Another large-scale clinical study showed that the incidence of AMI during hospitalization in patients with acute ischemic stroke was 2%, and the mortality rate of these patients with coexisting AMI can be as high as 56% after one year, indicating a very poor prognosis.

Source of this article: National Health and Family Planning Commission Expert Committee on Rational Drug Use, China Pharmacist Association. "Guidelines for the Rational Use of Coronary Heart Disease (2nd Edition)" [J]. Chinese Journal of Frontier Medicine (electronic version), 2018, 10 (6): 1-130.

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7.5.2.1.3 Intracranial hemorrhage treatment: Once intracranial hemorrhage occurs, the patient's severity should be evaluated as soon as possible in conjunction with neurology, neurosurgery and other departments, and the cardiology and neurologists should jointly formulate bleeding treatment and anti-thrombosis treatment plans.

(1) Assessment: ① Clinical evaluation: First, the patient's vital signs (such as disorders of consciousness, pupil changes, symptoms of cerebral nerve palsy, symptoms of focal neurological impairment, positive pathological signs, etc.), and use the stroke scale to evaluate the severity of the disease, judge the patient's prognosis, and guide the selection of treatment measures. Commonly used scales include the Glasgow Coma Scale (GCS), the National Institutes of Health stroke scale (NIHSS), and the cerebral hemorrhage score scale. ②Imaging evaluation: Imaging examination is an important means for diagnosing cerebral hemorrhage. The main imaging examinations include CT scan, MRI, cerebral angiography, etc. Among them, CT scan of the head is the gold standard for diagnosing early cerebral hemorrhage. ③ Evaluation of bleeding volume: Brain CT scan is the first imaging method of choice for patients with suspected bleeding. Neurologists and imaging doctors can determine the size of bleeding volume based on the results of brain CT scan. CT scan shows that the hematoma foci is a high-density shadow with clear boundaries and a CT value of 75 to 80 HU; the size of the hematoma can be estimated by simple formula [hematoma amount = 0.5 × maximum area long axis (cm) × maximum area short axis (cm) × number of layers, the scanning layer thickness is 1 cm], but for irregular hematoma foci, this calculation method is not accurate.

(2) Management of antiplatelet drugs: There is great controversy over whether antiplatelet therapy drugs can increase hematoma volume, adverse outcome events or affect functional recovery. The meta-analysis suggests that the use of antiplatelet drugs in patients with intracranial hemorrhage can lead to an increase in the mortality rate, but it does not affect functional recovery. The combination of clopidogrel and and aspirin is more obvious than those in patients with aspirin alone, and the mortality rate is also higher. The benefits of infusion of fresh platelets are not clear and are only recommended for patients with significantly reduced platelet counts.

If cerebral hemorrhage is related to antiplatelet therapy, the risk of bleeding and ischemia should be weighed, and the risk of cerebral hemorrhage should be stratified, and then treated as appropriate: ① The amount of cerebral hemorrhage is large, causing disorder of the patient's vital signs or a great risk of death after being evaluated; ② The amount of cerebral hemorrhage is large, causing new neurological damage and is very likely to lead to disability of the patient; ③ Although there are new cerebral hemorrhage, it has little impact on the patient's situation; or only new cerebral hemorrhage is found on imaging, which has little impact on the prognosis. For the first two situations, antiplatelet drugs should be stopped immediately to stabilize vital signs, reduce the degree of disability, and improve the overall prognosis. For the third case, if it is a high-risk patient with ischemia, it can be considered to resume antiplatelet therapy after 7 to 10 days of discontinuation of the drug. The type or dose of antiplatelet drugs can also be appropriately reduced according to the condition, and bleeding can be closely monitored. If cerebral hemorrhage is also accompanied by gastrointestinal bleeding, it is recommended to stop taking aspirin.

(3) Other treatments: includes surgical treatment and other internal medicine treatments. For surgical treatment, patients with cerebral hemorrhage, supratentorial bleeding is >30 ml, subtentorial bleeding is ≥10 ml and have any of the following, which is an absolute indication of surgery: ① The midline structure of the brain is shifted >1 cm; ② If the ventricle and cerebral sanitary are compressed and deformed or disappeared, especially the ring sanitary and fourth ventricle; ③ If the pupils are not as large as the pupils, the pupil light reflex is dull, and the pupils are even dilated and the reflex disappears; ④ If the patient has a poor state of consciousness, such as restlessness, drowsiness, and even coma.

