28 2012

77 ,



, ,
5 .

( 22 , CABG
20 , PTCA 3 )
( 40 / )

5mg, 1 /
6,25 mg bid
A 100mg, 1 /
850 mg bid

: 150/90 mmHg, : 70/ min, BMI: 28

:
:
:
.
.

:
Glu :140 mg/dl, U: 40 mg/dl, Creat :1,2 mg/dl,
Clearance Creat :60 ml/min, LFTs : ,
HbA1C :7,3%, Chol ;200 mg/dl,
HDL :50 mg/dl, LDL: 120 mg/dl, TGL :150
mg/d, K:3,6 mEq/lt, Na: 140 mEq/lt .
PT, PTT, INR :

CT :

MRI
( Diffusion
weighted imaging ) :

PWI ( Perfusion weighted
imaging ):

.()

,
24 ,

,
.

,
,
, .
:
.

American Heart Association American Stroke Association Guidelines

2009

:

,

.

TSI (Transient Symptoms

with Infarction )-

:
( <24 )
,


.

American Heart Association American Stroke Association Guidelines

MRI ( Diffusion Weighted Imaging )

.
DWI -
12 .
ADC : . ADC ,
.
PWI ( Perfusion Weighted Imaging ):
.
( Mismatch ) DWI PWI :
.
MRA :


- ABCD2 SCORE

> 60
> 140/90 mmHg :
:
1) :
2)
:
:
1) >60 min
2) 10- 59 min
3)< 10 min

1
1
1) 1
2) 2

1) 2
2) 1
3) 0


ABCD2

ABCD2 SCORE : 5

SCORE 6-7: 8%
48
SCORE 4-5 : 4%
SCORE 0-3 : 1%

TTE : .
: ,
:
: ANA, anti-DNA, RF, anti
URNP, antiENA, c,p ANCA, anti Scl 70, anti Jo 1,
anti b2 GPI, :
: C, S , APC, ATH
III, MTHFR :
Triplex :
70%

 CTA :

4 cm,

70-80 %
.

( ).


(Lacunar)
K



(Transient Ischemic Attacks)

CEA ( )
CAS ( stent
)
.

New ischaemic brain lesions on MRI after stenting

or
endarterectomy for symptomatic carotid stenosis: a
substudy of the International Carotid Stenting Study
(ICSS)

1) ( 6 )
... (7099%)
<6% (Class I, Level
of Evidence A).

2) (50% to 69%)

, , ,
(Class I, Level of
Evidence A).

21 October 2010 , ASA/AHA Guidelines

3) <50%
(Class III,
Level of Evidence A).

4)
, 2
(Class IIa, Level of Evidence B).

5)


,
>70 %,
> 50 %, . ( Class I, Level
of Evidence B )

21 October 2010 , ASA/AHA Guidelines

6. (>70
%)




,
Stent
(Class
IIb, Level of Evidence B).
21 October 2010 , ASA/AHA Guidelines

7. Stent



4-6%,

(Class IIa, Level of Evidence B).

21 October 2010 , ASA/AHA Guidelines

8)
EC/IC by-pass .
(Class III, Level of Evidence A)
9)

,

. (Class I, Level of Evidence B)
21 October 2010 , ASA/AHA Guidelines

,

(Class I, Level of
Evidence B )


,
.
(Class IIb, Level of Evidence C )
21 October 2010 , ASA/AHA Guidelines

,
50- 99 %
50-325 mg . (
Class I, Level of Evidence B )-
,
50- 99 % <140/90
mmHg Chol <200 mg/dl (Class IIb, Level of Evidence
B ) -
,
50- 99 %
stent (Class
IIb, Level of Evidence C )
,
50- 99 % , EC/IC by- pass
(Class III, Level of Evidence B )
21 October 2010 , ASA/AHA Guidelines

:
Glu :140 mg/dl, U: 40 mg/dl, Creat :1,2 mg/dl,
Clearance Creat :60 ml/min, LFTs : ,
HbA1C :7,3%, Chol ;200 mg/dl,
HDL :50 mg/dl, LDL: 120 mg/dl, TGL :150
mg/d, K:3,6 mEq/lt, Na: 140 mEq/lt .
PT, PTT, INR :

+ +
+ .

50 mg bid
.( HbA1C
1 % ) ,
2,5 mg
. ( <140/90 mmHg )
40 mg
.( LDL 43 % ,
LDL <70 mg/dl )
75
mg .

 AHA/ ASA

. ( ClassI, Level of
Evidence A.)
,
. (Class IIa, Level of Evidence B )

,
10/5 mmHg <120/ 80
mmHg JNC7. ( Class IIa, Level of Evidence B)
, , ,
,
( Class
IIa, Level of Evidence C)
,
-
. . ( Class IIa , Level
of Evidence B).

