切换至 "中华医学电子期刊资源库"

中华脑血管病杂志(电子版) ›› 2022, Vol. 16 ›› Issue (01) : 12 -16. doi: 10.11817/j.issn.1673-9248.2022.01.003

专家论坛

伴脑微出血的心房颤动患者抗栓策略的研究进展
于垚1, 李华军1, 李永杰1,()   
  1. 1. 100044 北京大学人民医院神经内科
  • 收稿日期:2022-01-04 出版日期:2022-02-01
  • 通信作者: 李永杰
  • 基金资助:
    北京大学人民医院研究与发展基金(RDY2019-25)

Progress in antithrombotic strategy for atrial fibrillation in patients with cerebral microbleeds

Yao Yu1, Huajun Li1, Yongjie Li1,()   

  1. 1. Department of Neurology, Peking University People's Hospital, Beijing 100044, China
  • Received:2022-01-04 Published:2022-02-01
  • Corresponding author: Yongjie Li
引用本文:

于垚, 李华军, 李永杰. 伴脑微出血的心房颤动患者抗栓策略的研究进展[J]. 中华脑血管病杂志(电子版), 2022, 16(01): 12-16.

Yao Yu, Huajun Li, Yongjie Li. Progress in antithrombotic strategy for atrial fibrillation in patients with cerebral microbleeds[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2022, 16(01): 12-16.

脑微出血系脑小血管病变所致,人群患病率高。越来越多的研究证据表明,脑微出血是缺血性卒中后发生出血转化和原发性颅内出血的独立危险因素,而出血正是抗栓治疗的最大顾虑所在。因此,伴脑微出血的心房颤动患者的抗栓治疗面临更大的挑战。然而,迄今为止,仍缺乏高质量的临床随机对照试验对脑微出血伴心房颤动患者抗栓治疗的获益和风险进行评价。本文对相关研究进行综述,为临床医师制定个体化的抗栓方案提供参考,使患者最大程度获益。

Cerebral microbleeds (CMBs) are caused by cerebral small vessel diseases with high prevalence. Emerging evidence shows that CMBs are an independent risk factor of intracranial hemorrhage and hemorrhagic transformation after ischemic stroke. Hemorrhage is the biggest concern of antithrombotic therapy. Therefore, antithrombotic therapy is one of the major challenges for atrial fibrillation in patients with CMBs. However, so far there is no high-quality clinical randomized controlled trial to evaluate the benefits and risks of the patients taking antithrombotic therapy. This article reviews the relevant studies to provide evidence for clinicians to antithrombotic strategy according to the clinical characteristics of patients, so as to maximize the benefits of patients.

