脳梗塞の慢性期のリスク管理―薬物療法と非薬物療法―


脳梗塞の慢性期のリスク管理―薬物療法と非薬物療法―

安井先生 2011年11月24日

 

脳梗塞の再発率(久山町研究)  JNNP 76:368, 2005

http://jnnp.bmj.com/content/76/3/368.full?sid=0cc89020-1fd7-46b8-b378-672e3a00433a

 

1年以内10%

10年以内50%

 

心血管障害による死亡

5年以内の死亡率 39%

Neurology 44:626, 1994

 

Nature Rev Neurol 6:477, 2010

予防効果

1、内膜剝離術 67%

2.地中海食 60%/4年間

3.禁煙 50%/6か月

4.WF 40~ 50%/1年

5.HT 40~50%/3年

6.アクトス47%/3年

7.抗血小板薬 25~30%/2年

8.運動 25~30%/2年

Secondary stroke prevention

http://www.nature.com/nrneurol/journal/v6/n9/full/nrneurol.2010.114.html

J. David Spence

Abstract

Secondary stroke prevention can reduce the risk of recurrent stroke by ≈90%. To achieve such a reduction, early implementation of preventative measures and administration of therapy appropriate to the underlying cause of the presenting transient ischemic attack or stroke are crucial. Smoking cessation and a Cretan Mediterranean diet are each more effective than any single medication in reducing the risk of recurrent stroke. Control of resistant hypertension can markedly reduce the risk of intracerebral hemorrhage and lacunar infarction but might require therapy that is specific to the underlying cause. New antiplatelet agents have been developed or are in development that might avoid the issues of resistance and drug interactions that prevail with established agents of this type. Furthermore, new anticoagulants in development offer promise of replacing warfarin, and devices to occlude the atrial appendage are on the horizon for patients with atrial fibrillation. Carotid endarterectomy is appropriate for severe symptomatic carotid stenosis, while stenting might be appropriate for symptomatic stenosis where the surgical risk is high. Most patients with asymptomatic stenosis, however, should be treated with medical therapy, unless indicators of high stroke risk are present. In this narrative Review, I discuss recent advances in secondary stroke prevention.

 

地中海食

Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study

Brit Med J 338:b2337, 2009

http://www.bmj.com/content/338/bmj.b2337.full

 

長寿

適量飲酒23.5%

肉類の低摂取 16.6%

野菜の高摂取 16.2%

ADにもかかりにくい

「ギリシア人の男女23,349人を平均8.5年追跡し(1,075人が死亡)、健康に良いとされる地中海食の9項目の中でどれが長寿に結びつくかを調べたところ、寄与が大きかったのは、「適量」飲酒(23.5%)、肉類の低摂取(16.6%)、野菜の高摂取(16.2%)、果物とナッツ類の高摂取(11.2%)、オリーブ油(10.6%)、豆類の高摂取(9.7%)の6項目だった。残りの3項目である、穀類の高摂取、乳製品の低摂取、魚介類の高摂取の寄与は小さかった。」

 

イタリア料理:ミルク・クリームが少ない

ワイン・オリーブ油・魚

スローフード;低インスリンダイエット(カロリー吸収穏やか)

抗酸化物質;ポリフェノール

オリーブオイル

カロリー吸収穏やか

 

血圧、脂質

Sir2遺伝子の活性化;長寿遺伝子

バランスのとれた食事

和食は炭水化物が多い

炭水化物70%、脂肪15%、蛋白15%

ナッツ30g

多価不飽和脂肪酸が多い;炎症を抑える

Ann Int Med 145:1, 2006

http://www.annals.org/content/145/1/1.full.pdf+html

Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors

A Randomized Trial

Abstract

Background: The Mediterranean diet has been shown to have beneficial effects on cardiovascular risk factors.

Objective: To compare the short-term effects of 2 Mediterranean diets versus those of a low-fat diet on intermediate markers of cardiovascular risk.