But special attention should be paid to the decision of treatment strategies with the cooperation of neurology and surgeons.

7.5.2.1.4 Related evaluation and significance of ischemia in patients with coronary heart disease: When intracranial hemorrhage has been controlled, it is necessary for clinicians to clarify the patient's ischemia risk and further determine the subsequent antithrombotic treatment plan.Table 7-18 briefly summarizes the main content and significance of ischemia-related assessment.

Currently, there is no clear guide to clearly define when antiplatelet therapy can be safely restarted. For patients with stable coronary heart disease who have experienced hemorrhagic stroke, in principle, the risk of intracranial hemorrhage recurrence (such as cerebral lobe hemorrhage, advanced age, anticoagulant treatment, etc.), strictly manage blood pressure (<130/80>

7.5.2.2 Coronary heart disease combined with ischemic stroke/transient ischemic attack

Coronary heart disease combined with ischemic stroke/TIA, the pathophysiological mechanisms of the two are similar, so the treatment principles are roughly the same. The following is a guide to the "HTM6 Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack in China" and related guidelines for coronary heart disease to focus on antiplatelet and anticoagulant treatment strategies in patients with coronary heart disease combined with ischemic stroke/TIA.

(1) Antiplatelet and anticoagulant treatment strategies: ① For patients with non-cardiogenetic embolizing ischemic stroke or TIA, oral antiplatelet drugs are recommended instead of anticoagulant drugs to prevent stroke recurrence and other cardiovascular events (I/A). ② Aspirin (50-325 mg/d) or clopidogrel (75 mg/d) can be used as the first choice antiplatelet drug (I/A). ③The optimal dose of aspirin monotherapy antiplatelet therapy is 75-150 mg/d. Aspirin (25 mg/time) + sustained-release dipyridamole (200 mg/time) 2 times/day or cilotazole (100 mg/time) 2 times/day can be used as a replacement therapy for aspirin and clopidogrel (II/B). ④ Antiplatelet drugs should be individually selected based on patient risk factors, costs, tolerance and other clinical characteristics (I/C). ⑤ Patients with acute non-cardiogenic TIA or mild ischemic stroke (NIHSS score ≤3 points) who have a high risk of recurrence of stroke (ABCD² score >4 points) within 24 hours should be given aspirin combined with clopidogrel for 21 days (I/A), but the risk of bleeding should be closely observed. After that, aspirin or clopidogrel can be used alone as the first-line drug for long-term secondary prevention of ischemic stroke (I/A). ⑥ Patients with ischemic stroke or TIA who are accompanied by symptomatic severe stenosis of the intracranial artery within 30 days of onset (70% to 99%) should be given aspirin and clopidogrel as soon as possible (II/B). After that, aspirin or clopidogrel alone can be used as a first-line medication for long-term secondary prevention (I/A). ⑦ For patients with ischemic stroke or TIA with evidence of aortic arch atherosclerotic plaque, antiplatelet and statin therapy are recommended (II/B). There is no positive conclusion on the comparison of the therapeutic effects of OAC and aspirin combined with clopidogrel (II/B).

Therefore, in combination with coronary heart disease related guidelines, the following conclusions can be drawn: First, patients with coronary heart disease combined with ischemic stroke/TIA attack should take aspirin antiplatelet therapy; second, when aspirin is intolerable, they can use clopidogrel and other drugs to replace it; finally, DAPT (aspirin + clopidogrel) should be started within 24 hours of ischemic stroke attack.