1
DeSimone CV, Graff-Radford J, El-Harasis MA, et al. Cerebral amyloid angiopathy and implications for atrial fibrillation management [J]. Lancet, 2017, 390(10089): 9-11.
2
Ntaios G, Perlepe K, Lambrou D, et al. Identification of patients with embolic stroke of undetermined source and low risk of new incident atrial fibrillation: the AF-ESUS score [J]. Int J Stroke, 2021, 16(1): 29-38.
3
Geisler T, Poli S, Meisner C, et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): rationale and study design [J]. Int J Stroke, 2017, 12(9): 985-990.
4
Huang WY, Ovbiagele B, Lee M. Oral anticoagulants vs antiplatelets in cryptogenic stroke with potential cardiac emboli: meta-analysis [J]. Eur J Internal Med, 2022, 95: 44-49.
5
Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source [J]. N Engl J Med, 2018, 378(23): 2191-2201.
6
Haeusler KG, Wilson D, Fiebach JB, et al. Brain MRI to personalise atrial fibrillation therapy: current evidence and perspectives [J]. Heart, 2014, 100(18): 1408.
7
Greenberg SM, Vernooij MW, Cordonnier C, et al. Cerebral microbleeds: a guide to detection and interpretation [J]. Lancet Neurol, 2009, 8(2): 165-174.
8
Yubi T, Hata J, Ohara T, et al. Clinical significance of Magnetic Resonance Imaging makers of vascular brain injury, a systematic review and Meta-anylasis [J]. JAMA Neurol, 2018, 10(28): E1-E14.
9
Yubi T, Hata J, Ohara T, et al. Prevalence of and risk factors for cerebral microbleeds in a general Japanese elderly community [J]. Neurol Clin Pract, 2018, 8(3): 223-231.
10
Akoudad S, Portegies MLP, Koudstaal PJ, et al. Cerebral microbleeds are associated with an increased risk of stroke: the Rotterdam study [J]. Circulation, 2015, 132(6): 509-516.
11
Charidimou A, Kakar P, Fox Z, et al. Cerebral microbleeds and recurrent stroke risk: systematic review and meta-analysis of prospective ischemic stroke and transient ischemic attack cohorts [J]. Stroke, 2013, 44(4): 995-1001.
12
蒋在军, 王田, 刘辉. 脑微出血与不常见疾病相关性的研究进展 [J/OL]. 中华脑血管病杂志(电子版), 2020, 14(3): 172-174.
13
Poels MM, Vernooij MW, Ikram MA, et al. Prevalence and risk factors of cerebral microbleeds: an update of the Rotterdam scan study [J]. Stroke J Cereb Circ, 2010, 41(10 Suppl): S103-S106.
14
Horstmann S, Möhlenbruch M, Wegele C, et al. Prevalence of atrial fibrillation and association of previous antithrombotic treatment in patients with cerebral microbleeds [J]. Eur J Neurol, 2015, 22(10): 1355-1362.
15
Akoudad S, Darweesh SK, Leening MJ, et al. Use of coumarin anticoagulants and cerebral microbleeds in the general population [J]. Stroke J Cereb Circ, 2014, 45(11): 3436-3439.
16
Lovelock CE, Cordonnier C, Naka H, et al. Antithrombotic drug use, cerebral microbleeds, and intracerebral hemorrhage: a systematic review of published and unpublished studies [J]. Stroke, 2010, 41(6): 1222-1228.
17
Song TJ, Kim J, Song D, et al. Association of cerebral microbleeds with mortality in stroke patients having atrial fibrillation [J]. Neurology, 2014, 83(15): 1308-1315.
18
Nam KW, Kwon HM, Lim JS, et al. The presence and severity of cerebral small vessel disease increases the frequency of stroke in a cohort of patients with large artery occlusive disease [J]. PLoS One, 2017, 12(10): e0184944.
19
Shoamanesh A, Hart RG, Connolly SJ, et al. Microbleeds and the effect of anticoagulation in patients with embolic stroke of undetermined source: an exploratory analysis of the NAVIGATE ESUS randomized clinical trial [J]. JAMA Neurol, 2021, 78(1): 11-20.
20
Gregoire SM, Brown MM, Kallis C, et al. MRI detection of new microbleeds in patients with ischemic stroke: five year cohort follow-up study [J]. Stroke, 2010, 41(1): 184-186.
21
孙伟, 张玉生. 进退维谷: 心房颤动患者抗凝治疗相关出血后的卒中预防 [J]. 中国卒中杂志, 2021, 16(8): 757-761.
22
Kimura T, Tucker A, Nakagaki A, et al. Anticoagulation protocol for secondary prevention of acute ischemic stroke associated with nonvalvular atrial fibrillation [J]. J Stroke Cerebrovasc Dis, 2021, 30(8): 105893.
23
Kuno T, Takagi H, Ando T, et al. Oral anticoagulation for patients with atrial fibrillation on long-term hemodialysis [J]. J Am Coll Cardiol, 2020, 75(3): 273-285.
