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第二卷第一期 5 34
第二卷第一期 5 34
ijıijıѮᢊသϛॳᏰོߨЖӰܒીՖܒသϛॳġ
תՖωݖݽސᕛࡾЕ
忂妲ἄ侭烉昛㝷暾, ⎘ᷕ㥖㮹䷥慓昊䤆䴻慓⬠ᷕ⽫儎ᷕ桐ᷕ⽫
E-mail: boringtw@gmail.com
DOI: 10.6318/FJS.202003_2(1).0002
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
埨ḳẞ10ˤ㖍㛔⇯⺢嬘aspirin㭷㖍∹慷䁢75-150 㗗7.15%炻侴aspirin䳬㗗7.71%炻ℑ䳬䃉栗叿ⶖ
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㮓 ˤAspirin⎗傥䘬∗ἄ䓐⊭㊔烉⺞攟↢埨 䔘(RR旵Ỷ7.3%烊95%CI = -5.7%–18.7%烊P =
㗪攻(䈡⇍㗗㭷⣑╅3㜗ẍᶲ䘬惺䱦梚㕁炻ㆾ㗗 0.26)ˤ侴偫儠㕡朊㔜橼侴妨炻㚵䓐clopidogrel
㚱↢埨⓷柴䘬か侭)ˣ儠偫忻⇢㽨(⤪儠偫忻 䘬偫儠忻↢埨䘤䓇䌯栗叿Ỷ㕤aspirin (1.99%
↢埨ˣ㳣≽⿏㼘䖵)ˤAspirin㚫㍸檀偫儠忻↢埨 㭼2.66%烊P < 0.05)ˤ⎎ᶨ枭PRoFESS娎槿14炻
䘬桐晒炻侴ᶼἧ䓐䘬∹慷グ檀炻桐晒グ檀 3, 6烊 ℙ㚱20,332ỵ朆⽫⚈⿏仢埨⿏儎ᷕ桐䕭Ṣ炻
攟㛇ἧ䓐aspirin㭷㖍∹慷<325㮓䘬䕭Ṣ炻㭷 晐㨇↮惵䴎Ḱclopidogrelㆾ⎰Ἕaspirin⍲
⸜䘤䓇♜慵偫儠忻↢埨䘬桐晒⣏䲬㗗0.4%炻㗗 dipyridamole䘬㱣䗪炻䘤䎦⎰Ἕ㱣䗪䳬䘬儎ᷕ
ᶵἧ䓐aspirin㕷佌䘬2.5ⶎ⎛3, 6, 12, 13ˤ㬌⢾炻 桐⽑䘤䌯㗗9.0%炻侴clopidogrel䳬㗗8.8%炻ℑ
晾䃞⼰⮹䘤䓇炻Ữaspirin⎗傥⮶农♜慵䘬哩湣 䳬㰺㚱ⶖ⇍炻Ữ㗗⎰Ἕ㱣䗪䳬㚱栗叿庫檀䘬栙
䕡(3.5%)炻埨䭉㯜儓(4.5%烊儓僡⎗傥䘤䓇⛐ ℏ↢埨䘤䓇䌯(1.4%㭼1.0%烊桐晒㭼ῤ˳hazard
⒯ˣ冴ˣ┱♐䓂军㚫⼙枧⏠)炻ㆾ㗗㓗㯋䭉㓞 ratio, HR˴= 1.42烊95%CI = 1.11–1.83)ˤ⚈㬌炻
䷖(㯋╀䘤ἄ)ˤ⼰⣂∗ἄ䓐冯aspirin䘬∹慷䚠 ⮵aspirin㚱䤩⽴䕯ㆾ䓊䓇ᶵ列⼙枧䘬䕭Ṣ炻⎗
斄炻∹慷庫檀⇯∗ἄ䓐庫⣂炻ỮỶ∹慷aspirin ẍ怠䓐clopidogrelˤ⮵㕤㚱㚜檀桐晒(⌛㚦㚱儎
ḇ⎗傥䘤䓇∗ἄ䓐ˤ ᷕ桐ˣ␐怲≽傰䕭嬲ˣ䕭⽝⿏ⅈ⽫䕭ㆾ䱾⯧䕭)
ㆾⅈ䉨≽傰ㇳ埻⼴䘬䕭Ṣ炻㚵䓐clopidogrel⎗
IJįĴġńŭŰűŪťŰŨųŦŭ 傥㭼aspirin㷃⮹庫⣂䘬⽫埨䭉ḳẞ13ˤ
Clopidogrel㗗⻟侴⮰ᶨ䘬埨⮷㜧ↅ普㈹⇞
∹ˤClopidogrel䘬ἄ䓐䁢怠㑯⿏㈹⇞埨⮷㜧ᶲ IJįĵġńŪŭŰŴŵŢŻŰŭ
䘬▴␌⍿橼(purinergic receptor P2Y, G-protein Cilostazol怠㑯⿏⛘㈹⇞䫔ᶱ✳䢟愠Ḵ愞
coupled 12, P2Y12)冯ADPᷳ䳸⎰炻⤪㬌ὧ㚫 (phosphodiesterase)炻⮶农埨⮷㜧䑘䉨儢▴␌㟠
㈹⇞䴻䓙ADP⨺ṳ䘬態噳䘥IIb/IIIa墯⎰橼䘬㳣 ╖䢟愠(cAMP)䘬㽫⹎⡆≈炻忚ᶨ㬍⡆≈噳䘥
⊾ἄ䓐炻忚侴㈹⇞埨⮷㜧ↅ普炻㬌ἄ䓐㗗ᶵ⎗ 㽨愞A (protein kinase A)㳣⊾✳ン炻侴㈹⇞埨
微䘬ˤ⚈㬌炻↉㍍妠⇘clopidogrel䘬埨⮷㜧炻 ⮷㜧䘬ↅ普ˤ噳䘥㽨愞Aḇ㚫㈹⇞倴䎫噳䘥庽
⛐℞⢥␥㛇攻⛯㚫⍿⇘⼙枧ˤ晾䃞clopidogrel 捰㽨愞(myosin light-chain kinase)䘬㳣⊾炻㈹⇞
ᶵ㚦⛐⽑䘤⿏儎ᷕ桐娎槿ᷕ冯⬱ㄘ∹ 忶㭼 ⸛㹹倴㓞䷖炻忈ㆸ埨䭉㒜⻝䘬㓰㝄炻⚈㬌⎗䓐
庫炻clopidogrel㚦䴻⛐ℑᾳ冐⸲娎槿ᷕ╖䌐冯 㕤攻㫯⿏嶃埴䘬㱣䗪ˤ⛐枸旚儎ᷕ桐⽑䘤ḇ㚱
℞Ṿ喍䈑 忶⮵㭼⿏䘬䞼䨞ˤ℞ᷕCAPRIE娎 䚠斄娎槿炻㖍㛔䘬CSPS娎槿 15 炻䲵ℍ1,052ỵ
槿13炻⊭㊔Ḯ19,185ỵ㚦㚱儎ᷕ桐ˣ⽫倴㠿⠆ˣ 仢埨⿏儎ᷕ桐䘤䓇1–6ᾳ㚰䘬䕭Ṣ炻晐㨇↮惵
ㆾ␐怲≽傰䕦䕭䘬䕭Ṣ炻晐㨇↮惵军aspirin 军cilostazol㱣䗪䳬(100㮓㭷㖍2㫉)ㆾ⬱ㄘ∹
㭷㖍325㮓ㆾclopidogrel㭷㖍75㮓炻徥巐2 䳬ˤ⬱ㄘ∹䳬㭷⸜儎㠿⠆⽑䘤䌯㗗5.78%炻侴
⸜炻䳸㝄栗䣢㔜橼⽫埨䭉䕦䕭ḳẞ䘤䓇䌯(⊭ cilostazol䳬⇯㗗3.37%炻䚠⮵桐晒ᶳ旵忼41.7%
㊔仢埨⿏儎ᷕ桐ˣ⽫倴㠿⠆⍲埨䭉ḳẞ忈ㆸ (95%CI = 9.2%–62.5%烊P = 0.015)ˤẍ仢埨⿏儎
䘬㬣ṉ)⛐aspirin䳬㗗5.83%炻侴clopidogrel䳬 ᷕ桐Ṇ✳Ἦ婒炻⤪㝄䕭Ṣ㗗僼晁⿏㠿⠆(lacunar
⇯䁢5.32%炻䚠⮵桐晒(relative risk, RR)旵ỶḮ stroke)炻cilostazol⎗ᶳ旵䚠⮵桐晒43.4%䘬
8.7% (95%ᾉ岜⋨攻˳confidence interval, CI˴ 仢埨⿏儎ᷕ桐⽑䘤(95%CI = 3.0%–67%烊P =
= 0.3–16.5%烊P = 0.043)炻⛐枸旚埨䭉ḳẞᶲ庫 0.0373)炻侴↢埨⿏ḳẞ㰺㚱栗叿⡆≈ˤ10⸜
aspirin䦵ἛˤỮ㗗憅⮵㚱儎ᷕ桐䕭⎚䕭Ṣ䘬㫉 ⼴䘤堐䘬⎎ᶨᾳ㖍㛔娎槿CSPS-216炻ℙ㚱2,757
↮㜸炻clopidogrel䳬㭷⸜䘤䓇⽫埨䭉䕦䕭ḳẞ ỵ朆⽫⚈⿏儎ᷕ桐䕭Ṣ炻崭忶ℕㆸ㗗僼晁⿏㠿
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
IJįĶįĴġőųŢŴŶŨųŦŭ ⢾炻儢功(adenosine)℟㚱埨䭉㒜⻝䘬ἄ䓐炻㬌
Ṏ䁢dipyridamole䓊䓇埨䭉㒜⻝ἄ䓐䘬㨇⇞ᷳ
Prasugrel䁢ᶨ䧖⇵槭喍䈑(prodrug)炻⛐ ᶨˤAspirin⎰Ἕdipyridamole㚦䴻⛐4ᾳ⣏✳䘬
廱㎃䁢㳣⿏ẋ嫅䈑⼴炻德忶怠㑯⿏ᶼᶵ⎗ 晐㨇娎槿忚埴炻ESPS-1 30 ⮯2,500ỵ仢埨⿏儎
微䳸⎰军埨⮷㜧䘬P2Y12 ADP⍿橼炻䚠庫㕤 ᷕ桐䕭Ṣ晐㨇↮惵军⬱ㄘ∹䳬ㆾ⎰Ἕ喍䈑䳬
clopidogrel炻prasugrel⎗ẍ㚜⾓忇䘬㈹⇞埨⮷ (⊭㊔325㮓䘬aspirin⍲75㮓䩳⌛慳㓦✳䘬
㜧ↅ普ἄ䓐炻侴ᶼᶵ⍿CYP2C19➢⚈⣂⚈✳䘬 dipyridamole㭷㖍ᶱ㫉)炻䴻忶2⸜䘬徥希炻⎰Ἕ
25, 26
⼙枧 ˤPrasugrel㚦⛐⿍⿏ⅈ⽫䕯㍍⍿⮶䭉ṳ 喍䈑䳬䘬儎ᷕ桐ㆾ㬣ṉ䘬䘤䓇䌯㗗16%炻侴⬱
ℍㇳ埻䘬䕭Ṣ冯clopidogrel㭼庫27炻prasugrel≈ ㄘ∹䳬㗗25% (RR = 33%烊P < 0.001)ˤESPS-231
ᶲaspirin䚠庫㕤clopidogrel≈ᶲaspirin㚱庫Ỷ䘬 㗗ᶨ枭晐㨇ˣ暁䚚ᷳ⮵䄏䞼䨞炻ℙ6,602ᾳ㚦䴻
⽫冇仢埨ḳẞ炻Ữℑ侭䘬儎ᷕ桐䘤䓇䌯㰺㚱ⶖ 儎ᷕ桐ㆾ㗗TIA䘬䕭Ṣ炻↮䁢4ᾳ䳬⇍炻⊭㊔烉