(2) Complications of intraventricular thrombosis and ischemic stroke/TIA: ischemic stroke after AMI is one of the extracardiac complications of myocardial infarction. Large-area myocardial infarction, especially anterior wall myocardial infarction with apical involvement, are prone to left ventricular wall thrombosis. If the patient has a low risk of bleeding, anticoagulation treatment should be considered to prevent the occurrence of thrombosis. Once a wall thrombosis is diagnosed, oral anticoagulation is required. However, when stenting and DAPT have been performed, oral anticoagulation drugs can increase the risk of bleeding in the patient. Therefore, anticoagulation + DAPT is only used for STEMI when the patient's wishes are fully considered.When the risk of systemic circulation or venous thromboembolism is greater than the risk of bleeding, triple antithrombosis treatment is required, INR must be controlled between 2.0 and 2.5.

specific recommendations are as follows: ① Patients with ischemic stroke or TIA with AMI, left ventricular wall thrombosis is found in imaging examinations. It is recommended to give warfarin oral anticoagulation treatment for at least 3 months (target INR is 2.5; range 2.0 to 3.0; II/B). ② If there is no left ventricular wall thrombosis, but no movement or abnormal movement is found in the anterior wall, warfarin oral anticoagulation treatment should also be considered for 3 months (target INR is 2.5; range 2.0 to 3.0; II/B). ③ For patients with ischemic stroke/TIA, combined with AMI with left ventricular wall thrombosis, if accompanied by anterior wall or apical ventricular wall dyskinesia and LVEF <40%,>

It should be pointed out that in terms of antiplatelet and anticoagulant treatment of coronary heart disease and stroke, only a single-discipline guideline recommends some issues. To obtain more accurate recommendations, multidisciplinary cooperation is required to jointly formulate relevant guidelines.

7.5.3 Specific treatment plan

In addition to improving lifestyle, low-salt and low-fat diet, quitting smoking and restricting alcohol, moderate activities, drug treatment includes anti-platelets, lowering blood pressure, lipid regulation, blood circulation, blood circulation, and Chinese medicines for improving heart and brain metabolism, as well as Chinese medicines for promoting blood circulation and removing blood stasis.

7.5.3.1 Antiplatelet therapy Antiplatelet therapy is the cornerstone of the treatment of coronary heart disease and ischemic stroke.

(1) Aspirin: It achieves the effect of anti-platelet aggregation by inhibiting the synthesis of cyclooxygenase and thrombane (TXA). All patients should take it if they do not have any contraindications for medication. The optimal dose range for aspirin is 75 to 150 mg/d. The main adverse reactions are gastrointestinal bleeding or allergic to aspirin.

(2) P2Y₁₂ receptor antagonist: ① Clopidogrel: Blocking the ADP-dependent activation of the GPⅡb/Ⅲa complex by selectively and irreversibly inhibiting the platelet ADP receptor can effectively reduce ADP-mediated platelet activation and aggregation. It is mainly used in patients with ACS, stent placement and aspirin contraindications. The drug takes effect quickly, and the effective blood drug concentration can be achieved 2 hours after taking 600 mg. The commonly used maintenance dose is 75 mg/d. ②Ticarol: It is an oral P2Y₁₂ receptor antagonist, which mainly has the following advantages: a. It directly acts on the P2Y₁₂ receptor without metabolization through the liver CYP enzyme system; b. It takes effect faster and has a stronger effect on inhibiting the P2Y₁₂ receptor; c. It binds reversibly to the receptor, and the platelet function recovers quickly after reducing dosage or stopping the drug.

In addition, studies have shown that the combined application of small doses of aspirin and dipyridamole can significantly reduce the risk of stroke by 23%, but it may cause "blood stealing" in patients with stroke and coronary heart disease, which may aggravate the condition. It is not recommended to use in patients with stroke and coronary heart disease in clinical practice.

7.5.3.2 Antihypertensive treatment The benefits of antihypertensive treatment in the secondary prevention of stroke and coronary heart disease are very clear, but the blood pressure management of patients with stroke and coronary heart disease is relatively complicated, and the target value for lowering blood pressure in different situations is different.

