Cardioembolic Stroke.
Cardioembolic Stroke.
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DOI：
10.1161/circresaha.116.308407
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发表时间：
2017-02-03
影响因子：
20.1
通讯作者：
Healey JS
中科院分区：
文献类型：
--
作者：
Kamel H;Healey JS
心脏栓塞在缺血性中风中所占的比例越来越大，并且在未来几十年内可能会增加数倍。然而，研究指出了几种潜在的策略来阻止这种预期的心源性栓塞性卒中的增加。首先，虽然三分之一的中风原因不明，但越来越多的人认为，许多隐源性中风是由远端栓塞引起的，而不是原位脑血管疾病，导致最近制定了“来源不明的栓塞性中风”（ESUS）作为一个独特的研究目标。其次，最近的临床试验表明，ESUS可能经常源于亚临床房颤（AF），可以通过长时间的心律监测进行诊断。第三，新出现的证据表明，即使没有AF，血栓形成的心房基质也可导致心房血栓栓塞。这种心房性心脏病可以解释许多ESUS病例，口服抗凝药物可能被证明可以降低心房性心脏病的中风风险，因为它与AF相似。非维生素K拮抗剂口服抗凝剂（NOAC）药物最近已经扩大了用于预防心源性栓塞性中风的治疗选择，并且目前正在ESUS患者（特别包括患有心房性心脏病的患者）中测试用于预防中风。第四，对血栓形成心房基质的认识不断增加，心内和心外卒中风险因素共同存在，表明除抗凝治疗外，还可从总体血管风险因素管理中获益。最后，改善心室血栓的成像加上NOAC药物的可用性可能会更好地预防急性心肌梗死和心力衰竭引起的卒中。
Cardiac embolism accounts for an increasing proportion of ischemic strokes, and might multiply several-fold over the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in-situ cerebrovascular disease, leading to the recent formulation of “embolic stroke of undetermined source” (ESUS) as a distinct target for investigation. Second, recent clinical trials have indicated that ESUS may often stem from subclinical atrial fibrillation (AF) which can be diagnosed with prolonged heart-rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of AF. Such an atrial cardiopathy may explain many cases of ESUS, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiopathy given its parallels to AF. Non-vitamin K antagonist oral anticoagulant (NOAC) drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with ESUS, including specifically those with atrial cardiopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common co-existence of cardiac and extra-cardiac stroke risk factors suggests benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of NOAC drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure.