommended therapies after stroke appears to be associated with a protective effect," said Dr. Douiri.

Suboptimal lipid-lowering post stroke

Although optimizing poststroke medications might improve cognitive outcomes, it is not always achieved in routine care. The results of a separate prospective population-based study showed that lipid-lowering targets are not always being achieved.

"The suboptimal lipid control we observed, both preceding and following a stroke or TIA [transient ischemic attack], even where there was established vascular disease or risk factors, highlights the need for improved lipid management in patients who are at risk of stroke or TIA," said Dr. Danielle Ní Chróinín of Mater University Hospital and University College Dublin.

Dr. Chróinín and colleagues assessed patients’ lipid profiles and clinicians’ adherence to evidence-based guidelines for lipid-lowering medications after a stroke or transient ischemic attack using data from the North Dublin Population Stroke Study.

Over the course of the 1-year study, the medical records of 428 patients who had had an ischemic stroke and 188 who had had a TIA were analyzed. The mean age of patients was 71 years.

Lipid measurement at presentation and prescription of statin therapy at discharge were found to be less likely in female patients, those who were older, those with poorer modified Rankin scores before the event, and those with higher National Institutes of Health Stroke Scale scores. There was no difference in the likelihood of measurement or statin treatment based on the type of event or if the patient required hospitalization.

At presentation, only 33.7% of high-risk patients were being treated with lipid-lowering medications. Although 75.5% of patients were discharged on statin therapy, approximately one in four patients who should have been prescribed this medication were not taking a statin at discharge.

Of patients who were on lipid-lowering therapy, less than half (44%-46%) were achieving recommended target levels set by U.S. or European guidelines.

Statin treatment at discharge was more likely in patients who had concomitant diabetes or atherothrombotic stroke.

The study presented by Dr. Chróinín was supported by the Health Research Board, the Irish Heart Foundation, and a Mater University postgraduate research and education grant. Dr. Chróinín and Dr. Douiri said they had no relevant financial disclosures.