非心栓塞性缺血性中风或高危短暂性脑缺血发作患者。第2部分。二级预防

A. Kulesh, S. N. Yanishevsky, D. A. Demin, L. Syromyatnikova, O. Vinogradov
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摘要

高风险和极高风险的非心栓塞性缺血性卒中(IS)包括三组患者:严重颅外动脉粥样硬化,颅内动脉粥样硬化,主动脉弓动脉粥样硬化。这种风险也是侵袭性短暂性脑缺血发作(TIA)表型患者的特征。二级预防的有效性可通过以下策略提高:在轻度IS或高风险TIA中,短期双抗血小板治疗使用乙酰水杨酸联合氯吡格雷或替格瑞洛;乙酰水杨酸和低剂量利伐沙班长期双重抗血栓治疗多灶性动脉粥样硬化伴低出血风险和非腔隙性卒中非致残性IS的早期手术血运重建术(颈动脉内膜切除术或支架置入术)和高风险TIA的紧急血运重建术;强化降脂治疗,包括联合使用高剂量他汀类药物、依折麦比、PCSK9抑制剂或inclisiran,使低密度脂蛋白水平<1.4 mmol/L;使用糖化血红蛋白水平<7%的2型葡萄糖钠共转运蛋白抑制剂和1型胰高血糖素样肽激动剂进行降糖治疗;处方降压治疗,达到目标血压水平。
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Patient with non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Part 2. Secondary prophylaxis
Non-cardioembolic ischemic stroke (IS) of high and very high risk includes three groups of patients: with severe extracranial atherosclerosis, with any intracranial atherosclerosis, and with aortic arch atheromatosis. This risk is also characteristic of patients with aggressive transient ischemic attack (TIA) phenotypes. Effectiveness of secondary prophylaxis can be raised by these strategies: short-term dual antiplatelet therapy using a combination of acetylsalicylic acid with clopidogrel or ticagrelor in minor IS or high-risk TIA; long-term dual antithrombotic therapy with acetylsalicylic acid and low doses of rivaroxaban for multifocal atherosclerosis with low hemorrhagic risk and non-lacunar stroke; early surgical revascularization (carotid endarterectomy or stenting) for non-disabling IS and urgent revascularization for high-risk TIA; intensive, including combined, lipid-lowering therapy with high doses of statins, ezetimibe, PCSK9 inhibitors, or inclisiran to achieve low-density lipoprotein levels <1.4 mmol/L ; antidiabetic therapy using type 2 glucose-sodium cotransporter inhibitors and type 1 glucagon-like peptide agonists with glycosylated hemoglobin level of <7%; prescribing antihypertensive therapy and achieving target blood pressure level.
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