急性心肌梗死并脑卒中二级预防的循证医学证据

Evidence-based medicine for secondary prevention of acute myocardial infarction-stroke combination

目的:临床在对心肌梗死并脑卒中的预防中,仍有许多不规范之处,文章探讨有循证医学证据的预防措施。资料来源:应用计算机检索Medline1995/2005-11与心肌梗死并脑卒中相关的临床文章,检索词“MI(AMI),stroke,”,并限定检索文章语言种类为“English”,发表类型为clinicaltrial。同时计算机检索中国期刊网医学专题全文数据库(CHKD期刊全文库)1995-01/2005-12的相关文章,限定文章语言种类为中文,检索词“心肌梗死、脑卒中”。资料选择:对资料进行初审,选取同时包括上述2种疾病的文献,然后筛除有关于其病因、治疗的研究和个案报道,对剩余的文献查找全文。资料提炼:共收集到英文文献695篇,中文文献5篇。其中222篇是关于其预防的临床试验,86篇是关于急性心肌梗死并脑卒中的文献,其中13篇是关于急性心肌梗死并脑卒中预防的文献。排除的文献因系重复的同一研究、治疗对照研究、Meta分析研究。纳入28条进行综述。资料综合:心肌梗死并脑卒中的危险因素有前壁心肌梗死、高血压(尤其是收缩压和脉压增大)、心房纤颤、脑卒中病史、高龄、入院时心率增快,后来又提出高血糖、吸烟、血脂异常、胰岛素抵抗、早发心脑血管病家族史、既往心肌梗死病史、无症状的颈动脉狭窄、感染、饮酒等。其预防强调以下几方面:预防应该从青少年开始;戒烟酒、控制体质量、消除压力和紧张状态;抗血小板治疗;控制血压和血糖;调脂;筛选高危人群,早期干预,降低急性心肌梗死和脑卒中急性期发病率。结论:有循证医学的证据表明急性心肌梗死和脑卒中都应在控制和改善危险因素的同时进行综合干预,将直接减少其复发,但仍有不确切和存在争议之处。

OBJECTIVE： There are still so many non-standard treatments for myocardial infarction combining stroke in clinic. To explore the preventive measures based on evidence-based medicine. DATA SOURCES： We retrieved the related articles about myocardial infarction combining stroke with computer on Medline Database from 1995 to November 2005 with the key words of ＂MI （AMI）, stroke＂ in English and publication type was clinical trial. Simultaneously, the related articles were searched in the China Hospital Knowledge Database （CHKD） full text database from January 1995 to December 2005 with the key words of ＂myocardial infarction, stroke＂ in Chinese. STUDY SELECTION： The data were scanned firstly, and the literatures contained the above-mentioned two kinds of diseases were selected, and then the articles on its cause, treatment and case report were excluded. The full-texts of the left articles were searched. DATA EXTRACTION： Totally 695 English literatures and 5 Chinese literatures were collected. Of them, 222 articles were on clinical trial of its prevention, 86 on acute myocardial infarction combining stroke, including 13 articles on the prevention of acute myocardial infarction combining stroke. The articles with the same content, treatment control study, or Meta analysis were excluded. A total of 28 articles were included for review. DATA SYNTHESIS： Risk factors of myocardial infarction combining stroke were myocardial infarction of anterior wall, hypertension （especially the increasing of systolic blood pressure and pulse pressure）, atrial fibrillation, history of stroke, advanced age, increasing of heart rate on admission. It was proposed that afterwards hyperglycaemia, smoking, abnormal blood fat, insulin resistance, family history of early onset cerebrovascular disease, past history of myocardial infarction, nonsymptomatic carotid artery stenosis, infection, drinking and so on. It was stressed that prevention should be done from adolescent; stopping smoking and drinking, controlling body mass, eliminating pressure and tension, antiplatelet treatment, controlling blood pressure and blood glucose, regulating lipid, screening out high-risk population, early intervention, reducing incidence rate of acute myocardial infarction and stroke in acute phase. CONCLUSION： The evidence-based medicine suggests that comprehensive intervention should be conducted when we control risk factors for acute myocardial infarction and stroke, which will decline its recurrence directly, but there still are some uncertain and controversial factors.