䔘炻侴ᶼprasugrel㚱庫⣂䘬慵⣏↢埨ḳẞ炻䈡 aspirin 25㮓≈ᶲ䶑慳✳dipyridamole 200㮓
⇍㗗⸜漉> 75㬚ˣ橼慵< 60℔㕌ㆾ㚱儎ᷕ桐䕭⎚ 㭷㖍ℑ㫉ˣaspirin 25㮓㭷㖍ℑ㫉ˣ䶑慳✳
䘬䕭Ṣˤ⛐2015⸜䘬䴙⎰↮㜸ḇ栗䣢prasugrel dipyridamole 200㮓㭷㖍ℑ㫉ˣ⬱ㄘ∹ˤ⎬䳬
䚠庫㕤clopidogrel䃉㱽ᶳ旵儎ᷕ桐䘤䓇䌯炻侴 ⇍冯⬱ㄘ∹䚠庫炻ἧ䓐╖ᶨaspirin⎗㷃⮹18%
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ᶼ㚱庫檀䘬↢埨桐晒 ˤᶨᾳẍ朆⿍⿏㛇䘬朆 䘬儎ᷕ桐䚠⮵桐晒(P = 0.013)炻ἧ䓐╖ᶨ䶑慳✳
⽫⚈⿏儎ᷕ桐䕭Ṣ䁢㓞㟰⮵尉䘬晐㨇冐⸲娎 dipyridamole⎗㷃⮹16%䘬儎ᷕ桐䚠⮵桐晒(P =
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槿䘤䎦 炻ᷕỶ∹慷䘬prasugrel (㭷㖍3.75㮓) 0.039)炻⎰Ἕ喍䈑䳬⇯⎗㷃⮹37%䘬儎ᷕ桐䚠⮵
⎗ẍ栗叿䘬㷃⮹P2Y12䘬⍵ㅱ╖ỵ(prasugrel 桐晒(P < 0.001)烊侴䚠庫㕤╖ᶨaspirin炻⎰Ἕ喍
reaction units, PRU)炻侴ᶼᶵ⍿CYP2C19䘬➢ 䈑䳬⎗㷃⮹23%䘬儎ᷕ桐䚠⮵桐晒(P = 0.006)炻
⚈⣂✳⿏䘬⼙枧ˤ晐㨇冐⸲娎槿PRASTRO-I⮯ 侴ᶼ↢埨ḳẞ᷎㰺㚱栗叿⡆≈炻Ữ㗗柕䖃䕯
3,753ỵ朆⽫⚈⿏仢埨⿏儎ᷕ桐䘬䕭Ṣ㕤䘤䕭 䉨䘬䡢㚫⡆≈ˤ䫔3ᾳ⣏✳娎槿㗗ESPRIT 32炻
⼴1-26忙攻晐㨇↮惵军prasugrel (㭷㖍3.75㮓) ℙ4,500ỵ⛐6ᾳ㚰ᷳℏ㚦䴻㚱TIAㆾ仢埨⿏儎
ㆾclopidogrel (㭷㖍75㮓)炻娎槿㛇攻䁢96军 ᷕ桐䘬䕭Ṣ炻晐㨇↮㳦军╖ᶨaspirin (30–325
104忙炻䘤䎦⇅䳂娎槿䳪溆(仢埨⿏ḳẞ䘤䓇䌯) 㮓)ㆾaspirin≈ᶲdipyridamole (200㮓㭷㖍
᷎㰺㚱栗叿ⶖ䔘炻ℑ䳬䘬䘤䓇䌯⛯䁢4% (RR = ℑ㫉)炻奨⮇ℑ䳬㱣䗪⛐枸旚儎ᷕ桐⽑䘤ˣ⽫
1.05烊95%CI = 0.76–1.44)炻ℑ䳬ᷳ攻䘬⎬枭↢ 倴㠿⠆ˣ埨䭉⿏㬣ṉㆾ㗗℞Ṿ慵⣏↢埨䘬㓰
埨⿏ḳẞḇ㰺㚱栗叿ⶖ䔘炻prasugrel䃉㱽忼⇘ 㝄ˤ㬌娎槿aspirin䘬⸛⛯∹慷㗗㭷㖍75㮓ˤ
ᶵ≋㕤(non-inferiority) clopidogrel䘬`姕ˤ 䴻3.5⸜䘬徥希炻䷥橼埨䭉ḳẞ䘤䓇䌯⛐⎰Ἕ
喍䈑䳬㗗13%炻⛐╖ᶨaspirin䳬㗗16% (HR =
IJįķġġӫٺځҢŢŴűŪųŪůЅѪՖωݖސ 0.80烊95%CI = 0.66–0.98)ˤᶲ徘ᶱᾳ娎槿䘬
䴙⎰↮㜸䘤䎦 32炻aspirin≈dipyridamole䚠庫㕤
IJįķįIJġġӫٺځҢŢŴűŪųŪůЅťŪűźųŪťŢŮŰŭŦ aspirin炻⎗䚠⮵㷃⮹18%䘬䵄⎰⿏埨䭉ḳẞˤ
Dipyridamole䘬ἄ䓐㨇廱㗗德忶㈹⇞ 䫔4ᾳ⣏✳䘬娎槿㗗PRoFESS14炻椾㫉⮵20,332
phosphodiesterase炻⇢㽨埨⮷㜧ᷳ儢㟠䑘䉨愞 ỵ儎ᷕ桐䕭Ṣ忚埴䚜㍍㭼庫aspirin≈ᶲ䶑慳✳
(platelet adenylate cyclase)炻⮶农cAMP䘬㽫 dipyridamole墯㕡冯clopidogrel⮵㕤枸旚儎ᷕ桐
⹎⡆≈炻忚ᶨ㬍㈹⇞埨⮷㜧农㳣⚈⫸(platelet ⽑䘤䘬喍㓰⬱ℐ⿏ˤ䞼䨞栗䣢晾䃞aspirin≈
activating factor)ˣ先⍇(collagen)ˣ儢▴␌㟠 ᶲ䶑慳✳dipyridamole墯㕡㭼clopidogrel㚱庫⣂
Ḵ䢟愠(ADP)䫱⺽崟䘬埨⮷㜧ↅ普ἄ䓐ˤ㬌 䘬↢埨ḳẞ(4.1%㭼3.6%烊HR = 1.15烊95%CI
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
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檀Ữ䴙妰ᶵ栗叿䘬埨䭉䊡䨬ら⊾㭼ἳ(9.6%㭼 炻䈡⇍㗗Ṇ㳚㕷佌炻栙ℏ儎≽傰䱍䉨䠔⊾䘬
5.6%烊P = 0.53)炻ᶵ忶㫉䳂娎槿䳪溆䘬㚱埨 䚃埴䌯㭼㫸伶㕷佌檀 42, 43ˤ2005⸜伶⚳WASID
䭉ḳẞㆾᷕ桐ḳẞ⇯㖶栗庫Ỷ(⊅䬿㭼˳odd 暁䚚晐㨇娎槿䘬㓞㟰⮵尉㗗仢埨⿏儎ᷕ桐ㆾ
ratio, OR˴= 0.37烊P = 0.04)ˤ TIA炻ᶼ⎰Ἕ㚱栙ℏ儎≽傰䊡䨬忼50–99%䘬569
㕤2019⸜䘤堐䘬CSPS.com䞼䨞ᷫ㗗ᶨ枭 ỵ䕭Ṣ炻晐㨇↮惵军warfarin (INR㍏⇞⛐2–3)
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㕤㖍㛔㓞㟰ᷳ⣂ᷕ⽫晐㨇⮵䄏冐⸲娎槿 炻㓞 ㆾaspirin (㭷㖍1,300㮓)44ˤ䳸㝄䘤䎦仢埨⿏儎
䲵1,884ỵ⿍⿏ᷕ桐䘤䓇8-180⣑ℏᷳ䕭Ṣ炻㓞 ᷕ桐ˣ儎↢埨⍲℞Ṿ埨䭉䕦䕭忈ㆸ䘬㬣ṉ㰺㚱
㟰㧁㸾䁢檀桐晒䘬朆⽫⚈⿏ᷕ桐䕭Ṣ炻℞檀 ⶖ䔘炻Ữwarfarin䳬䘬㬣ṉ䌯⍲慵⣏↢埨䘤䓇䌯
桐晒⭂佑䁢烉(1) ≥ 50%ᷳ栙ℏ⢾⣏埨䭉䊡䨬烊 㭼aspirin䳬栗叿⡆檀ˤ䓙㕤WASID娎槿䘬㫉↮
ㆾ (2) ℑ䧖ẍᶲ䘬埨䭉⌙晒⚈⫸(⊭㊔⸜䲨≥ 65 㜸䘤䎦45炻栙ℏ儎≽傰䊡䨬≥ 70%䘬䕭Ṣ䘤䓇ᷕ
㬚ˣ檀埨⡻ˣ䱾⯧䕭ˣㄊ⿏僶䕭ˣ␐怲≽傰䕦 桐⽑䘤䘬㭼䌯栗叿檀㕤< 70%䘬䕭Ṣ炻2008⸜
䕭ˣ㚱㛔㫉昌⢾ᷳ仢埨⿏ᷕ桐䕭⎚ˣ仢埨⿏⽫ 伶⚳⚳⭞堃䓇昊憅⮵栙ℏ儎≽傰䊡䨬70–99%ᶼ
冇䕭ˣㆾ㊩临㉥厠侭)ˤ⮯㓞㟰䕭Ṣ晐㨇↮䁢 ⎰Ἕ仢埨⿏儎ᷕ桐䘬䕭Ṣ炻忚埴䘣抬䞼䨞 46炻
ℑ䳬炻ᶨ䳬㈽ẍcilostazol䁢ᷣ⸡ᷳ暁慵㈿埨⮷ 㭷ỵ䕭Ṣ⛯⎰Ἕἧ䓐clopidogrel(㭷㖍75㮓)⍲
㜧喍(cilostazola㭷㖍200㮓炻≈ᶲaspirin㭷㖍 aspirin (㭷㖍81–325㮓) 4–12忙炻᷎㍍⍿栙ℏ
81ㆾ100㮓ㆾclopidogrel㭷㖍50ㆾ75㮓)炻 儎≽傰㓗㝞㱣䗪炻䘤䎦6ᾳ㚰䘬ḳẞ䘤䓇䌯(⊭
⎎ᶨ䳬⇯䓐㧁㸾ᷳ╖㕡㈿埨⮷㜧喍(aspirinㆾ ㊔ảỽ儎ᷕ桐⍲30㖍ℏ㬣ṉ)䁢14.0%炻冯⇵徘
clopidogrel)炻᷎攟㛇㚵䓐军⮹6ᾳ㚰ẍᶲˤ䳸 䘬WASID娎槿ᷕ栙ℏ儎≽傰䊡䨬70–99%䘬䘤䓇
㝄⛐⸛⛯1.4⸜䘬徥希㗪攻ℏ炻ἧ䓐cilostazolᷳ 䌯䚠Ụ炻栗䣢暁㈿⮷埨㜧喍䈑⎰Ἕ栙ℏ儎≽傰
暁㈿埨⮷㜧喍䳬炻℞䘤䓇仢埨⿏ᷕ桐䘬桐晒㖶 㓗㝞㱣䗪㓰㝄⎗傥ᶵṆ㕤㈿埨㞻喍䈑ˤ
栗旵ỶḮᶨ⋲(3%㭼7%烊HR = 0.49烊95%CI = 晐⼴伶⚳䘬SAMMPRIS娎槿 47炻䲵ℍ30㖍
0.31–0.76)炻䵄⎰⿏埨䭉ḳẞḇ⎴㧋旵Ỷᶨ⋲ ℏ㚱庽⽖仢埨⿏儎ᷕ桐ㆾTIAᶼ⎰Ἕ㚱栙ℏ儎
(4%㭼8%烊HR = 0.52烊95%CI = 0.35–0.77)炻 ≽傰䊡䨬忼70–99%䘬451ỵ䕭Ṣ炻㭷ỵ䕭Ṣ⛯
侴ᶼ℞♜慵↢埨ㆾ栙ℏ↢埨(1%㭼1%烊HR = ἧ䓐暁㈿埨⮷㜧喍䈑(clopidogrel㭷㖍75㮓⍲