24
Pasquini M, Benedictus MR, Boulouis G, et al. Incident cerebral microbleeds in a cohort of intracerebral hemorrhage [J]. Stroke, 2016, 47(3): 689-694.
25
Lim JS, Hong KS, Kim GM, et al. Cerebral microbleeds and early recurrent stroke after transient ischemic attack: results from the Korean Transient Ischemic Attack Expression Registry [J]. JAMA Neurol, 2015, 72(3): 301-308.
26
Wilson D, Ambler G, Shakeshaft C, et al. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study [J]. Lancet Neurol, 2018, 17(6): 539-547.
27
Imaizumi T, Inamura S, Kohama I, et al. Antithrombotic drug uses and deep intracerebral hemorrhages in stroke patients with deep cerebral microbleeds [J]. J Stroke Cerebrovasc Dis, 2013, 22(6): 869-875.
28
Thijs V, Lemmens R, Schoofs C, et al. Microbleeds and the risk of recurrent stroke [J]. Stroke, 2010, 41(9): 2005-2009.
29
Soo YO, Yang SR, Lam WW, et al. Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds [J]. J Neurol, 2008, 255(11): 1679-1686.
30
Smith EE, Saposnik G, Biessels GJ, et al. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association [J]. Stroke, 2017, 48(2): e44-e71.
31
Tsivgoulis G, Zand R, Katsanos AH, et al. Risk of symptomatic intracerebral hemorrhage after intravenous thrombolysis in patients with acute ischemic stroke and high cerebral microbleed burden: a meta-analysis [J]. JAMA Neurol, 2016, 73(6): 675-683.
32
O'donnell MJ, Eikelboom JW, Yusuf S, et al. Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study [J]. Am Heart J, 2016, 178: 145-150.
33
Chairidimou A, Shoamanesh A, Al-Shahi Salman R, et al. Cerebral amyloid anbgiopathy, cerebral microbleeds and implications for anticoagulation decisions: the need for a balanced approach [J]. Int J Stroke, 2018, 13(2): 117-120.
34
Charidimou A, Imaizumi T, Moulin S, et al. Brain hemorrhage recurrence, small vessel disease type, and cerebral microbleeds: a meta-analysis [J]. Neurology, 2017, 89(8): 820-829.
35
Eckman MH, Rosand J, Knudsen KA, et al. Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis [J]. Stroke J Cereb Circ, 2003, 34(7): 1710-1716.
36
Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage [J]. JAMA J Am Med Assoc, 2015, 313(8): 824-836.
37
Horstmann S, Zugck C, Krumsdorf U, et al. Left atrial appendage occlusion in atrial fibrillation after intracranial hemorrhage [J]. Neurology, 2014, 82(2): 135-138.
[1] 刘丹妮, 敖梦, 冉海涛, 李世玉, 秦芳. 三维超声心动图及二维斑点追踪成像对持续性心房颤动复律后双心房逆向重构的评估[J]. 中华医学超声杂志(电子版), 2023, 20(08): 827-835.
[2] 邹勇, 顾应江, 丁昊, 杨呈浩, 陈岷辉, 蔡昱. 基于Nrf2/HO-1及NF-κB信号通路探讨葛根素对大鼠脑出血后早期炎症反应及氧化应激反应的影响[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 271-277.
[3] 运陌, 李茂芳, 王浩, 刘东远. 微创穿刺引流联合吡拉西坦、乌拉地尔治疗基底节区高血压性脑出血的临床研究[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 278-285.
[4] 刘政委, 仪立志, 尹夕龙, 孔文龙, 纠智松, 张文源. 锥颅血肿外引流与神经内镜手术治疗老年基底节区高血压性脑出血的疗效分析[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 299-303.
[5] 韦维, 李忠华, 黄礼德. 机器人辅助第四脑室血肿穿刺抽吸外引流术[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(04): 255-256.
[6] 陈显金, 吴芹芹, 何长春, 张庆华. 利用多模态医学数据和机器学习构建脑出血预后预测模型的研究[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(04): 193-198.
[7] 谭可, 李锦平, 彭玉涛, 吴文汧, 杨子文, 汪阳, 陶立波, 刘畅. 机器人辅助立体定向血肿引流术治疗自发性脑出血疗效及卫生经济学评价[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(04): 205-214.
[8] 王震, 杨晓月, 苏康康, 王朝阳, 李少杰, 陈淑霞, 谷剑. β受体阻滞剂对心力衰竭合并房颤患者预后影响的研究进展[J]. 中华临床医师杂志(电子版), 2023, 17(04): 479-482.
[9] 丁晶, 李培雯, 许迎春. 醒脑开窍针刺法在神经急重症中的应用[J]. 中华针灸电子杂志, 2023, 12(04): 161-164.
[10] 曹宾, 郭瑛, 夏盼盼, 刘佳榛, 王骏, 孙育民. 非阵发性心房颤动的治疗策略:来自心脏电生理一线医师的问卷调查[J]. 中华心脏与心律电子杂志, 2023, 11(03): 147-153.
[11] 段园霞, 顾柳娜, 张磊, 周丽婷, 朱海瀛, 杨超, 陈海英, 顾晓青, 高宗尚, 黄蛟灵. 上海市奉贤区基层全科医师对心房颤动的认知现状及影响因素分析[J]. 中华心脏与心律电子杂志, 2023, 11(03): 154-159.
[12] 范家宁, 林大卫, 李明飞, 张峰, 张晓春, 潘文志, 周达新. 左心耳封堵术联合房间隔缺损封堵术一站式手术安全性与有效性研究[J]. 中华心脏与心律电子杂志, 2023, 11(02): 109-113.
[13] 蒋子涵, 于丰源, 张宏达, 丁蕾, 米利杰, 唐闽. 2023年美国心律学年会心律失常领域最新临床研究进展[J]. 中华心脏与心律电子杂志, 2023, 11(02): 125-128.
[14] 赵暾, 徐霁华, 何有娣, 鲁明. 误诊为脑梗死且险些溶栓的急性自发微量脑出血一例[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 369-372.
[15] 邱令智, 胡萍, 罗婷, 鄢华. 脂蛋白(a)与心房颤动关系的研究进展[J]. 中华脑血管病杂志(电子版), 2023, 17(03): 280-284.
阅读次数
全文


摘要