1例缺血性卒中合并高血压房颤患者的循证治疗

Evidence-based Treatment for a Patient with Ischemic Stroke Accompanied by Hypertension and Atrial Fibrillation

目的介绍1例缺血性卒中合并高血压房颤患者的循证治疗体会。方法按PICO原则,针对患者的临床问题,计算机检索Cochrane图书馆(2006年第4期)、SUMsearch(1980.1～2006.12)、PubMed(1980.1～2006.12)中有关抗凝剂预防及治疗缺血性脑卒中合并心房纤颤,缺血性卒中降压治疗的循证临床指南、RCT、系统评价和Meta分析,并评价其质量,判断研究结论的真实性,重要性和适用性,获取最佳证据用于临床治疗。结果共检索到4篇指南,3篇系统评价和6篇RCT。分析结果表明:低剂量抗凝治疗对患者安全有效,卒中急性期血压不宜快速降低,根据检索到的证据及患者的具体病情和意愿,该患者抗凝治疗使用小剂量的华法林口服,INR调整为2.0左右,待患者进入恢复期后再口服福辛普利加吲达帕胺控制血压。经2周低剂量抗凝及辅助康复治疗后患者症状缓解,经过一个月的治疗随访,证实所选方案适合患者。结论对于急性缺血性卒中合并房颤患者,抗凝治疗仍是一线选择,且华法林疗效优于其他药物,针对老年患者应个体化调整INR比值,必要时维持较小值亦可获得最大效益同时减少出血风险,在不能耐受抗凝治疗时可选用阿司匹林治疗。卒中急性期的血压控制不宜太过积极,恢复期可选用ACE抑制剂加小剂量利尿剂控制血压。

Objective To formulate an evidence-based treatment plan for a patient with ischemic stroke accompanied by hypertension and atrial fibrillation. Methods We searched The Cochrane Library （Issue 4, 2006）, SUMsearch （January 1980 to December 2006） and PubMed （January 1980 to December 2006） to identify randomized controlled trials （RCTs）, systematic reviews （SRs） and meta-analyses about the efficacy and safety of anticoagulant therapy for ischemic stroke coupled with atrial fibrillation, and blood pressure lowering therapy for ischemic stroke coupled with hypertension. We evaluated the validity, reliability and feasibility of each study to identify the current best evidence. Results Four guidelines, 3 SRs and 6 RCTs were included. The evidence showed that low-intensity anticoagulant therapy was safe and effective for this patient, and that rapid blood pressure lowering therapy was not suitable for acute ischemic stroke. According to the current evidence, as well as the patient＇s clinical condition and preference, low-intensity warfarin was given with a target INR （international normalized ratio） of 2.0. During convalescence, he was given oral fosinopril and indapamide. His symptoms were relieved after two weeks of treatment, and follow-up at one month indicated that this plan was suitable for the patient. Condusions Anticoagulant therapy is still preferred for acute ischemic stroke accompanied by hypertension and atrial fibrillation. The current evidence suggests that warfarin is superior to other anticoagulants. The target INR should be adjusted individually, especially in old patients. The maintenance of a low INR level, if necessary, could maximise utility and minimise the risk of hemorrhage. Aspirin is recommended when anticoagulants cannot be tolerated. Intensive blood pressure lowering therapy is not reasonable for patients with acute ischemic stroke. Antihypertensive drugs like ACEI and low-dose diuretics mav be chosen during convalescence.