0.66烊P = 0.35)ᷳ㭼ἳ᷎㰺㚱ᶲ⋯炻ⓗ䌐⚈䁢 aspirin㭷㖍325㮓)军90㖍炻ᶼ䧵㤝⛘㱣䗪⌙
ᶵ怑⍵ㅱ侴 喍ᷳ㭼ἳṵ庫檀(66Ṣ㭼12Ṣ)ˤ 晒⚈⫸炻䕭Ṣ晐㨇↮惵军㍍⍿栙ℏ儎≽傰㓗㝞
㬌䞼䨞ᷫ㗗䚖⇵㚱ᷕ桐㕷佌ἧ䓐暁㈿埨⮷㜧 㱣䗪(㓗㝞䳬)ㆾᶵ㍍⍿㓗㝞㱣䗪(喍䈑䳬)ˤ䳸㝄
喍䔞ᷕ炻ⓗᶨ䘬ᶨᾳ攟㛇㚵䓐㚱㖶栗⤥嗽ᶼᶵ 栗䣢㍍⍿㓗㝞䳬䘬⍇䘤ḳẞ(儎ᷕ桐ㆾ㬣ṉ)䘤
㚫⡆≈↢埨䘬娎槿䳸㝄ˤ晾䃞㬌䞼䨞⛐㖍㛔 䓇䌯栗叿檀㕤ἧ䓐喍䈑䳬烊侴ᶼ⛐㬌娎槿2⸜
忚埴炻℞冐⸲㓰≃⢾㍐军℞ṾṢ䧖ㆾ姙ṵ㚱 ẍᶲᷳ攟㛇徥希䳸㝄ḇ栗䣢 48炻╖䲼喍䈑䳬ℵ
䔹ㄖ炻Ữcilostazol⛐Ṇ㳚ᷕ桐䕭Ṣ㕷佌䘬㱣䗪 ᷕ桐桐晒᷎ᶵ㚫㭼㓗㝞䳬檀炻嫱⮎喍䈑㛔幓䘬
㓰䙲㚱⣂䭯䞼䨞嫱⮎炻㓭䕭Ṣ䕭ね劍䫎⎰ 㓰㝄⎗ẍ⺞临ᶳ⍣ˣ侴栙ℏ㓗㝞᷎㰺彎㱽⛐攟
CSPS.comᷳ㓞㟰㧁㸾炻⇯⎗侫ㄖ⛐Ṇ⿍⿏㛇⼴ 㛇㍸ὃ㚜⣂䘬⤥嗽ˤ
㓡䓐ẍcilostazol䁢ᷣ⸡ᷳ暁㈿埨⮷㜧喍䈑ẍ枸 㬌⢾炻⛐ᶳᶨ䪈ᷕ㚫㍸⇘䘬CHANCE娎
旚ℵᷕ桐ˤ 槿 炻 ℞ ᷕ ᶨ ᾳ 㫉 ↮ 㜸 栗 䣢 49炻 栙 ℏ 儎 ≽ 傰 䊡
䨬忼50–99%䘬䕭Ṣ炻ἧ䓐暁㈿埨⮷㜧喍䈑
IJįĸġᢓϱသଢ଼๔ޑϽ (clopidogrel⍲aspirin)䘬䳬⇍䚠⮵㕤aspirin炻
栙ℏ儎≽傰䱍䉨䠔⊾㗗忈ㆸ儎ᷕ桐䘬ᷣ 㷃⮹Ḯ21%䘬儎ᷕ桐桐晒(HR = 0.79烊95%CI
⚈炻䕭Ṣ䘤䓇⽑䘤⿏儎ᷕ桐䘬桐晒ḇ朆ⷠ檀 = 0.47–1.32)炻晾䃞㰺㚱栗叿ⶖ䔘炻⌣栗䣢役
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
㛇儎仢埨⎰Ἕ⎴“㿴㳩栙ℏ儎≽傰䊡䨬䘬䕭 䓐aspirinˣclopidogrelˣdipyridamoleˣㆾ暁慵
Ṣ炻䞕㛇ἧ䓐暁㈿埨⮷㜧喍䈑(clopidogrel⍲ ㈿埨⮷㜧喍)炻㕤䕭䘤⼴⸛⛯3.26⣑㓞㟰炻ἧ
aspirin)炻⎗傥㷃⮹儎ᷕ桐⽑䘤ˤᶲ㔯㍸忶ᷳ 䓐喍䈑军⮹3ᾳ㚰ˣ᷎徥希1⸜炻䳸㝄䘤䎦⛐⎴
37 38 39
TOSS ˣTOSS-2 ˣCATHARSIS 娎槿ᷕ炻䘤 “埨䭉䭬⚵ℏ㚱6㫉ℵᷕ桐ḳẞ(1⸜2.4%)炻
䎦cilostazol傥䦵⽖㓡┬栙ℏ≽傰䊡䨬ら⊾ᷳ桐 ℞ᷕ㈿埨⮷㜧喍䳬㚱4ỵˣ㈿ↅ埨喍䳬㚱2ỵ炻
40
晒ㆾ㷃⮹⽫埨䭉ḳẞ炻⛐CSPS.com娎槿ᷕ 炻 ᷎㰺㚱忼⇘䴙妰ᶲⶖ䔘(㈿ↅ埨喍䚠庫㈿埨⮷
䛇㬋⚈栙ℏ≽傰> 50%䊡䨬侴㓞㟰侭⌈Ḯ30%ⶎ 㜧喍䳬ᷳHR = 0.56烊95%CI = 0.10–3.21烊P =
⎛炻㬌㕷佌ἧ䓐cilostazolᷳ暁㈿埨⮷㜧喍Ṏ⎗ 0.51)炻ᶼ⮵㕤徥希䘬埨䭉㓅⼙ᶲ㗗⏎㚱埨䭉ℵ
栗叿旵Ỷℵᷕ桐桐晒(4.0%㭼9.2%烊HR = 0.47烊 忂(recanalization)ḇ㰺㚱ⶖ䔘(OR = 1.04烊95%CI
95%CI = 0.23–0.95)ˤ䵄妨ᷳ炻嫱㒂栗䣢憅⮵栙 = 0.69–3.37烊P = 0.09)ˤ㬌䞼䨞栗䣢炻⮵㕤柠悐
ℏ儎≽傰䱍䉨䠔⊾䘬䕭Ṣ炻aspirin䚖⇵ṵ䁢⺢ ≽傰∅暊⮶农䘬仢埨⿏ᷕ桐炻ἧ䓐㈿ↅ埨喍ㆾ
嬘ᷳ椾怠㈿埨⮷㜧喍䈑炻᷎⎗侫ㄖ⛐⿍⿏㛇ㆾ ㈿埨⮷㜧喍᷎ᶵ㚫⮵枸⼴㚱㖶栗䘬ⶖ䔘炻⚈㬌
Ṇ⿍⿏㛇炻ẍ䞕㛇暁㈿埨⮷㜧喍䈑(aspirin≈ ℑ䧖喍䈑䘮⎗侫ㄖἧ䓐ˤ
clopidogrel)Ἦ枸旚仢埨⿏儎ᷕ桐⽑䘤炻Ữẍᶵ
ἧ䓐崭忶90⣑䁢⍇⇯烊憅⮵㠿⠆檀桐晒ᶼ䫎⎰ IJįĺġкଢ଼๔ޑϽය༵
CSPS.com㓞㟰㡅ẞᷳ䕭Ṣ炻⎗侫ㄖ攟㛇ἧ䓐ẍ 姙⣂嫱㒂㊯↢炻ᷣ≽傰⺻ㆾ傠ᷣ≽傰䘬䱍
cilostazol䁢➢䢶ᷳ暁㈿埨⮷㜧喍䈑Ἦ枸旚儎ᷕ 䉨䠔⊾㔹⟲冯仢埨⿏儎ᷕ桐䘬桐晒ᶲ⋯㚱斄Ὢ
53, 54
桐ˤ 炻䈡⇍㗗儎ᷕ桐䘬桐晒冯ᷣ≽傰䘬䱍䉨䠔
⊾㔹⟲♜慵⹎㚱䚠斄 55炻䔞䱍䉨䠔⊾㔹⟲䘬⍂
IJįĹġᓛഋଢ଼থᚔ ⹎> 4 mm㗪炻儎ᷕ桐䘬桐晒㗗< 1 mm侭䘬13.8
柠悐≽傰(柠≽傰ˣ傲㢶≽傰)∅暊⮶农䘬 ˤ⎎⢾炻昌Ḯ⍂⹎炻℞Ṿ䈡⽝ḇ⎗ẋ堐♜慵
ᷕ桐䲬⌈㚱儎ᷕ桐䘬1-2%炻Ữ⌣㗗⸜庽✳ᷕ ᷣ≽傰䘬䱍䉨䠔⊾㔹⟲炻ἳ⤪㚱埨㞻ˣ㼘䖵ˣ
50
桐䘬慵天ㆸ⚈炻⎗檀忼10-25% ˤ⛐埨䭉∅暊 ㆾ⣏䘬傪偒㟠(lipid core)炻悥㚱庫檀䘬儎ᷕ桐
嗽⼊ㆸ䘬埨㞻⼨怈䪗旣⠆炻塓㍐㷔㗗忈ㆸᷕ桐 桐晒 56, 57炻⼰栗䃞䘬炻♜慵䘬ᷣ≽傰⺻䱍䉨䠔
䘬ᷣ⚈炻⚈㬌忶⼨㚱⬠侭㍸Έἧ䓐㈿ↅ埨∹⎗ ⊾㔹⟲㗗儎ᷕ桐䘬⌙晒⚈⫸ˤ军㕤㈿埨㞻喍䈑
傥㭼庫㚱㓰炻ỮṎ㚱ᶨ㳦婒㱽奢⼿╖䲼ἧ䓐㈿ ⛐ᷣ≽傰⺻䱍䉨䠔⊾㔹⟲䘬㱣䗪䞼䨞䚠䔞㚱旸
埨⮷㜧喍䈑ḇ埴炻ᶼ㭼庫ᶵ㚫ら⊾埨䭉⡩ℏ䘬 ᶼ䳸㝄↮㬏 58-60炻侴ἧ䓐statin䘬か侭炻䚠庫㕤
↢埨(mural hematoma)ˤ忶⍣㚱ᶨ䭯㟡㒂40䭯奨 㰺㚱ἧ䓐侭炻⇯⎗傥㚫㚱庫Ỷ䘬㬣ṉ䌯ㆾ㷃⮹
51
⮇⿏䞼䨞ἄ䘬䴙⎰↮㜸䘤䎦 炻ἧ䓐㈿埨⮷ 儎ᷕ桐⍲℞Ṿ㞻⠆ḳẞ 60, 61 ˤ⛐ARCH冐⸲娎
㜧喍䈑ㆾ㈿ↅ埨喍⮵㕤ℵᷕ桐(2.6%㭼1.8%烊 槿ᷕ 62 炻㓞㟰⮵尉㗗㚱仢埨⿏儎ᷕ桐ˣTIAㆾ
OR = 1.49)ㆾ㬣ṉ䌯(1%㭼0.8%烊OR = 1.27)⛯ ␐怲⿏㞻⠆ḳẞ炻ᶼ⎰Ἕ㚱傠ᷣ≽傰䱍䉨㔹⟲
㰺㚱栗叿ⶖ䔘ˤỮ䚜⇘2019⸜䘤堐䘬CADISS ⍂⹎> 4 mm䘬䕭Ṣ炻晐㨇↮惵军暁㈿埨⮷㜧
52
娎槿 炻ㇵ椾㫉ἧ䓐晐㨇↮惵ᷳ冐⸲娎槿Ἦ㭼 喍䈑(aspirin㭷㖍75–150㮓≈clopidogrel㭷㖍
庫㬌ℑ䧖䗪㱽炻⮵尉㗗250ỵ⛐7⣑ℏ䘤䓇柠悐 75㮓炸ㆾ⎋㚵㈿ↅ埨∹warfarin (䚖㧁PT INR
≽傰(柠≽傰ㆾ傲㢶≽傰)∅暊⮶农仢埨⿏ᷕ 2-3)炻Ữ⚈㓞㟰⚘暋炻䲵ℍ349ỵ䕭Ṣ炻⸛⛯
桐ㆾTIA䕭Ṣ(⸛⛯⸜漉䲬49㬚)炻126ỵ↮惵⇘ 徥巐3.4⸜炻暁㈿埨⮷㜧喍䈑䳬㭷⸜䘬䵄⎰⿏埨
㈿ↅ埨∹(⿍⿏㛇ἧ䓐㧁㸾heparinㆾỶ↮⫸慷 䭉ḳẞ䘤䓇䌯㗗2.2%炻侴㈿ↅ埨∹䳬㗗3.5%炻
heparin炻㍍叿攟㛇ἧ䓐warfarin᷎⮯INR㍏⇞ 暁㈿埨⮷㜧喍䈑䚠⮵㷃⮹24%桐晒(HR = 0.76烊
⛐2-3)炻⎎⢾124ỵ⇯↮惵⇘㈿埨⮷㜧喍(⎗ἧ 95%CI = 0.36–1.61烊P = 0.5)炻晾䃞㰺㚱䴙妰ⶖ
11
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
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ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
㟰炻⎗ẍ䞕㛇⎰Ἕἧ䓐aspirin⍲clopidogrel军3 ⮷㜧喍䈑㱣䗪䘬㗪攻ˤ晾䃞㚱ẍᶲℑᾳ奨⮇⿏
ᾳ㚰ˤ䚖⇵㰺㚱嫱㒂㓗㊩攟㛇⎰Ἕἧ䓐䘬㓰䙲 䞼䨞䘬䳸㝄㓗㊩炻䚖⇵᷎㰺㚱晐㨇冐⸲娎槿嫱
⍲⬱ℐ⿏炻Ữ儎ᷕ桐䘬䕭Ṣ⤪⎴㗪⎰Ἕ⿍⿏ⅈ ⮎炻䔞䕭Ṣἧ䓐aspirinね㱩ᶳṵ䘤䓇仢埨⿏儎
⽫䕯ㆾ㍍⍿ⅈ䉨≽傰埨䭉㓗㝞䘬ね㱩ᶳ炻⎗ẍ ᷕ桐炻廱㎃ㆾ≈ᶲ䫔Ḵ栆㈿埨⮷㜧喍䈑㗗⏎㚱
侫ㄖ攟㛇⎰Ἕἧ䓐aspirin⍲clopidogrel 71, 72ˤ军 㓰ˤ⚈㬌炻㚵䓐╖㕡㈿埨⮷㜧喍䈑䘬ね㱩ᶳṵ