Design: Substudy of a multicenter, randomized, primary prevention trial of cardiovascular disease (Prevención con Dieta Mediterránea [PREDIMED] Study).

Setting: Primary care centers affiliated with 10 teaching hospitals.

Participants: 772 asymptomatic persons 55 to 80 years of age at high cardiovascular risk who were recruited from October 2003 to March 2004.

Interventions: Participants were assigned to a low-fat diet (n = 257) or to 1 of 2 Mediterranean diets. Those allocated to Mediterranean diets received nutritional education and either free virgin olive oil, 1 liter per week (n = 257), or free nuts, 30 g/d (n = 258). The authors evaluated outcome changes at 3 months.

Measurements: Body weight, blood pressure, lipid profile, glucose levels, and inflammatory molecules.

Results: The completion rate was 99.6%. Compared with the low-fat diet, the 2 Mediterranean diets produced beneficial changes in most outcomes. Compared with the low-fat diet, the mean changes in the Mediterranean diet with olive oil group and the Mediterranean diet with nuts group were −0.39 mmol/L (95% CI, −0.70 to − 0.07 mmol/L) and − 0.30 mmol/L (CI, −0.58 to − 0.01 mmol/L), respectively, for plasma glucose levels; −5.9 mm Hg (CI, −8.7 to −3.1 mm Hg) and − 7.1 mm Hg (CI, −10.0 to −4.1 mm Hg), respectively, for systolic blood pressure; and −0.38 (CI, −0.55 to − 0.22) and − 0.26 (CI, −0.42 to −0.10), respectively, for the cholesterol–high-density lipoprotein cholesterol ratio. The Mediterranean diet with olive oil reduced C-reactive protein levels by 0.54 mg/L (CI, 1.04 to 0.03 mg/L) compared with the low-fat diet.

Limitations: This short-term study did not focus on clinical outcomes. Nutritional education about low-fat diet was less intense than education about Mediterranean diets.

Conclusion: Compared with a low-fat diet, Mediterranean diets supplemented with olive oil or nuts have beneficial effects on cardiovascular risk factors.

 

運動 25~30%減少

血圧の低下

インスリン感受性の低下

脂質の低下

血管内皮の保護

抗炎症

30分以上歩行;脳卒中を減少させる

男 6700歩、女 5400歩 散歩5日/週

 

PROGRESS試験

降圧剤+利尿剤;脳梗塞発症抑制;28%減少

ARBの脳卒中予防効果;DM発症予防効果もあり

血圧140/90未満が良い

JSH2009

 

DM

HT/HL治療要

治療により、7倍が2倍に減少

DMでは、小脳、脳幹梗塞が多い。嚥下障害

 

IGTでも脳梗塞は増加する

OGTT2時間後血糖140-200、FBSは正常

脳梗塞の53%;耐糖能異常

Urabe Stroke 2009

23%DM, OGTTを施行すると、38%IGT

 

Prevalence of Abnormal Glucose Metabolism and Insulin Resistance Among Subtypes of Ischemic Stroke in Japanese Patients

http://stroke.ahajournals.org/content/40/4/1289.full?sid=95deca27-ee88-46b2-a16b-14eadbbac413

Abstract

Background and Purpose— The purpose was to assess the prevalence of disorders of glucose metabolism and insulin resistance in Japanese ischemic stroke patients with no history of diabetes by performing 75-gram oral glucose tolerance test (OGTT).

Methods— We recruited 427 ischemic stroke patients (atherothrombotic infarction, n=220; lacunar infarction, n=125; cardioembolic infarction, n=82). OGTT was used to evaluate disorders of glucose metabolism in stroke patients without previously known diabetes (n=113). We investigated the relationships among the prevalence of abnormal glucose metabolism, ischemic stroke subtypes, and the prevalence of insulin resistance using homeostasis model assessment for insulin resistance and immunoreactive insulin at 120 minutes after glucose loading (IRI120).