21 October 2010 , ASA/AHA Guidelines

The PROGRESS study, a large-scale randomized trial

conducted among individuals with previous stroke or
tranSient ischemic attack, demonstrated that a flexible
blood-pressure-lowering regimen based on the ACE inhibitor
perindopril for all participants, with the addition
of the diuretic indapamide for the majority, not only
reduced the risk of stroke but also substantially reduced
the risks of major vascular events; cardiac outcomes, and
cognitive decline,

. (Class I,
Level of Evidence B )

Peter Gaede et al, NEJM,2008 ;358:580-91

,
LDL >100mg/dl, CHD ( Class I, Level of Evidence B )

CHD , LDL
50 % LDL <70 mg/dl.( Class IIa, Level of Evidence B )

CHD NCEP III. ( Class I, Level of
Evidence A )
HDL
. (Class IIb,
Level of Evidence B )

21 October 2010 , ASA/AHA Guidelines

Can J Cardiol Vol 24, No 9, September 2008

.

.

.
2
.

30 , 1-3
.

.

21 October 2010 , ASA/AHA Guidelines

. (Class I, Level of Evidence A )
( 50mg- 325mg) ( Class I, Level of
Evidence A ) , o 25mg 200 mg
(Class I, Level of Evidence B ) ,
75 mg (Class IIa, Level of Evidence B )
.


.
21 October 2010 , ASA/AHA Guidelines

. (Class III, Level of Evidence A )
,
. (Class a,
Level of Evidence C).

,
.
,

. (Class b,
Level of Evidence C ).
21 October 2010 , ASA/AHA Guidelines

CAPRIE : 75 mg
325 mg.
( ESPS-2, ESPIRIT ) :

25 mg 200 mg , bid.
PROFESS : 25 mg
200 mg , bid
75 mg .
MATCH :
.

ESPS-2

 MATCH

:
.
( Aflen ):
325 mg,
.
: 3,
.

.

 20%

INR 2,5 ( 2-3 ).Class I,
Level of Evidence A.

(Class I,
Level of Evidence A ).

.(Class , Level of
Evidence )- .

( 3
, CHADS2 Score 5-6,
) ,

, .
(Class , Level of Evidence C ). .
21 October 2010 : AHA/ASA GUIDELINES

 Dabigatran .

Lars Wallentin et al , Analysis of the RE-LY trial, Lancet Vol 376 , 975983. August 2010.

, ,

,

, INR 2,5
( 2-3 ) 3
. ( Class I, Level of Evidence B ).
21 October 2010 : AHA/ASA GUIDELINES

,

,
( <35% ),
. ( Class IIb, Level of Evidence
B).

( INR 2-3 ),
81 mg/ day, 75 mg/ day,
25 mg 200 mg , 2

. (Class IIb, Level of Evidence ) .

21 October 2010 : AHA/ASA GUIDELINES

INR 2,5 (
2-3 )
( Class IIa, Level of Evidence C ).

.(Class , Level of
Evidence C ).

, ,

. (Class b, Level of Evidence C).

.
(Class b, Level of Evidence C).

. (Class b,
Level of Evidence C).
21 October 2010 : AHA/ASA GUIDELINE

,

INR 3 ( 2,5-3,5 ) ( Class I, Level of
Evidence B ).

,
75 mg- 100mg,
INR 3,
. ( Class IIa , Level of Evidence B ).

,
, ( INR
2 3 ) (Class Ib , Level of Evidence C ).

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

...
(.. )
3-6 .

Class IIa, Level

B

3-6 ,
...
.

Class IIb, Level

C

(stent) .

Class IIb, Level

C

Class IIb, Level

C

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

...
.

Class IIa, Level

B

, .

Class IIa, Level

C

...
... ...
... .

Class IIb, Level

C

... (>10mol/L)
,
.
...

Class I,
Level A

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

...
,
,
.

Class IIa, Level

A

...

Class IIa, Level

C

,
.

21 October 2010 : AHA/ASA GUIDELINES

Class IIb, Level

C


(Transient Ischemic Attacks)

Class/Level
Evidence

Ab

...
.

Class IIa, Level

B

...
,
livedo reticularis,
INR 2-3.

Class IIa, Level

B

...

.

Class IIa, Level

B

HbS <30-50% (bypass)
.

Class IIb, Level

C

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

, .

Class IIa,
Level B

3-6 ,
.

Class IIa,
Level C

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

...
,
:
12
aPTT

Xa
13
3 ,
( ) .

Class IIb,
Level C

Class IIb,
Level C

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

Class/Level
Evidence

,
1-2

(.. . , ).

Class III, Level

B

,
.
3-4 , INR
.

Class IIb, Level

C

Class III, Level

C

MRI
- .

.

Class IIb, Level

C

21 October 2010 : AHA/ASA GUIDELINES


(Transient Ischemic Attacks)

...
.

21 October 2010 : AHA/ASA GUIDELINES

Class/Level
Evidence
Class III, Level
A