㕤ticlopidine⛐枸旚儎ᷕ桐⽑䘤ᶲ⎗傥㭼aspirin 䘤䓇儎ᷕ桐炻ㅱ⎴㗪侫慷䕭Ṣ䘬⌙晒⚈⫸㗗⏎
Ἦ⼿㚱㓰20炻Ữ㗗⬱ℐ⿏䘬䔹ㄖ(⯌℞㗗柮䰺䎫 䴻㍏⇞⼿⭄炻䴻㔜橼姽Ộ⤥嗽⍲⢆嗽⼴炻⎗
㷃⮹䕯䘬∗ἄ䓐)旸⇞Ḯ⬫䘬冐⸲ㅱ䓐ˤ㬌⢾炻 ẍ侫ㄖ廱㎃㈿埨⮷㜧喍䈑ㆾ䞕㛇≈ᶲ䫔Ḵ栆㈿
㕤Ṇ㳚㕷佌炻cilostazol⎗ẍἄ䁢枸旚儎ᷕ桐⽑ 埨⮷㜧喍䈑ˤ
䘤䘬喍䈑烊⮵㕤䃉㱽ἧ䓐aspirinㆾẍaspirin㱣䗪 军㕤⮎槿⭌ᷕ㈿埨⮷㜧喍䈑䘬㈿喍⿏㩊
ᶳṵ䘤䓇䵄⎰埨䭉ḳẞ䘬䕭Ṣ炻㕤㌺昌⽫堘䪕 槿炻㚱⟙⏲㊯↢ⅈ䉨≽傰䕦䕭䘬䕭Ṣ⤪㝄⮵
䕭⎚⼴炻⎗ἧ䓐cilostazol (100㮓㭷㖍ℑ㫉)㕤 aspirinㆾ㗗clopidogrel䘬㈿埨⮷㜧⍵ㅱ庫ⶖ炻
㫉䳂儎ᷕ桐枸旚炻䈡⇍㗗僼晁✳儎㠿⠆ㆾ檀↢ ⎗傥㚫㚱庫⣂䘬仢埨⿏埨䭉ḳẞㆾ㗗㬣ṉḳẞ
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埨⿏桐晒䘬䕭Ṣ烊⮵㕤檀桐晒㕷佌炻ἳ⤪㖶䡢 ˤ晾䃞冐⸲ᶲ⎗ẍ⮯忁ṃ℟㚱㈿喍⿏䘬䕭Ṣ
䘬栙ℏ⢾⣏埨䭉䊡䨬炻ㆾ㚱⣂枭埨䭉⌙晒⚈⫸ 廱㎃ㆸ℞Ṿ㚧ẋ喍䈑ㆾℵ≈ᶲ䫔Ḵ䧖㈿埨⮷㜧
ᷳ䕭Ṣ炻Ṏ⎗侫ㄖἧ䓐ẍcilostazol䁢ᷣˣ≈ᶲ 喍䈑炻Ữ忁㧋䘬 㱽℞⮎㚱桐晒炻⚈䁢䚖⇵᷎
aspirinㆾclopidogrelᷳ暁慵㈿埨⮷㜧喍䈑ˤ 㰺㚱䞼䨞嫱㒂㓗㊩忁㧋䘬ἄ㱽ˤ㚱ᶨᾳ娎槿⇑
䓐⮎槿⭌㩊㞍Ἦ⇌⭂㍍⍿ⅈ䉨≽傰㓗㝞㱣䗪
IJįIJijġġ݈ҢתՖωݖޟސݷή 䘬䕭Ṣ㗗⏎⮵㚵䓐ᷕ䘬㈿埨⮷㜧喍䈑䁢ᶵ⍵ㅱ
ϫีҡသϛॳ 侭炻᷎㒂㬌Ἦ婧㔜喍䈑炻䘤䎦㚦䴻婧㔜喍䈑䘬
䔞ᶨᾳ䴻⛐㚵䓐㈿埨⮷㜧喍䈑䘬䕭Ṣ 䕭Ṣ晾䃞㚱庫檀䘬⽫埨䭉ḳẞ䘤䓇䌯炻Ữ㰺㚱
ṵ䘤䓇儎ᷕ桐㗪炻廱㎃㈿埨⮷㜧喍䈑㗗⏎傥㷃 栗叿䘬䴙妰ⶖ䔘 76 ˤ侴⎎⢾ᶨᾳ䞼䨞 77 炻⊭⏓
⮹㛒Ἦ儎ᷕ桐⽑䘤䘬㨇䌯㗗ᶨᾳⷠ夳䘬冐⸲⓷ Ḯ仢埨⿏儎ᷕ桐ㆾTIA䘬䕭Ṣ炻⇑䓐埨⮷㜧ↅ
73
柴ˤ㚱ᶨ䭯䞼䨞⇑䓐⎘䀋ᾅ屯㕁⹓ 炻↮㜸 普㷔娎Ἦ㰢⭂䕭Ṣ㗗⏎⮵㈿埨⮷㜧喍䈑㚱⍵ㅱ
ἧ䓐aspirinね㱩ᶳṵ䘤䓇儎ᷕ桐䘬䕭Ṣ炻廱㎃ ⿏炻ḇ䘤䎦㚦㍍⍿㈿埨⮷㜧喍䈑婧㔜䘬ᾳ㟰㚱
䁢clopidogrelㆾ䵕㊩ἧ䓐aspirin⮵㛒Ἦ儎ᷕ桐䘤 庫檀䘬㬣ṉ䌯ˣ↢埨⍲仢埨⿏ḳẞ(HR = 2.24烊
䓇䌯䘬ⶖ䔘炻䳸㝄栗䣢廱㎃䁢clopidogrel䘬䕭 95%CI = 1.12–4.47烊P = 0.02)ˤ昌Ḯ喍䈑㛔幓炻
Ṣ㚱庫Ỷ䘬䵄⎰ḳẞ䘤䓇䌯(HR = 0.54烊95%CI 䕭Ṣ㚵喍䘬思⽆⿏ˣ⎰Ἕ䕯ˣㆾ⌙晒⚈⫸ḇ⎗
= 0.43–0.68烊P < 0.001)⍲庫Ỷ䘬儎ᷕ桐⽑䘤䌯 傥⼙枧㈿埨⮷㜧喍䈑䘬㈿喍⿏㩊槿䳸㝄 75炻侴
(HR = 0.54烊95%CI = 0.42–0.69烊P < 0.001)ˤ ᶼ㈿喍⿏㩊槿䘬㔠ῤ⯂㛒㧁㸾⊾炻⚈㬌ẍ䚖⇵
74
⎎⢾炻⛐ᶨᾳ杻⚳䘬䘣抬䞼䨞ᷕ 炻⮵㕤㚵 䘬嫱㒂侴妨炻ἳ埴⿏㩊㷔埨⮷㜧ↅ普≇傥᷎ᶵ
䓐aspirinṵ䘤䓇仢埨⿏儎ᷕ桐䘬䕭Ṣ炻⤪㚧㎃ 傥䓐Ἦ䔞ἄ㗗⏎婧㔜㈿埨⮷㜧喍䈑㱣䗪䘬⍫
军℞Ṿ㈿埨⮷㜧喍䈑䘬╖㕡㱣䗪(clopidogrelỼ 侫ˤ
80.5%)ㆾ≈ᶲ⎎ᶨ㈿埨⮷㜧喍䈑䘬暁㈿埨⮷㜧
喍䈑㱣䗪(aspirinἝ䓐clopidogrelỼ87.1%)炻1⸜ IJįIJĴġġ݈ҢתՖωݖޟސݷή
ℏ㚫㚱庫Ỷ䘬⽫埨䭉⍲㬣ṉḳẞ炻ᶼ暁㈿埨⮷ ีҡသюՖ
㜧喍䈑㱣䗪䘬䕭Ṣ㚱庫Ỷ䘬儎ᷕ桐䘤䓇䌯(HR ⎎ᶨ䧖冐⸲ᶲ㢀ㇳ䘬ね㱩⇯㗗炻䔞ᶨᾳ
= 0.45烊95%CI = 0.25–0.83)ˤ娚䞼䨞㰺㚱䴙妰 䴻⛐㚵䓐㈿埨⮷㜧喍䈑䘬䕭Ṣ䘤䓇Ḯ儎↢
↢埨⿏ḳẞ䘤䓇䌯炻ḇᶵ㶭㤂㊩临ἧ䓐暁㈿埨 埨ˣ䈡⇍㗗冒䘤⿏儎↢埨㗪炻㈿埨⮷㜧喍䈑
13
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
㗗⏎娚两临≈⚆⍣炻ẍ⍲娚怠㑯⒒䧖䓐喍ˤ椾 1. 儎ᷕ桐䕭Ṣℵ㫉儎ᷕ桐䘬⌙晒⿏⡆檀炻⚈㬌
⃰炻PICASSO娎槿娎⚾㍊妶⒒䧖㈿埨⮷㜧喍 枸旚儎ᷕ桐⽑䘤䘬㱣䗪ㅱ⍲㖑ᶼ攟㛇忚埴ˤ
78
䈑庫䁢⬱ℐ 炻㬌娎槿㓞䲵Ḯ1,534ỵ役㛇ℏ䘤 䎦昶㭝⛐枸旚朆⽫⚈⿏儎㠿⠆䘬⽑䘤㕡㱽
䓇仢埨⿏儎ᷕ桐ˣỮ⍰㚱儎↢埨檀⹎桐晒ᷳ䕭 ᶲ炻⺢嬘ἧ䓐怑䔞䘬㈿埨⮷㜧喍䈑Ἦ枸旚仢
Ṣ炻檀桐晒⭂佑䁢㚦㚱儎↢埨ᷳ䕭⎚ㆾ⼙⁷嫱 埨⿏儎ᷕ桐䘬⽑䘤℞Ṿ埨䭉ḳẞ䘬䘤䓇
㒂炻ㆾ侭儎悐㟠䡩ℙ㋗䘤䎦军⮹㚱ℑᾳẍᶲ䘬 (Class IˣLOE A)ˤ㟡㒂冐⸲娎槿䘬嫱㒂Ἦ怠
⽖↢埨溆(cerebral microbleeds)炻℞ᷕᶨ䳬ἧ䓐 㑯喍䈑㱣䗪炻㚱ẍᶳ⚃䧖椾怠䘬㕡㱽⎗ὃ怠
cilostazol (㭷㖍200㮓)炻⎎ᶨ䳬ἧ䓐aspirin (㭷 㑯ˤ
㖍100㮓)ˤ䳸㝄䘤䎦ἧ䓐cilostazol䳬㭷⸜䘤 (1) ἧ䓐aspirin (㭷㖍75–100㮓)Ἦ旵Ỷ儎ᷕ
䓇儎↢埨䘬㨇㚫䚠庫aspirin䦵ỶˣỮ㰺㚱忼⇘ 桐⽑䘤䘬㨇㚫(Class IˣLOE A)ˤ(䃉㚜≽)
䴙妰栗叿(0.61%㭼1.20%烊HR = 0.51烊95%CI (2) Clopidogrel⎗ẍἄ䁢枸旚儎ᷕ桐⽑䘤䘬㱣
= 0.20–1.27)炻侴䵄⎰⿏埨䭉ḳẞ⇯㗗ᶵ≋㕤 䗪㕡㱽炻⮵㕤䃉㱽ἧ䓐aspirinㆾẍaspirin
aspirin (4.27%㭼5.33%烊HR = 0.80烊95%CI = 㱣䗪ᶳṵ䘤䓇䵄⎰埨䭉ḳẞ(儎ᷕ桐ˣ⽫
0.57-1.11烊P = 0.0077)ˤ㓭憅⮵㚦㚱儎↢埨ᷳ䕭 倴㠿⠆ˣ㬣ṉ⍲慵⣏↢埨)䘬䕭Ṣ炻⎗
Ṣ炻ṵ⎗侫ㄖἧ䓐㈿埨⮷㜧喍Ἦ枸旚炻ⓗ枰㲐 ẍ怠㑯ἧ䓐clopidogrel (Class IIaˣLOE
シ㬌娎槿ᷕ㓞㟰䕭Ṣ䛇㬋䘤䓇忶儎↢埨䘬Ỽ B-R)ˤ(䃉㚜≽)
䲬40%ˤ (3) ⎰ Ἕ ἧ 䓐 a s p i r i n ( 㭷 㖍 5 0 㮓 ) 攟 㓰
⎎ᶨ枭㕤2019⸜䘤堐䘬RESTART䞼䨞䁢 dipyridamole (200㮓㭷㖍2㫉)⎗ẍ 䁢
ᶨ晐㨇ˣ朆暁䚚(Ữ㚱䌐䩳姽Ộ侭⇌㕟枸⼴)冐 㷃⮹儎ᷕ桐⽑䘤桐晒䘬㱣䗪㕡㱽(Class
79
⸲娎槿 炻㓞䲵Ḯ537ỵ⛐㚵䓐㈿埨⮷㜧喍䈑ᷳ IˣLOE B-R)ˤ(䃉㚜≽)
ᶳ䓊䓇冒䘤⿏儎↢埨ᷳ䕭Ṣ炻℞儎↢埨橼䧵⸛ (4) Cilostazol⎗ẍἄ䁢枸旚儎ᷕ桐⽑䘤䘬喍
⛯䁢4㮓⋯炻᷎⛐䘤䓇↢埨⼴⸛⛯76⣑ⶎ⎛晐 䈑烊⮵㕤䃉㱽ἧ䓐aspirinㆾẍaspirin㱣䗪
㨇↮惵炻ᶨ䳬慵㕘≈⚆㈿埨⮷㜧喍(⊭㊔aspirin ᶳṵ䘤䓇䵄⎰埨䭉ḳẞ䘬䕭Ṣ炻㕤㌺昌
ㆾclopidogrel)炻⎎ᶨ䳬⇯ᶵ≈⚆喍䈑炻䳸㝄 ⽫堘䪕䕭⎚⼴炻⎗ἧ䓐cilostazol (100㮓
䘤䎦⛐⮯役4⸜䘬徥希忶䦳ᷕ炻ἧ䓐㈿埨⮷㜧 㭷㖍ℑ㫉)㷃⮹儎ᷕ桐⽑䘤䘬桐晒(Class
喍䈑䳬㚱庫Ỷ䘬儎↢埨⽑䘤䌯(4%㭼9%烊HR IIaˣLOE B-R)炻䈡⇍㗗僼晁✳儎㠿⠆ㆾ
= 0.51烊95%CI = 0.25–1.03烊P = 0.06)炻㚱㠿 檀↢埨⿏桐晒䘬䕭Ṣ(Class IIaˣLOE A)ˤ
⠆⿏埨䭉ḳẞ⇯ᶵ䚠ᶲᶳ(HR = 1.02烊95%CI = (䃉㚜≽)
0.65–1.60烊P = 0.92)烊⛐㫉㕷佌↮㜸䔞ᷕ炻ᶵ婾 2. 㚱TIA䘬䕭Ṣ⺢嬘ἧ䓐㈿埨⮷㜧喍䈑Ἦ枸旚
