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Lancet Neurol:>60岁隐源性TIA或卒中合并PFO的比例

2018-08-07 杨中华 脑血管病及重症文献导读

越来越多的隐源性TIA和卒中检测到卵圆孔未闭(PFO),最近的三项试验显示经皮封堵术优于内科治疗。这些试验纳入了年龄<=60岁的患者,同时大部分为非致残性事件合并PFO或房间隔动脉瘤。


越来越多的隐源性TIA和卒中检测到卵圆孔未闭(PFO),最近的三项试验显示经皮封堵术优于内科治疗。这些试验纳入了年龄<=60岁的患者,同时大部分为非致残性事件合并PFO或房间隔动脉瘤。

如果在老年人中隐源性血管事件与PFO有关,那么临床试验纳入这些患者是合理的,但是临床试验并未纳入这一部分患者,因此需要更多老年人的数据,并且更需要采取了最适合筛查策略的最佳证据。

经食道超声心动图是诊断PFO的金标准,已经被几项最近的临床研究采纳。然而,高达1/3的老年卒中患者(>60岁)并未进行经食道超声检查,因为卒中的严重性、吞咽困难、咽反射活跃或拒绝。除了经食道超声以外,增强TCD(TCD发泡试验)是一种无创、床旁和可重复的技术,检测PFO具有高敏感性和高特异性的特点。一小部分右向左分流与PFO无关,比如肺分流,但是大部分(95%左右)TCD检测到的右向左分流被经食道超声证实存在PFO。但是10%的患者,由于颞窗不良,影响了TCD在这些患者中的使用,但是此时采用经枕后循环超声也可以检测到右向左分流。

Sara Mazzucco等以前报道过一组数据提示在全年龄段隐源性TIA和卒中患者中,心源性病因的比例很低,但是并未系统性筛查右向左分流。因此,Sara Mazzucco等对基于人群的大型队列中TIA或非致残性卒中的患者进行了TCD发泡试验,以筛查右向左分流。另外,他们还系统综述了已发表的研究和本研究数据,报道了不同年龄段隐源性TIA或卒中患者的PFO检出率。该研究结果发表在2018年7月的Lancet Neurology上。

在这项基于人群的研究中(嵌套于OXVASC研究),研究者探讨了右向左分流的流行情况以及较大右向左分流(>20个微气泡)的患者比例。共572例连续的TIA或非致残性卒中患者,其中年龄>60岁者439例(77%),平均年龄70岁。523例(91%)适合进行TCD发泡试验,其中397例年龄>60岁。与已知病因的TIA或卒中相比,隐源性事件者检测到右向左分流的比例更高(OR 1.93, 95% CI 1.32–2.82; p=0.001),年龄超过60岁者也得到了类似的结果(2.06, 1.32–3.23; p=0.001)。把OXVASC的数据和其他以前发表的小型研究(年龄>=50岁,并且进行了TCD发泡试验)的数据pooled后,研究者发现右向左分流和隐源性事件相关(OR 2.35, 95% CI 1.42–3.90; p=0.0009; P-heterogeneity=0.15),这与经食道超声研究(2.0, 1.15–4.22; p=0.02; P-heterogeneity=0.02)的结果一致。以前的研究中,没有较大右向左分流的数据可以被用于比较隐源性事件(TOAST定义的隐源性事件)和其他事件,但是在这些病例中研究者未发现这种关系被减弱的证据。在隐源性TIA或非致残性卒中合并较大右向左分流的41例患者(本研究)中,25例(61%)年龄超过60岁,以此类推的话在英国每年有近6000例这样的患者。

最终作者认为,大部分TIA或非致残性卒中患者进行TCD发泡试验是可行的,TCD发泡试验检测到右向左分流的比率高于经食道超声的比例。较大右向左分流通常与隐源性TIA或卒中相关,这可能是一些患者的病因,PFO封堵手术的队列研究和临床试验把老年患者纳入进去是合理的。TCD发泡试验检测PFO可以作为一线筛查项目。

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    2019-06-28 howi
  2. [GetPortalCommentsPageByObjectIdResponse(id=1829738, encodeId=79d31829e38a5, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Fri Jun 28 13:52:00 CST 2019, time=2019-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1924753, encodeId=cfa31924e5333, content=<a href='/topic/show?id=f9dc1412453' target=_blank style='color:#2F92EE;'>#PFO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14124, encryptionId=f9dc1412453, topicName=PFO)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=726030, createdName=Boyinsh, createdTime=Wed Jun 12 03:52:00 CST 2019, time=2019-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2000530, encodeId=332b2000530d2, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Wed Jan 30 02:52:00 CST 2019, time=2019-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337252, encodeId=641233e2522e, content=嗯嗯,学习学习。, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:39:50 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026118, encodeId=b2251026118c8, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Aug 07 12:52:00 CST 2018, time=2018-08-07, status=1, ipAttribution=)]
    2019-06-12 Boyinsh
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    2019-01-30 yinhl1978
  4. [GetPortalCommentsPageByObjectIdResponse(id=1829738, encodeId=79d31829e38a5, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Fri Jun 28 13:52:00 CST 2019, time=2019-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1924753, encodeId=cfa31924e5333, content=<a href='/topic/show?id=f9dc1412453' target=_blank style='color:#2F92EE;'>#PFO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14124, encryptionId=f9dc1412453, topicName=PFO)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=726030, createdName=Boyinsh, createdTime=Wed Jun 12 03:52:00 CST 2019, time=2019-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2000530, encodeId=332b2000530d2, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Wed Jan 30 02:52:00 CST 2019, time=2019-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337252, encodeId=641233e2522e, content=嗯嗯,学习学习。, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:39:50 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026118, encodeId=b2251026118c8, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Aug 07 12:52:00 CST 2018, time=2018-08-07, status=1, ipAttribution=)]
    2018-08-08 liumin1987

    嗯嗯,学习学习。

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1829738, encodeId=79d31829e38a5, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Fri Jun 28 13:52:00 CST 2019, time=2019-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1924753, encodeId=cfa31924e5333, content=<a href='/topic/show?id=f9dc1412453' target=_blank style='color:#2F92EE;'>#PFO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14124, encryptionId=f9dc1412453, topicName=PFO)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=726030, createdName=Boyinsh, createdTime=Wed Jun 12 03:52:00 CST 2019, time=2019-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2000530, encodeId=332b2000530d2, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Wed Jan 30 02:52:00 CST 2019, time=2019-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337252, encodeId=641233e2522e, content=嗯嗯,学习学习。, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:39:50 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026118, encodeId=b2251026118c8, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Tue Aug 07 12:52:00 CST 2018, time=2018-08-07, status=1, ipAttribution=)]
    2018-08-07 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

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