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我国卒中一级预防任重道远

2015-09-10 孙海欣 王文志 国际脑血管病杂志

在过去40年里,全球卒中发病率在高收入国家下降了42%,在中低收入国家则增高了超过100%,目前中低收入国家的卒中发病率已超过高收入国家。脑血管病已成为危害我国中老年人群健康和生命的主要疾病。2004年至2005年期间国家卫生部(现为国家卫计委)组织完成的《全国第三次死因回顾抽样调查报告》显示,脑血管病已成为我国居民死亡的首位原因。此外,卒中也是导致功能障碍的首要原因。年龄>65岁的卒中

在过去40年里,全球卒中发病率在高收入国家下降了42%,在中低收入国家则增高了超过100%,目前中低收入国家的卒中发病率已超过高收入国家。脑血管病已成为危害我国中老年人群健康和生命的主要疾病。2004年至2005年期间国家卫生部(现为国家卫计委)组织完成的《全国第三次死因回顾抽样调查报告》显示,脑血管病已成为我国居民死亡的首位原因。此外,卒中也是导致功能障碍的首要原因。年龄>65岁的卒中患者在发病后6个月时,26%日常生活不能自理,46%存在认知损害。卒中不仅改变了患者本人的生活,同时也改变了其家人和其他看护者的生活状况,给社会和家庭带来沉重的负担。另一个不容忽视的状况是,近年来我国居民中高血压、糖尿病、高脂血症等患病率快速递增,而这些疾病均为引起卒中的明确危险因素。因此,预计近期我国卒中发病率仍会继续上升,造成的危害也会日趋严重。

幸运的是,卒中是一种可防可治的疾病。鉴于76%以上的卒中患者为首发卒中,因此卒中一级预防尤为重要。一项包括6000名受试者的国际性病例对照研究显示,10项潜在可干预的危险因素可解释90%的卒中风险。基于一级预防的重要性,近年来美国、欧洲等多个国家或地区相继颁布并更新了本地区的卒中一级预防指南。我国于2006年向全国推广使用《中国脑血管病防治指南》第1版,其中包括脑血管病的一级预防。2010年发布了《中国卒中一级预防指南2010》(即修订版)。目前,基于近几年国内外的研究进展和国外指南的更新情况,中华医学会神经病学分会脑血管病学组正在对一级预防指南进行全面修订。然而,一级预防指南的颁布可以说只是卒中一级预防迈出的第一步,尚需全社会进一步重视卒中一级预防,在实际工作和生活中“紧跟指南走”,按照科学的方法积极预防卒中,才能尽快降低卒中的发病率和死亡率,减少其危害。

总体来讲,我国卒中一级预防的现状可谓任重而道远。首先,应提高公众和基层医务工作者的卒中相关知识水平,使其了解卒中的危害,认识卒中一级预防的重要性,主动进行卒中风险的评估,并进一步对已有的危险因素给予干预。国内曾有调查显示,我国社区居民和社区医务人员的卒中相关知识水平均不容乐观,需要尽快提高。使用卒中风险评估工具评估个体首次发生卒中的风险,无论对公众还是对医务人员都是有帮助的。风险评估有助于识别能从干预治疗中获益的个体,对临床医生和可能存在卒中风险的患者也具有预警作用。2014版美国卒中一级预防指南作为推荐意见明确提出,公众可使用美国心脏协会推出的风险计算器在线进行风险评估(http://my.americanheari.org/cvriskcalculalor)。目前,我国尚无一种针对我国居民的简单适用并得到普遍认可的卒中风险评估工具,这也是我国科研工作者需要进一步研究的方向。

广大医务人员应让卒中一级预防从“指南”走向“医疗实践”,从“临床试验”走向“医疗服务”。随着新研究证据的不断出现,各国指南也在新证据基础之上不断进行更新。然而,循证医学指南中所包含的知识只有在转变为临床实践之后才能发挥其价值。大量证据表明,一级预防在实践中的应用与指南推荐的差距甚大。例如,美国50个州之间血管健康管理情况的差距也非常大。仅有3%的成年人在包括高血压、高脂血症、血压、体质指数、糖尿病、体力活动、果蔬摄入量等7个领域内均处于理想的血管健康状态。要想真正使卒中一级预防从指南转化为医疗实践,通常需要联合多种措施来实现,包括对医务工作者进行教育培训、对临床实践进行监督审查和及时反馈等。其中,帮助广大医务工作者及时进行知识更新应是关键环节之一。例如,2014版美国卒中一级预防指南结合最新研究证据对有关心房颤动、其他心脏问题、无症状颈动脉狭窄、偏头痛、抗血小板治疗等内容均有较多新的推荐意见。这些推荐意见必然要在医务工作者接受知识更新之后,才能真正应用在其医疗服务中,否则再可靠的证据和再完美的指南,终将是纸上谈兵。

另一方面,我国政府应进一步加强“预防为主”的卫生工作方针,提高在预防工作和科研方面的支持力度。建国以来,我国政府大力提倡“预防为主”的卫生工作方针,在控制传染性疾病方面确实发挥了重大作用,并取得了辉煌的成就。在当前慢性非传染性疾病发病率上升,特别是卒中对居民健康危害严重的情况下,仍应坚持以“预防为主”的方针,增加预防方面的科研投入,帮助科研工作者产出更多来源于我国人群的科研数据,弥补目前我国在可应用的科研证据,尤其是预防证据方面的不足,更好地服务于我国广大民众。

总之,全面提升卒中一级预防的意识和能力,需要动员全社会的力量通力合作,政府的重视和支持无可替代;广大医务工作者更是指南与实践之间桥梁的建设者,作用至关重要;而媒体需要积极参与宣教,告知公众卒中一级预防的重要性和可及性,也不可缺少;同时,科研工作者应努力发现并验证可用于我国人群防治的适宜技术。慢性病的预防在我国方兴未艾,卒中一级预防任重道远。

作者单位:北京市神经外科研究所;首都医科大学附属北京天坛医院;临床流行病学北京市重点实验室


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    2016-07-25 oo902

    任重道远

    0

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    2015-10-08 hlycom3356

    这篇文章写得很好

    0

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    2015-10-06 段段

    普及大众最重要

    0

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    2015-09-10 yydlt

    普及!

    0

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    2015-09-10 Dr.LV

    知识普及是最主要的,人的预防为主

    0

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