㗗䕭Ṣ⸜漉ˣ儎↢埨悐ỵˣἧ䓐⒒ᶨ䧖㈿埨⮷ 朆⽫⚈⿏TIA⺽䘤䘬儎ᷕ桐(Class IˣLOE
㜧喍䈑ˣ≈喍⚆⍣䘬㗪攻ˣ䓂军儎悐⽖↢埨溆 A)ˤ(䃉㚜≽)
(cerebral microbleeds)䘬㔠慷⣂⮉⍲ỵ伖䫱炻⛯ 3. 椾㫉ἧ䓐thienopyridine栆喍䈑㱣䗪䘬䕭Ṣ
㰺㚱㖶栗䘬䳬攻ⶖ䔘ˤ䓙㬌⎗夳炻憅⮵㚱ἧ䓐 ⎗ẍ侫ㄖẍclopidogrelẋ㚧ticlopidine炻⚈䁢
㈿埨⮷㜧喍䈑怑ㅱ䕯ᷳ䕭Ṣ炻⯙䬿䘤䓇忶冒䘤 clopidogrel䘬∗ἄ䓐㭼庫⮹(Class IIaˣLOE
⿏儎↢埨炻῀劍↢埨慷ᶵ⣏ᶼ枸㛇枸⼴ᶵⶖ炻 B-NR)ˤ(䃉㚜≽)
⼭埨⟲⏠㓞⼴炻㕤怑䔞㗪攻溆≈⚆㈿埨⮷㜧喍 4. 庽⹎≇傥⍿㎵ᷳ役㛇仢埨⿏儎ᷕ桐ㆾTIAᷳ
䈑㗗⎗㍍⍿䘬ˤ 䕭Ṣ炻ᶼ⎰Ἕ仢埨“栙ℏ㿴㳩儎埨䭉㚱╖ᶨ
嗽䊡䨬忼70–99%炻⼿䴻慓ⷓ姽Ộ⇑䙲⍲桐
࡚ដȈ 晒⼴炻⎰Ἕἧ䓐aspirin (㭷㖍100-325㮓)⍲
14
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
15
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
᷎㰺㚱↢䎦䤆䴻⬠ら⊾ㆾ㗗儎↢埨䘬ね㱩ˤ 䈑(clopidogrel㭷㖍75㮓⍲aspirin㭷㖍81㮓)
⎎⢾ᶨᾳ喍䈑cilostazolḇ㚦⛐ᶨᾳ⮷✳晐 ㆾ╖㕡aspirin㱣䗪ℙ90⣑炻⮵㕤㰺㚱㍍⍿忶
88
㨇娎槿ᷕ冯aspirin 㭼庫炻ℙ458ỵ⿍⿏仢埨⿏ clopidogrelㆾaspirin䘬䕭Ṣ炻椾㖍䘬⇅⥳∹慷
儎ᷕ桐䕭Ṣ炻伶⚳⚳⭞堃䓇䞼䨞昊儎ᷕ桐慷堐 㗗clopidogrel 300㮓炻侴aspirin㗗162㮓ˤ
(National Institute of Health Stroke Scale, NIHSS) 晾䃞忁ᾳ娎槿⚈㓞㟰⚘暋侴㍸㖑䳸㜇炻Ữ䳸
≤ 15ˣᶼ㕤䘤䕭48⮷㗪ℏ↮⇍ἧ䓐cilostazolㆾ 㝄栗䣢㕤儎ᷕ桐⿍⿏㛇ἧ䓐暁㈿埨⮷㜧喍䈑㚱
aspirin炻䳸㝄栗䣢⛐䫔90⣑䘬列⤥枸⼴㭼䌯ℑ 㷃⮹仢埨⿏ḳẞ䘤䓇䌯䘬嵐⊊炻⎰Ἕ喍䈑㱣䗪
侭䚠䔞炻侴ᶼᶵ列ḳẞ䘤䓇䌯炻⊭㊔儎ᷕ桐⍲ 䳬㗗7.1%炻aspirin╖㕡㱣䗪䳬㗗10.8%炻儎ᷕ
↢埨炻ℑ侭ḇ䃉ⶖ⇍ˤ㬌⢾炻cilostazol⛐⎎ᶨ 桐䘬桐晒ᶳ旵3.8%炻Ữⶖ䔘ᶵ栗叿(P = 0.19)ˤ
ᾳℙ507ᾳ㟰䘬⮷✳晐㨇娎槿ᷕ冯⬱ㄘ∹㭼庫 晾䃞䃉䕯䉨⿏䘬↢埨ḳẞ栗叿⡆≈(30.8%㭼
89
炻㚱ᾳ㟰悥㚵䓐㈿埨⮷㜧ㆾ㈿埨㞻喍䈑炻 13.9%烊95%CI = 8.8–25.0烊P = 0.0001)炻Ữ慵
晐㨇↮惵军cilostazolㆾ⬱ㄘ∹炻䳸㝄栗䣢㖑㛇 ⣏↢埨ḳẞ㰺㚱ⶖ䔘炻⎒㚫⡆≈䲬1%䃉䴙妰
儎ᷕ桐ら⊾䘬桐晒㰺㚱ⶖ⇍ˤẍᶲℑᾳ䞼䨞䘬 ⶖ䔘䘬䕯䉨⿏儎↢埨ˤ䫔Ḵᾳ娎槿㗗⛐ᷕ⚳忚
仢溆㗗ᾳ㟰庫⮹炻嫱㒂䫱䳂䔍䁢ᶵ嵛ˤ 埴䘬CHANCE娎槿92炻㓞㟰⮵尉㗗5,170ỵ㕤24
⮷㗪ℏ䘤䓇⿍⿏庽⽖仢埨⿏儎ᷕ桐(NIHSS ≤ 3)
ijįijġځҢڍᆍο݈תՖωݖސ ㆾ侭㗗檀桐晒䘬TIA (ABCD2 ≥ 4)䘬40㬚ẍᶲ
暁㈿埨⮷㜧喍䈑ἧ䓐㕤⿍⿏仢埨⿏儎ᷕ桐 䕭Ṣ炻晐㨇↮惵军╖ᶨaspirin㱣䗪(⇅⥳∹慷
90-93 90
䘬㓰㝄ḇ㚱䚠斄娎槿 ˤ℞ᷕEARLY 㗗ᶨᾳ 75–300㮓炻℞⼴㭷㖍75㮓)ㆾ暁㈿埨⮷㜧
晐㨇⣂ᷕ⽫娎槿炻㓞㟰⮵尉㗗24⮷㗪ᷳℏ⿍⿏ 喍䈑(aspirin≈ᶲclopidogrel⇅⥳∹慷300㮓⍲
仢埨⿏儎ᷕ桐ˣ㌺昌㳣≽⿏儠偫忻㼘䖵ㆾ↢埨 㭷㖍75㮓)炻℞ᷕ暁㈿埨⮷㜧喍䈑䳬ἧ䓐ℑ
⿏䕦䕭ˣᶼNIHSS ≤ 20䘬䕭Ṣ炻ℙ㚱543ỵ䕭 䧖㈿埨㜧喍䈑21⣑炻℞⼴ἧ䓐╖㕡clopidogrel
Ṣ↮ㆸḴ䳬炻ᶨ䳬㍍⍿㭷㖍100㮓䘬aspirin╖ 军90⣑炻䳸㝄栗䣢暁㈿埨⮷㜧喍䈑䳬⛐䫔90
㕡㱣䗪7⣑炻᷎㕤7⣑⼴廱㎃ㆸ25㮓䘬aspirin ⣑䘬儎ᷕ桐䘤䓇䌯㗗8.6%炻侴㍍⍿╖ᶨaspirin
≈ᶲ200㮓䘬dipyridamole㭷㖍ℑ㫉䘬⎰Ἕ㱣 㱣䗪䳬䘬䘤䓇䌯㗗11.7% (HR = 0.68烊95%CI =
䗪炻⎎ᶨ䳬⇯㕤䫔1⣑⯙㍍⍿25㮓䘬aspirin⍲ 0.57–0.81)炻㚱栗叿䘬⤥嗽烊ℑ䳬䘬↢埨⿏儎
200㮓䘬dipyridamole㭷㖍ℑ㫉䘬⎰Ἕ㱣䗪炻 ᷕ桐䘤䓇䌯悥㗗0.3%炻侴ᶼᷕ慵⹎↢埨⿏ḳẞ
姽Ộ䫔90⣑䘬≇傥枸⼴炻䳸㝄栗䣢⎰Ἕ㱣䗪䘬 㗗䚠Ụ䘬ˤCHANCE⎎⢾䘤䎦炻徥希忁ṃ䕭Ṣ
䳬⇍㚱56%䕭Ṣ㚱列⤥䘬枸⼴炻侴ἧ䓐aspirin 军1⸜㗪炻暁㈿埨⮷㜧喍䈑䳬ṵ䵕㊩庫Ỷ䘬儎
╖㕡㱣䗪䘬䳬⇍㚱52%㚱列⤥枸⼴炻ℑ䳬䃉㖶 ᷕ桐䘤䓇䌯(10.6%㭼14.0%烊HR = 0.98烊95%CI
栗ⶖ䔘(䳽⮵ῤⶖ䔘4.1%烊95%CI = -4.5–12.6烊 = 0.65–0.93烊P = 0.006)炻㫉↮㜸栗䣢 49炻栙ℏ
P = 0.45)炻䵄⎰⿏ḳẞ䘤䓇䌯(㬣ṉˣ儎ᷕ桐ˣ ≽傰栗叿䊡䨬(50–99%)ᶼ↮惵军暁㈿埨⮷㜧喍
⽫倴㠿⠆⍲慵⣏↢埨)⛐㖑㛇ἧ䓐暁㈿埨⮷㜧喍 䈑䳬䘬䕭Ṣ炻䚠庫㕤╖㕡aspirin䳬炻㚱䚠⮵庫
䈑䘬䳬⇍庫Ỷ炻Ữḇ㰺㚱䴙妰ⶖ䔘(HR = 0.73烊 ỶỮ䃉䴙妰ⶖ䔘䘬儎ᷕ桐⽑䘤䌯(HR = 0.79烊
95%CI = 0.44–1.19烊P = 0.20)ˤ 95%CI = 0.47–1.32)炻⎎ᶨᾳ⼙⁷㫉↮㜸栗䣢
95
㚱3ᾳ⣏✳⿍⿏仢埨⿏儎ᷕ桐娎槿⎰Ἕἧ 炻CHANCE娎槿ᷕ⼙⁷⏰䎦⣂䘤⿏儎ᷕ桐✳
91, 92, 94
䓐aspirin⍲clopidogrel ˤ䫔ᶨᾳ㗗≈㊧⣏ ン侭䘬儎ᷕ桐⽑䘤䌯檀㕤╖ᶨ儎ᷕ桐✳ン侭炻
91
⍲伶⚳䘬FASTER娎槿 炻㓞㟰⮵尉㗗392ỵ㕤 ᶼ⣂䘤⿏儎ᷕ桐✳ン侭炻ἧ䓐暁㈿埨⮷㜧喍
24⮷㗪ẍℏ䘤䓇⿍⿏庽⽖仢埨⿏儎ᷕ桐(NIHSS 䈑侭䘬儎ᷕ桐⽑䘤䌯栗叿Ỷ㕤ἧ䓐╖㕡aspirin
≤ 3)ㆾTIA䘬䕭Ṣ炻晐㨇↮惵⇘暁㈿埨⮷㜧喍 侭(HR = 0.5烊95%CI = 0.3–0.96烊P = 0.04)炻⍰
16
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
⣂䘤⿏儎ᷕ桐✳ン侭䘬ᷕ桐↮栆栗䣢檀忼65% ℏ炻暁㈿埨⮷㜧喍䈑⎗栗叿㷃⮹仢埨⿏ḳẞ䘤
䘬䕭ṢⰔ㕤⣏埨䭉䱍䉨䠔⊾↮✳ˤAspirin≈ 䓇䌯(HR = 0.74烊95%CI = 0.55–0.99烊P = 0.04)炻
ᶲclopidogrel䘬暁㈿埨⮷㜧喍䈑䳬⎰ḇ㚦䴻⛐ Ữ䃉㱽㷃⮹䫔8-90⣑䘬仢埨⿏ḳẞ䘤䓇䌯(HR
93
CLAIR娎槿ᷕ㷔娎 炻㓞㟰⮵尉㗗100ỵ⿍⿏仢 = 1.03烊95%CI = 0.70–1.53烊P = 0.88)ˤᶨ枭⊭
埨⿏儎ᷕ桐ㆾTIAᶼ㚱儎≽傰ㆾ柠≽傰䊡䨬䘬 ⏓FASTERˣCHANCE⍲POINT䫱3ᾳ娎槿䘬
䕭Ṣ炻晐㨇↮惵军7⣑䘬aspirin≈ᶲclopidogrel 䴙⎰↮㜸炻⮯ᷕ桐⼴㗪攻庠↮䁢ᶱ㭝 97炻⌛䫔
暁㈿埨⮷㜧喍䈑ㆾ㗗╖ᶨaspirin炻᷎ẍ䨧栙崭 0-10⣑ˣ11-21⣑⍲22-90⣑炻↮㜸ᶵ⎴㗪攻㭝
