Letter by Gutierrez Regarding Article, "Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes".
Letter by Gutierrez Regarding Article, "Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes".
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Gutierrez 关于文章“双重抗血小板治疗改善进行性腔隙性中风患者的功能结果”的信函。
DOI：
10.1161/strokeaha.119.025708
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发表时间：
2019
期刊：
影响因子：
8.3
通讯作者：
Gutierrez,Jose
中科院分区：
文献类型：
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作者：
Gutierrez,Jose
我们饶有兴趣地阅读了Berberich等人的文章1早期神经退化（END）在腔隙性卒中患者中很常见，值得进一步研究。理想情况下，从业者希望识别出那些有临终风险的人，并在其发生之前进行预防，但我们可以看到临终后改善结果的价值。这篇文章，可能是由于它的格式短，缺乏一些信息，可能有助于临床医生理解这项工作的价值。目前尚不清楚是什么因素决定了对腔隙性梗死患者进行双抗血小板治疗（DAPT）还是单抗血小板治疗。是否有关于谁应该服用DAPT的制度性指导方针？它是否依赖于主治医生？当地实践中可能存在的偏差可能会削弱DAPT与单一抗血小板药物在改善终末期预后方面的疗效。腔隙性卒中的生理病理并不相同，在某些情况下，穿透性动脉闭塞的潜在病理实际上可能是大动脉疾病，即分支闭塞性疾病（又称分支动脉粥样硬化性疾病）。在CHANCE试验（氯吡格雷在高危急性非致残性脑血管事件患者中的应用）中，DAPT在有颅内动脉粥样硬化证据的患者中比在前2周没有DAPT的患者更有效。3,4在这种情况下，在一个相对不同的人群中，替格瑞洛（被认为是比阿司匹林更好的抗血小板药物）对那些有同侧动脉粥样硬化性狭窄的患者也更有效。不幸的是，POINT试验（新TIA和轻微缺血性卒中中的血小板导向抑制）没有系统地评估颅内大动脉粥样硬化，以评估这种效应是否可能在其他人群中存在。如果作者对被认为是动脉粥样硬化引起的同侧狭窄或管腔不规则患者进行分层，这项工作的结果会有所不同吗？最后，作者是否尝试在入院时进行磁共振成像的患者中测量梗死体积
We read with interest the article by Berberich et al1 Early neurological deterioration (END) is common in patients with lacunar strokes and deserves further study. Ideally, practitioners would want to identify those at risk of END and prevent it before it happens, but we can see the value of improved outcomes after END. The article, perhaps due to its short format, lacks some information that may help clinicians understand the value of this work. It is unclear what factors drove the decision to start a given patient with a lacunar infarct on dual antiplatelet (DAPT) versus single antiplatelet. Is there an institutional guideline regarding who is prescribed DAPT versus not? Was it attending-dependent? The possible biases in local practice may undermine the claims of efficacy of DAPT versus single antiplatelet for improving outcomes after END.Lacunar strokes are not homogenous in their physiopathology, and in some cases, the underlying pathology of the penetrating artery occlusion may be in fact large artery disease, that is, branch occlusive disease (also known as branch atheromatous disease). 2 In the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events), DAPT was more effective among those with evidence of intracranial atherosclerosis that among those without it in the first 2 weeks. 3, 4 In this context, and in a relatively different population, ticagrelor (supposedly a superior antiplatelet than aspirin) was also more effective among those with evidence of ipsilateral atherosclerotic stenosis. 5 Unfortunately, the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) did not systematically assess for intracranial large artery atherosclerosis to evaluate whether such effect modification may exist in other populations. Could the results of this work be different if the author stratify patients with ipsilateral stenosis or luminal irregularities thought to be due to atherosclerosis? Lastly, did the author attempt to measure infarct volume among those who had magnetic resonance imaging at admission