Results— OGTT identified the presence of disorders of glucose metabolism in 62.8% of ischemic stroke patients without previously known diabetes, including diabetes (24.8%) and impaired glucose tolerance (lone impaired glucose tolerance and impaired fasting glucose plus impaired glucose tolerance, 34.5%). The prevalence of newly diagnosed diabetes and impaired glucose tolerance was the highest in the atherothrombotic infarction group (68.9%). The highest values of homeostasis model assessment for insulin resistance and immunoreactive insulin at 120 minutes after glucose loading were found in atherothrombotic infarction patients with abnormal glucose tolerance.

Conclusions— In this study, a significantly large percentage of Japanese patients with ischemic stroke and no history of diabetes were found to have disorders of glucose metabolism by OGTT. Impaired glucose tolerance and insulin resistance could play an important pathogenic role in the development of atherothrombotic infarction.

 

 

死の四重奏

HL、DM, HT, 肥満

 

PROACTIVE試験

Lancet 366:1279, 2005

アクトス; 2型糖尿病患者のstrokeの再発を予防する効果があり。

The Lancet, 366:1279 – 1289, 2005

Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial

Summary

Background

Patients with type 2 diabetes are at high risk of fatal and non-fatal myocardial infarction and stroke. There is indirect evidence that agonists of peroxisome proliferator-activated receptor γ (PPAR γ) could reduce macrovascular complications. Our aim, therefore, was to ascertain whether pioglitazone reduces macrovascular morbidity and mortality in high-risk patients with type 2 diabetes.

Methods

We did a prospective, randomised controlled trial in 5238 patients with type 2 diabetes who had evidence of macrovascular disease. We recruited patients from primary-care practices and hospitals. We assigned patients to oral pioglitazone titrated from 15 mg to 45 mg (n=2605) or matching placebo (n=2633), to be taken in addition to their glucose-lowering drugs and other medications. Our primary endpoint was the composite of all-cause mortality, non fatal myocardial infarction (including silent myocardial infarction), stroke, acute coronary syndrome, endovascular or surgical intervention in the coronary or leg arteries, and amputation above the ankle. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN NCT00174993.

Findings

Two patients were lost to follow-up, but were included in analyses. The average time of observation was 34·5 months. 514 of 2605 patients in the pioglitazone group and 572 of 2633 patients in the placebo group had at least one event in the primary composite endpoint (HR 0·90, 95% CI 0·80—1·02, p=0·095). The main secondary endpoint was the composite of all-cause mortality, non-fatal myocardial infarction, and stroke. 301 patients in the pioglitazone group and 358 in the placebo group reached this endpoint (0·84, 0·72—0·98, p=0·027). Overall safety and tolerability was good with no change in the safety profile of pioglitazone identified. 6% (149 of 2065) and 4% (108 of 2633) of those in the pioglitazone and placebo groups, respectively, were admitted to hospital with heart failure; mortality rates from heart failure did not differ between groups.

Interpretation

Pioglitazone reduces the composite of all-cause mortality, non-fatal myocardial infarction, and stroke in patients with type 2 diabetes who have a high risk of macrovascular events.

 

SPARCL試験

高脂血症薬であるAtorvastatinの高容量;2次予防に有効。

80mgは日本で使用される量の8倍。

http://www.lifescience.jp/ebm/cms/ms/no.17/topics.pdf

http://www.nejm.org/doi/pdf/10.1056/NEJMoa061894

High-Dose Atorvastatin after Stroke or Transient Ischemic Attack

 

The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators

N Engl J Med 2006; 355:549-559August 10, 2006

 

頸動脈エコー/HL

Plaque炎症が強い

スタチンは炎症を抑制

急性期;スタチンの使用

TIA;ACEの使用、スタチンの使用

クリックをお願いします。

http://blog.with2.net/link.php/36571 (ブログランキングに登録しています)

 

 

 

広告

marugametorao について

神経内科専門医 neurologist
カテゴリー: 神経学 パーマリンク

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