枛㲊奨⮇⮵⮷㞻⫸妲嘇䘬⼙枧炻䘤䎦暁㈿埨 䘬暁㈿埨⮷㜧喍䈑䗪㓰炻栗䣢暁㈿埨⮷㜧喍䈑
⮷㜧喍䈑䳬⇍䘬㞻⫸䘤䓇㭼䌯㗗33%炻侴╖ᶨ 㷃⮹ᷕ桐⼴10⣑ℏ䘬儎ᷕ桐⽑䘤䌯䳽⮵ῤ忼2%
aspirin䳬㗗65% (P = 0.022)ˤẍᶲ嫱㒂㊯↢暁㈿ (OR = 0.64烊95%CI = 0.55–0.76)炻䫔11-21⣑䘬
埨⮷㜧喍䈑(aspirin≈ᶲclopidogrel)⛐⿍⿏仢埨 桐晒ᶳ旵⇯㰺㚱栗叿ⶖ䔘(OR = 0.73烊95%CI =
⿏儎ᷕ桐Ἕ㚱⎴“儎≽傰栗叿䊡䨬㗪炻⎗傥㚜 0.47–1.13)炻军㕤䫔22-90⣑炻暁㈿埨⮷㜧⸦᷶
檀䘬㓰䙲 49, 93, 95ˤ䘤堐䘬POINT娎槿㗗ᶨᾳ ᶵ⎗傥㚱⤥嗽(OR = 1.47烊95%CI = 0.84–2.56)ˤ
94
⇵䝣⿏ˣ晐㨇ˣ暁䚚䘬⣂ᷕ⽫䞼䨞 炻ᷣ天䘬 侴䳸⎰CHANCE冯POINTℑ⣏娎槿䘬䴙⎰↮㜸
䞼䨞䃎溆ḇ㗗暁㈿埨⮷㜧喍䈑⮵⿍⿏仢埨⿏ 栗䣢 98炻㕤晐㨇↮惵⼴21⣑ℏ炻暁㈿埨⮷㜧喍
儎ᷕ桐ㆾTIA䕭Ṣ枸⼴䘬⼙枧炻Ữ䞼䨞㝞㥳冯 䈑⎗栗叿㷃⮹慵⣏仢埨⿏ḳẞ䘬䘤䓇䌯(5.2%
CHANCE娎槿㚱悐ấⶖ䔘(堐1)炻㓞㟰⮵尉㗗 㭼7.8%烊HR = 0.66烊95%CI = 0.56–0.77烊P <
12⮷㗪ℏ䘤ἄ䘬⿍⿏庽⽖仢埨⿏儎ᷕ桐ㆾTIA 0.001)炻侴ᶼ⤥嗽ᷣ天Ἦ冒㕤晐㨇↮惵⼴10
䕭Ṣ炻晐㨇↮惵军clopidogrel (⇅⥳∹慷600㮓 ⣑ℏ(4.7%㭼7.1%烊HR = 0.65烊95%CI = 0.55–
⍲㭷㖍∹慷75㮓)ㆾ⬱ㄘ∹炻㚱䕭Ṣ⛯ 0.77烊P < 0.001)炻军㕤䫔22军90⣑炻CHANCE
ἧ䓐㭷㖍50–325㮓䘬aspirin (娎槿⺢嬘∹慷䁢 POINT娎槿悥㰺㚱忼⇘栗叿䴙妰ⶖ䔘炻侴↮
⇵5⣑㭷㖍162㮓炻℞⼴㭷㖍81㮓)炻᷎奨 㭝䴙妰⼴䘬慵⣏↢埨ḳẞ炻晾䃞暁㈿埨⮷㜧
⮇90⣑ℏ䘬儎ᷕ桐⽑䘤炻䳸㝄栗䣢暁㈿埨⮷㜧 喍䈑䳬⛐POINT娎槿ᷕ䘬䫔22-99⣑檀㕤aspirin
喍䈑䳬䚠庫㕤╖㕡aspirin䳬炻⎗栗叿㷃⮹䵄⎰ 䳬炻Ữ㰺㚱忼⇘栗叿ⶖ䔘(0.6%㭼0.2%烊HR =
⿏埨䭉⿏ḳẞ(HR = 0.75烊95%CI = 0.59–0.95烊 2.63烊95%CI = 0.93–7.40烊P = 0.07)ˤ
P = 0.02)炻↮⇍䚠⮵㷃⮹26%儎ᷕ桐⽑䘤桐晒 晾䃞clopidogrel≈ᶲaspirin䘬暁㈿埨⮷
(HR = 0.74烊95%CI = 0.58–0.94烊P = 0.01)⍲28% 㜧喍䈑䳬⎰䘬䗪㓰㚱䞼䨞嫱㒂㓗㊩炻天㲐
仢埨⿏儎ᷕ桐⽑䘤桐晒(HR = 0.72烊95%CI = シclopidogrelẋ嫅䘬➢⚈⣂✳⿏ḇ㚫⼙枧暁
0.56–0.92烊P = 0.01)炻Ữ㚫栗叿⡆≈90⣑䘬慵 ㈿埨⮷㜧喍䈑䘬䗪㓰炻㚱䞼䨞㊯↢炻ἧ䓐
⣏↢埨ḳẞ(HR = 2.32烊95%CI = 1.10–4.87烊P = clopidogrel枸旚儎ᷕ桐䘬䕭Ṣ炻ⷞ㚱CYP2C19
0.02)ˤ䵄⎰CHANCE冯POINTℑ⣏娎槿炻怑䔞 ⣙⍣≇傥䫱ỵ➢⚈(loss-of-function alleles烉*2ˣ
䘬暁㈿埨⮷㜧喍䈑(aspirin≈ᶲclopidogrel)ἧ䓐 *3ˣ*8)侭㚱庫檀䘬儎ᷕ桐䘤䓇䌯(RR = 1.92烊
㗪攻ㅱ性崭忶21⣑炻军㕤㗗⏎傥ℵ忚ᶨ㬍䷖ 95%CI = 1.57–2.35烊P < 0.001)99ˤCHANCE娎槿
䞕暁㈿埨⮷㜧喍䈑䘬ἧ䓐㗪攻烎㟡㒂CHANCE 栗䣢 100炻⣙⍣≇傥䫱ỵ➢⚈(*2ˣ*3)㚫⼙枧暁
娎槿䘬㗪攻庠↮㜸 96炻仢埨⿏儎ᷕ桐⽑䘤ḳẞ ㈿埨⮷㜧喍䈑䘬䗪㓰(P = 0.02 for interaction)炻
㚱檀忼3/4䘤䓇㕤ᷕ桐⼴䫔1忙炻ᶼ䚠庫㕤╖ᶨ 䚠庫㕤╖ᶨaspirin䳬炻暁㈿埨⮷㜧喍䈑䃉㱽旵
aspirin䳬炻暁㈿埨⮷㜧喍䈑㷃⮹䘬仢埨⿏儎 Ỷ㬌栆䕭Ṣ䘬儎ᷕ桐䘤䓇䌯(HR = 0.93烊95%CI
ᷕ桐ḳẞ炻㕤ᷕ桐10⣑⼴᷎㰺㚱ⶖ䔘ˤPOINT = 0.69–1.26)炻⍵ᷳ炻暁㈿埨⮷㜧喍䈑⇯⎗栗
94
娎槿憅⮵㗪攻庠䘬↮㜸ḇ䘤䎦 炻⛐ᷕ桐⼴7⣑ 叿旵Ỷᶵⷞ⣙⍣≇傥䫱ỵ➢⚈侭䘬儎ᷕ桐桐晒
17
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
堐1ˢCHANCE娎槿冯POINT娎槿㭼庫堐
18
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
19
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
ijįķġ๖፣
ĴįġॶԩသϛॳႱ٩
朆⽫⚈⿏⿍⿏仢埨⿏儎ᷕ桐䘤䓇⼴48⮷㗪 ⣏悐ấ㚱斄aspirin䓐㕤⽫埨䭉䕦䕭⇅䳂
ẍℏ炻䴎Ḱ⎋㚵庫檀⇅⥳∹慷䘬aspirin炷160- 枸旚䘬䞼䨞 114-117 炻栗䣢aspirin⮵儎ᷕ桐䘤䕭
300㮓炸⎗ẍ栗叿⛘㷃⮹㬣ṉ䌯⍲ᶵ列枸⼴炻 䌯㰺㚱⼙枧ˤ℞ᷕ⊭⏓Ḯ6ᾳ娎槿ℙ95,000
⤥嗽⎗傥㗗Ἦ冒㕤㷃⮹Ḯ㖑㛇䘬儎ᷕ桐⽑䘤烊 ỵᾳ㟰䘬䴙⎰↮㜸(Antithrombotic Trialists’
嫱㒂ḇ栗䣢㕤䫎⎰娎槿䲵ℍ㧁㸾䘬⿍⿏庽⽖仢 Collaboration)117炻aspirin䚠庫㕤⬱ㄘ∹炻䃉㱽㷃
埨⿏儎ᷕ桐ㆾ檀桐晒䘬TIA䕭Ṣ炻⃀㖑ᶼ䞕㛇 ⮹儎ᷕ桐䘬䘤䓇䌯炻ᶼ㚫⡆≈↢埨ḳẞˤ2011
⎰Ἕἧ䓐aspirin冯clopidogrel炻⎗栗叿㷃⮹儎ᷕ ⸜ᶨᾳ⊭⏓Ḯ9ᾳ娎槿 118炻ℙ100,076ỵᾳ㟰䘬
桐⽑䘤炻᷎ᶵ㚫⡆≈儎↢埨⍲慵⣏↢埨ḳẞ䘤 䴙⎰↮㜸炻aspirin晾䃞⎗ẍ㷃⮹ᷣ天⽫埨䭉ḳ
䓇䌯ˤ ẞ(RR = 0.88烊95%CI = 0.83–0.94)⍲仢埨⿏儎ᷕ
桐(RR = 0.86烊95%CI = 0.75–0.98)炻Ữ⌣㚫⡆≈
࡚ដȈ ↢埨⿏儎ᷕ桐(RR = 1.36烊95%CI = 1.01–1.82)⍲
1. ⛐⿍⿏仢埨⿏儎ᷕ桐䘤ἄ48⮷㗪ℏ炻⤪䃉㈿ 慵⣏↢埨ḳẞ(RR = 1.66烊95%CI = 1.41–1.95)ˤ
埨⮷㜧喍䈑䤩⽴䕯炻⺢嬘ἧ䓐aspirin炻⤪䕭 忁ṃ䞼䨞䳸㝄栗䣢炻ᶨ凔⣏䛦ἧ䓐aspirin㰺㚱
Ṣ㍍⍿朄傰rt-PA㱣䗪炻⎗㕤㲐⮬䳸㜇24⮷㗪 栗叿䘬㔜橼⤥嗽ˤ
⼴ἧ䓐㈿埨⮷㜧喍䈑(Class IˣLOE A)ˤ(㚜 Ữ㗗⛐2005⸜䘤堐䘬WHS娎槿 119 炻⊭⏓
≽) 39,876ᾳ⽆㛒㚱⽫埨䭉䕦䕭⍲儎ᷕ桐䕭⎚䘬45
2. 朆⽫⚈⿏檀桐晒TIA (ABCD2 score ≥ 4)ㆾ⿍ 㬚ẍᶲ⤛⿏炻晐㨇↮惵军aspirin (100㮓㭷ℑ
20
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
㖍ᶨ㫉)ㆾ⬱ㄘ∹炻䴻忶10⸜徥希炻䘤䎦⎗ẍṃ 1.01–1.29)炻↮㜸℞ᷕ䘬㬣ṉ⍇⚈炻䘤䎦aspirin
⽖㷃⮹9%䘬⽫埨䭉䕦䕭䚠⮵桐晒炻㰺㚱䴙妰⬠ 䳬㚱庫檀䘬䗴䕯䚠斄㬣ṉ桐晒(HR = 1.31烊
ⶖ䔘炻Ữ㗗⌣⎗ẍ栗叿⛘㷃⮹17%䘬儎ᷕ桐䚠 95%CI = 1.01–1.56)炻忚ᶨ㬍↮㜸䗴䕯䚠斄㬣ṉ