(1) Antihypertensive strategies and blood pressure targets for ischemic stroke recovery and coronary heart disease: It is generally believed that antihypertensive treatment should be performed after the acute phase of ischemic stroke to reduce stroke recurrence and other vascular events. What level should the blood pressure of stroke patients be controlled? The Perindopril Prevention of Recurrence of Stroke (PROGRESS) analyzed the effects of antihypertensive therapy in patients with cerebrovascular disease with different baseline blood pressure levels on stroke recurrence events and compared it with placebo. The results showed that antihypertensive treatment reduced the relative risk of stroke recurrence in patients with baseline systolic blood pressure ≥160 mmHg, 140-159 mmHg and 120-139 mmHg, respectively. The "China Hypertension Prevention and Treatment Guidelines 2010" recommends that patients with hypertensive patients with stable coronary heart disease, UA, STEMI and NSTEMI have a target blood pressure level generally <130/80>

The general target of blood pressure control in non-acute stage is <>

(2) Blood pressure control and blood pressure targets of acute ischemic stroke combined with coronary heart disease: ischemic stroke is common in the acute stage of acute stage, accounting for about 80% of patients. Even if 2/3 of the patients do not undergo antihypertensive treatment, the increased blood pressure drops by about 4 days. Lower blood pressure may reduce blood perfusion from the ischemic area around the infarct foci of collateral blood vessels, resulting in neuronal loss and widening of infarction. On the other hand, normal or reduced blood pressure after acute stroke often indicates serious brain injury, coronary heart disease events, or heart failure. Therefore, clinicians should not routinely use antihypertensive drugs within the first week after acute ischemic stroke, especially patients with increased blood pressure should be treated with caution within 24 hours of onset. The "China Hypertension Prevention and Treatment Guidelines 2010" proposes that unless the systolic blood pressure is ≥180 mmHg or diastolic blood pressure is ≥100 mmHg, or those with severe cardiac insufficiency, aortic dissection, and hypertensive cerebral diseases, they generally do not lower blood pressure. These cardiovascular emergencies can be treated according to the corresponding principles after 3 days of onset of stroke. For patients with coronary heart disease, elevated blood pressure will increase heart load and aggravate myocardial ischemia. If patients with a previous history of stroke develop AMI, if their blood pressure level is moderately elevated (to reach grade 2 or grade 3 hypertension levels), they should actively control their blood pressure. However, when formulating treatment strategies, we will also encounter the problem of how to improve the balance between the prognosis of myocardial infarction and the benefits of cerebrovascular diseases.

In short, for patients with acute ischemic stroke and coronary heart disease, unless AMI or severe heart failure occurs and blood pressure is clearly required to reduce blood pressure immediately and significantly, the blood pressure control strategies and goals when other types of coronary heart disease are still unclear, and further research is needed to clarify.

7.5.3.3 Statin lipid-regulating treatment statin treatment can significantly reduce the stroke risk in people with high risk of coronary heart disease and cardiovascular disease. For every 10% reduction in LDL-C, the risk of ischemic stroke decreases by 15.6%. Meta-analysis found that high doses of statins can further reduce stroke risk at lower doses. The results of the SPARCL study showed that atorvastatin treatment can reduce the absolute risk of stroke in patients within 5 years by 2.2% (HR = 0.84), and the absolute risk of major cardiovascular events by 3.5% (HR = 0.80). Subgroup analysis also found that the greater the decrease in LDL-C, the lower the risk of ischemic stroke recurrence: compared with the group without change in LDL-C, the risk of major coronary events in the group with ≥50% decrease in LDL-C and the risk of death for all causes is 14%. Another study also found that the risk of coronary heart disease in patients with relapsed stroke will double, and atorvastatin treatment can reduce the risk of all coronary heart disease events in patients with relapsed stroke by 47% and 53% of severe coronary heart disease events. Therefore, lipid regulation treatment will benefit patients with coronary heart disease and stroke.

For the target target of lipid regulation treatment, AHA/ACC recommends that it is reasonable for patients with coronary heart disease or stroke to have LDL-C target target level <1.8>

as a reasonable treatment target for coronary heart disease or other atherosclerotic diseases, some scholars believe that whether LDL-C <>

7.5.3.4 Others According to the patient's clinical manifestations and symptoms, blood vessel expansion drugs, beta blockers, and drugs to improve heart and brain metabolism. In addition, traditional Chinese medicines to promote blood circulation, remove blood stasis, and unblock menstruation and activate meridians. For example, Salvia miltiorrhiza, safflower, ginkgo leaves and other drugs have anticoagulation, improve cerebral blood flow, reduce blood viscosity and neuroprotective effects.

(Author of this chapter: Zhao Quanming, Yan Yunfeng, Zhou Yujie)

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