⮵桐晒炻℞ᷕ⊭㊔㷃⮹24%仢埨⿏儎ᷕ桐䘬䚠 ⍇⚈䘬䗴䕯栆⇍栗䣢炻aspirin䳬㚱庫檀䘬⣏儠
⮵桐晒炻侴ᶼ↢埨⿏儎ᷕ桐䘬桐晒᷎ᶵ㚫栗叿 䚜儠䗴䕯䚠斄䘬㬣ṉ桐晒(HR = 1.77烊95%CI
⡆≈炻栗䣢aspirin⎗ẍ㷃⮹⤛⿏伡か椾㫉儎ᷕ = 1.02–3.06)ˤ⎎⢾ᶨᾳ⇅䳂枸旚䘬晐㨇娎槿
桐䘬桐晒炻Ữ㚫ṃ⽖⡆≈偫儠忻慵⣏↢埨䘬䘤 ASCEND 130炻⮯≥ 40㬚䘬䱾⯧䕭䕭Ṣ晐㨇↮惵
䓇䌯(RR = 1.40烊95%CI = 1.07–1.83烊P = 0.02)ˤ 军aspirin䳬(㭷㖍100㮓)ㆾ⬱ㄘ∹䳬炻⸛⛯徥
⛐⎴䭯⟙⏲ᷕ䳸⎰⣂䭯娎槿ᷕ䘬⤛⿏ᾳ㟰 希㗪攻䁢7.4⸜炻䘤䎦aspirin䳬㚱庫Ỷ䘬♜慵埨
119
䘬䴙⎰↮㜸ḇ栗䣢 炻aspirin⎗㷃⮹⤛⿏伡か 䭉ḳẞ䘤䓇䌯(8.5%㭼9.6%烊RR = 0.88烊95%CI
椾㫉儎ᷕ桐䘬桐晒炻㫉↮㜸䘤䎦⤛⿏㚱⽫埨䭉 = 0.79–0.97烊P = 0.01)炻Ữaspirin䳬ḇ㚱庫檀䘬
䕦䕭⌙晒⚈⫸炻⤪㚜⸜㛇ˣ檀埨⡻ˣ檀埨傪ˣ 慵⣏↢埨ḳẞ䘤䓇䌯(4.1%㭼3.2%烊RR = 1.29烊
䱾⯧䕭ˣ10⸜䘬⽫埨䭉䕦䕭檀桐晒ˣㆾảℑᾳ 95%CI = 1.09–1.52烊P = 0.003)炻⚈㬌aspirin㷃
⌙晒⚈⫸侭炻ἧ䓐aspirin⎗ẍ栗叿⛘㷃⮹儎ᷕ ⮹䘬慵⣏⽫埨䭉ḳẞ䘬⣏悐↮⤥嗽塓慵⣏↢埨
桐䘬桐晒炻䈡⇍㗗䱾⯧䕭Ṣ⍲10⸜⽫埨䭉䕦䕭 ⿏ḳẞ㉝㴰炻侴ᶼ≈ℍ娎槿⇵㍐Ộ䁢庫檀⽫
檀桐晒侭ˤ⚈㬌⣂ᾳ憅⮵⇅䳂枸旚䘬㱣䗪㊯⺽ 埨䭉ḳẞ桐晒䘬䕭Ṣ炻慵⣏↢埨⿏ḳẞ䘬䘤䓇
㊯↢120-122炻⤪㝄㍐Ộ䕭Ṣ䘬10⸜⽫埨䭉䕦䕭桐 䌯ḇ晐ᷳᶲ⋯ˤ⎎⢾ᶨᾳ⇅䳂枸旚䘬晐㨇娎槿
晒≥ 10%炻㕤堉慷䙲嗽冯桐晒⼴炻⎗ẍ侫ㄖἧ 㗗ARRIVE 131炻䞼䨞⮵尉䁢㌺昌檀↢埨桐晒⍲
䓐aspirinἮ枸旚椾㫉⽫埨䭉䕦䕭ˤ 䱾⯧䕭⼴炻10⸜ⅈ⽫䕭桐晒ṳ㕤10–20%䘬䓟⿏
Ữ㗗憅⮵㛒㚦儎ᷕ桐䘬䱾⯧䕭䕭Ṣ忚埴 (≥ 50㬚)ㆾ⤛⿏(≥ 60㬚)炻ᾳ㟰䘬⸛⛯10⸜桐晒
䘬䞼䨞⌣㊯↢123, 124炻ἧ䓐aspirin᷎ᶵ傥栗叿㷃 䲬14%炻℞ᷕ䲬65%䘬ᾳ㟰㚵䓐檀埨⡻㱣䗪䓐
⮹䵄⎰⿏埨䭉ḳẞ儎ᷕ桐䘤䓇䌯ˤᶨᾳ⊭⏓7ᾳ 喍炻⮯ᾳ㟰晐㨇↮惵军aspirin䳬(㭷㖍100㮓)
124
娎槿炻ℙ11,618ỵ䱾⯧䕭䕭Ṣ䘬䴙⎰↮㜸 炻 ㆾ⬱ㄘ∹䳬炻⸛⛯徥希㗪攻䁢60ᾳ㚰炻䳸㝄䘤
䘤䎦ἧ䓐aspirin⎗ẍṃ⽖㷃⮹䲬9%䘬ᷣ天⽫埨 䎦ℑ䳬䘬⽫埨䭉ḳẞ䘬䘤䓇䌯㰺㚱ⶖ䔘(4.29%
䭉ḳẞ(RR = 0.91烊95%CI = 0.82–1.00)炻Ữ㗗 㭼4.48%烊HR = 0.96%烊95%CI = 0.81–1.13烊P =
᷎䃉㱽㷃⮹儎ᷕ桐䘬䘤䓇䌯(RR = 0.83烊95%CI 0.604)炻ᶼaspirin䳬㚱栗叿庫檀䘬偫儠忻↢埨ḳ
= 0.63–1.10)ˤ⚈㬌炻aspirin㕤⽫埨䭉䕦䕭⇅䳂 ẞ䘤䓇䌯(0.97%㭼0.46%烊HR = 2.11烊95%CI =
枸旚䘬奺刚⍲ἧ䓐㗪㨇ṵᶵ㶭㤂ˤ⯌℞㗗晐叿 1.36–3.28烊P = 0.0007)ˤ
㗪ẋ䘬忚⯽炻忶⍣㔠⋩⸜攻炻⎬⚳憅⮵⽫埨䭉 ⛐2019⸜炻ᶨᾳ⊭⏓13ᾳἧ䓐aspirin㕤⇅
䕦䕭⌙晒⚈⫸䘬㍏⇞⍲喍䈑ἧ䓐䘬㘖⍲炻ἧ⎬ 䳂枸旚䘬冐⸲娎槿132-144 ᷳ䴙⎰↮㜸145炻㓞䲵Ḯ
⚳儎ᷕ桐䘤䓇䌯徸⸜ᶳ旵125-128炻⎗傥攻㍍⼙枧 ℙ164,225ỵ㰺㚱㖶栗⽫埨䭉䕦䕭䘬⍿娎侭炻℞
aspirin㕤⽫埨䭉䕦䕭⇅䳂枸旚䘬奺刚ˤ ᷕ47.2%䁢䓟⿏ˣ枸㛇10⸜⽫埨䭉桐晒䁢10.2%
129
ASPREE㗗ᶨᾳ⣏✳䘬晐㨇冐⸲娎槿 炻 (2.6–30.9%)炻⸛⛯徥希5⸜炻ᷣ天奨⮇䳸㝄䁢䵄
⮵尉㗗ᶵ㚦㚱⽫埨䭉䕦䕭⎚ˣᶼ⸜䲨≥ 70㬚ẍ ⎰⿏⽫埨䭉ḳẞ(⊭⏓⽫埨䭉㬣ṉˣ朆农␥⿏⽫
ᶲ䘬侩Ṣℙ19,114Ṣ炻晐㨇↮惵军aspirin 倴㠿⠆ˣ朆农␥⿏ᷕ桐)ˤ䳸㝄䘤䎦ἧ䓐aspirin
䳬(㭷㖍100㮓)ㆾ⬱ㄘ∹䳬炻⸛⛯徥希㗪攻 傥⣈㚱㓰㷃⮹䵄⎰⿏⽫埨䭉ḳẞ(HR = 0.89烊
䁢4.7⸜炻℞ᷕ䲬74%䘬ᾳ㟰㚱檀埨⡻䕭⎚炻䲬 95%CI = 0.84–0.94)炻ḇ⎗旵Ỷ仢埨⿏ᷕ桐忼
19%䘬䕭Ṣ㚱䗴䕯䕭⎚炻䳸㝄䘤䎦aspirin䳬䘬 19% (1.27%㭼1.47%烊HR = 0.81烊95%CI = 0.76–
㬣ṉ䌯栗叿檀㕤⬱ㄘ∹䳬(HR = 1.14烊95%CI = 0.81)炻Ữ枰㲐シ℞旵Ỷᷳ䳽⮵桐晒䁢0.19%
21
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
(0.06–0.30%)炻ẋ堐⸛⛯天⛐540ỵ䕭Ṣἧ䓐 栗䣢炻⮵㕤㰺㚱㖶䡢⽫埨䭉䕦䕭䕭⎚䘬䕭Ṣ
aspirinㇵ傥⼿⇘1㫉ᷕ桐旵Ỷ䘬ᾅ嬟㓰㝄(暨㱣 Ἦ婒炻aspirin䘬⇅䳂枸旚㓰㝄᷎ᶵ㖶䡢炻Ữ⌣
䗪䕭Ṣ㔠˳number need to treat, NNT˴= 540)ˤ 㚫㖶栗⡆≈儎↢埨桐晒炻䈡⇍㗗⛐Ṇ㳚㕷佌ㆾ
䚠⮵Ἦ婒炻⛐忁ṃ⍿娎侭幓ᶲἧ䓐aspirin䚠庫 BMI庫Ỷ侭炻⛐忁ṃṢ幓ᶲἧ䓐天㟤⢾⮷⽫ˤ
㕤⬱ㄘ∹炻㚫栗叿⡆≈↢埨ḳẞ炻⊭⏓慵⣏↢ Aspirinḇ㚦⛐␐怲埨䭉䕦䕭䘬䕭Ṣ 忶
埨(HR = 1.43烊95%CI = 1.30–1.56烊暨塓 ⭛䕭 娎槿ˤ⛐ᶨᾳ⊭⏓9ᾳ晐㨇娎槿䘬䴙⎰↮㜸
147
Ṣ㔠˳number need to harm, NNH˴= 210)ˣ栙 炻ℙ㚱3,019ỵ䕯䉨⿏ㆾ䃉䕯䉨⿏␐怲埨䭉
ℏ↢埨(HR = 1.34烊95%CI = 1.14–1.57烊NNH = 䕦䕭䕭Ṣ炻䳸㝄栗䣢ἧ䓐aspirin⎗㷃⮹36%朆
927)ˣẍ⍲♜慵儠偫忻↢埨(HR = 1.56烊95%CI 农㬣⿏儎ᷕ桐䘬䚠⮵桐晒(RR = 0.64烊95%CI =
= 1.38–1.78烊NNH = 334)ˤ劍ẍ⋩⸜⽫埨䭉桐 0.42–0.99烊P = 0.04)炻ᶼᶵ㚫⡆≈慵⣏↢埨ḳẞ
晒10%䁢↯溆炻⛐Ỷ桐晒㕷佌(< 10%)ᷕ炻ἧ䓐 䘬桐晒ˤỮ⛐AAA娎槿ᷕ148炻3,350ỵ䃉䕯䉨⿏
aspirin晾⎗旵Ỷ䵄⎰⿏⽫埨䭉ḳẞ(HR = 0.87烊 ␐怲≽傰䕦䕭䕭Ṣ(巅偙㊯㔠炻˳ankle-brachial
95%CI = 0.79–0.95)炻Ữ旵Ỷ仢埨⿏ᷕ桐䘬㓰䙲 index, ABI˴≤ 0.95炻⸛⛯0.86)炻晐㨇↮惵军ἧ
᷎ᶵ栗叿(HR = 0.83烊95%CI = 0.69–1.06)ˣᶼ 䓐aspirinㆾ⬱ㄘ∹炻徥巐8.2⸜⼴炻䘤䎦aspirin
ṵ㚫栗叿⡆≈慵⣏↢埨ˣ栙ℏ↢埨⍲儠偫忻↢ 䃉㱽㷃⮹⽫倴㠿⠆ㆾ儎ᷕ桐ˤ⎎⢾炻POPADA
埨烊⛐檀桐晒㕷佌(ʁ10%)侭炻旵Ỷ䵄⎰⿏⽫ 娎槿㗗ᶨᾳ暁䚚䘬晐㨇䞼䨞 149 炻㓞抬Ḯ1,276
埨䭉ḳẞ(HR = 0.91烊95%CI = 0.84–0.98)ㆾ仢埨 ỵ䱾⯧䕭ᶼ䃉䕯䉨⿏␐怲≽傰䕦䕭(ABI ≤ 0.99)
⿏ᷕ桐(HR = 0.88烊95%CI = 0.76–1.02)䘬䦳⹎ḇ 䘬䕭Ṣ炻忶⍣ḇ䃉⽫埨䭉䕦䕭䕭⎚炻晐㨇䴎Ḱ
栆Ụ炻Ữ栙ℏ↢埨桐晒⇯㗗ᶵ栗叿⛘㍸檀(HR = aspirinㆾ⬱ㄘ∹炻䳸㝄栗䣢aspirin䃉㱽㷃⮹㔜
1.19烊95%CI = 0.89–1.60)烊⛐㛒㚦ᷕ桐䘬䱾⯧ 橼䘬⽫埨䭉ḳẞ⍲ⅈ䉨埨䭉䕦䕭ㆾ儎ᷕ桐农
䕭Ṣᷕ炻⎴㧋⎗ẍ旵Ỷ䵄⎰⿏⽫埨䭉ḳẞ(HR = 㬣ṉ炻ḇ䃉㱽㷃⮹农㬣⿏儎ᷕ桐炻晾䃞⎗旵Ỷ
0.90烊95%CI = 0.82–1.00)炻䃉㱽栗叿⛘旵Ỷ仢 29%朆农㬣⿏儎ᷕ桐䘬䚠⮵桐晒炻Ữ䳸㝄᷎ᶵ
埨⿏ᷕ桐(HR = 0.70烊95%CI = 0.36–1.37)炻侴㚫 栗叿(RR = 0.71烊95%CI = 0.44–1.14烊P = 0.15)ˤ
⡆≈慵⣏↢埨(HR = 1.29烊95%CI = 1.11–1.51)⍲ ⚈㬌炻⛐䃉䕯䉨䘬␐怲≽傰䕦䕭䕭Ṣ炻aspirin
栙ℏ↢埨(HR = 1.35烊95%CI = 1.05–1.75)ˤ ᷎䃉栗叿䙲嗽ˤ
146炻
⛐2019⸜ḇ䘤堐Ḯ⎎ᶨ䭯䴙⎰↮㜸 娎 ⛐CAPRIE娎槿ᷕ13炻䕯䉨⿏␐怲≽傰䕦䕭
⚾㍊妶⛐忶⼨㰺㚱䕯䉨⿏⽫埨䭉䕦䕭⎚侭炻ἧ 䕭Ṣ(6%㚦㚱仢埨⿏儎ᷕ桐䕭⎚)䘬↮㜸䳸㝄⇯
䓐Ỷ∹慷(㭷㖍< 100㮓) aspirin忈ㆸ栙ℏ↢埨 栗䣢炻clopidogrel䳬㭷⸜䘬㔜橼⽫埨䭉ḳẞ䘤
䘬⌙晒炻㓞䲵Ḯ13ᾳ娎槿ℙ134,446ỵ⍿娎侭炻 䓇䌯㗗3.71%炻侴aspirin䳬䁢4.86%炻䚠⮵桐晒
䳸㝄䘤䎦Ỷ∹慷aspirin䚠庫㕤⮵䄏䳬炻㚫栗叿 ᶳ旵23.8% (95%CI = 8.9–36.2烊P = 0.0028)炻Ữ
⡆≈ảỽ栙ℏ↢埨䘬桐晒(HR = 1.37烊95%CI = 㗗忁ᾳ⤥嗽ᷣ天㗗Ἦ冒㕤⽫倴㠿⠆⍲℞Ṿ埨䭉
1.13–1.66)炻㎃䬿崟Ἦ䚠䔞⛐㭷1,000Ṣἧ䓐㚫 ḳẞ䚠斄㬣ṉ䘬ᶳ旵炻儎ᷕ桐䘬䘤䓇䌯㰺㚱ⶖ
䘤䓇2ᾳ栙ℏ↢埨烊劍䳘↮栙ℏ↢埨䘬✳ン炻 ⇍ˤ
⇯ẍ䠔儎兄ᶳ(subdural)ㆾ䠔儎兄⢾(epidural)↢ 㚱斄㕤cilostazol⛐枸旚椾㫉儎ᷕ桐䘬嫱
埨䘬桐晒㚨檀(HR = 1.53烊95%CI = 1.08–2.18)炻 㒂炻ᶨᾳ⊭⏓Ḯ3,782ỵ␐怲≽傰䕦䕭䕭Ṣ䘬
儎ℏ↢埨㫉ᷳ(HR = 1.23烊95%CI = 0.98–1.54)烊 䴙⎰↮㜸栗䣢 150炻cilostazolἧ䓐⛐␐怲≽傰䕦
⛐㫉㕷佌↮㜸䔞ᷕ炻ẍṆ㳚䕭Ṣㆾ幓橼岒慷㊯ 䕭ᾳ㟰⎗ẍ栗叿⛘㷃⮹儎埨䭉ḳẞ䘬桐晒(RR
㔠庫Ỷ侭(body mass index˳BMI˴< 25)桐晒庫 = 0.58烊95%CI = 0.43–0.78烊P < 0.001)炻侴ᶼᶵ
檀(HR = 1.84烊95%CI = 1.04–3.27)ˤ忁ṃ䞼䨞 㚫⡆≈♜慵↢埨䘬Ἕ䘤䕯(RR = 1.00烊95%CI =
22
ߨЖӰܒીՖܒသϛॳתՖωݖݽސᕛࡾЕ
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ABSTRACT
In the past 7 years, several important antiplatelet trials have been completed with pivotal findings.
These results were significant and have been already changing the daily practice of treatment for ischemic
stroke (IS). One of the most important findings is the concept of dual antiplatelet therapy for acute
noncardioembolic IS or transient ischemic attack. The timing and duration of antiplatelet therapy also
have significant impact on the outcomes of IS. In addition to traditional antiplatelets, such as aspirin or
clopidogrel, other antiplatelets, including cilostazol, ticagrelor, and prasugrel have also been investigated
for the efficacy and safety in the treatment for IS. Another important issue is the use of antiplatelet therapy
in primary prevention of cerebro- and cardio-vascular events, the results of several large clinical trials have
shown the antiplatelet therapy in specific populations with various estimated risks.
The purpose of this current guideline is to update the 2016 Taiwan Stroke Society (TSS) Guideline on
Antiplatelet Therapy for Noncardioembolic Ischemic Stroke particularly in areas for which new evidence
has emerged since its publication. The TSS Guideline Consensus Group revised the guideline based on the
data of several studies which are important and influential. This guideline focuses on three major topics,
including secondary prevention, acute management, and primary prevention for noncardioembolic ischemic
stroke. Recommendations and reviews of the evidences are provided.
Corresponding author: Po-Lin Chen, MD, Stroke Center, Department of Neurology, Neurological Institute, Taichung Veterans
General Hospital, Taichung, Taiwan
E-mail: boringtw@gmail.com
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