A COMPARISON OF WARFARIN AND ASPIRIN FOR THE PREVENTION OF RECURRENT ISCHEMIC STROKE
② PFO ＋ Cryptogenic Stroke に関しては、抗血小板薬が第一選択
として推奨されているが、その根拠となる evidence は脆弱であり、
今後覆る可能性がある．
③抗凝固薬の risk は、主に出血性イベントが増加する可能性である
（その他に定期的な採血や薬剤相互作用や食事制限 etc）．
④本来なら抗凝固薬が必要となるはずの心房細動が、
単に発見されていない可能性がある．
⑤ PFO の場合は閉鎖術が第一選択として推奨されていないが、
これは今後覆る可能性があり、 ASD の場合は閉鎖術を推奨する立場 もあるが、これに関する evidence は非常に乏しい．
以上の内容をチーム内で議論し、患者本人に
risk & benefit
を伝えた．最終的に・・・
ASD 閉鎖術は、今後外来で検討することとなった．
※Cryptogenic Stroke
以外の点で手術適応は無かったWarfarin による再発予防をすることとなった．
Warfarin から Aspirin などの抗血小板薬に
変更することはいつでも可能であることを伝えた．
ちなみに・・・
もし深部静脈血栓症があったとしたら？？
UpToDate
●VTE
とPFO
を伴うCryptogenic Stroke
においては、３ヶ月の抗凝固を行ったのちに抗血小板薬に変更するが、
VTE
の再発リスクが高い場合は、長期の抗凝固を推奨する
2014 AHA/ASA guidelines
●PFO
とVTE
を伴うstroke
の再発予防に抗凝固を推奨する（Class I; LOE A）
※抗凝固の推奨期間は記載なし
●PFO
とVTE
を伴うstroke
の再発予防において、VTE
の再発リスクに応じてPFO
閉鎖術を考慮する（Class IIb; LOE C）Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Diseaseon behalf of the American Heart Association Stroke Council, Council on Cardiovascular andRich, DeJuran Richardson, Lee H. Schwamm and John A. Wilson Claiborne (Clay) Johnston, Scott E. Kasner, Steven J. Kittner, Pamela H. Mitchell, Michael W.Guidelines for the Prevention of Stroke in Patients With Stroke and Transient IschemicWalter N. Kernan, Bruce Ovbiagele, Henry R. Black, Dawn M. Bravata, Marc I. Chimowitz,Michael D. Ezekowitz, Margaret C. Fang, Marc Fisher, Karen L. Furie, Donald V. Heck, S. Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Print ISSN: 0039-2499. Online ISSN: 1524-4628
Copyright © 2014 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Stroke Stroke. 2014;45:2160-2236; originally published online May 1, 2014;doi: 10.1161/STR.0000000000000024
http://stroke.ahajournals.org/content/45/7/2160 World Wide Web at:
The online version of this article, along with updated information and services, is located on the
http://stroke.ahajournals.org/content/45/8/e172.full.pdf
An erratum has been published regarding this article. Please see the attached page for:
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2012 ACCP guidelines
●VTE+PFO
を伴うCryptogenic Stroke
に3
ヶ月の抗凝固を推奨(Grade
１B)
●VTE+PFO
を伴うCryptogenic Stroke
にPFO
閉鎖術を考慮(Grade2C)
e576S
CHEST Supplement
Antithrombotic Therapy for Valvular Disease
ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES
Background: Antithrombotic therapy in valvular disease is important to mitigate thromboembo-lism, but the hemorrhagic risk imposed must be considered.
Methods: The methods of this guideline follow those described in Methodology for the Develop-ment of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
Results: In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is . 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recom-mend VKA therapy until thrombus resolution, and we recomrecom-mend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitu-tion of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C).
We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the fi rst 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C).
In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspi-rin (50-100 mg/d ) (Grade 1B). In valve repair patients, we suggest aspiaspi-rin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fi brinolysis for right-sided valves and left-sided valves with thrombus area , 0.8 cm 2 (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ! 0.8 cm 2 , we recommend early surgery (Grade 2C).
Conclusions: These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk. CHEST 2012; 141(2)(Suppl):e576S–e600S Abbreviations: AF 5 atrial fi brillation; APA 5 antiplatelet agent; AVR 5 aortic valve replacement; GRADE 5 Grades of Recommendations, Assessment, Development, and Evaluation; ICH 5 intracerebral hemorrhage; IE 5 infective endocarditis; INR 5 international normalized ratio; LMWH 5 low-molecular-weight heparin; MAC 5 mitral annular calcifi cation; MVP 5 mitral valve prolapse; NBTE 5 nonbacterial thrombotic endocarditis; NYHA 5 New York Heart Association; OAC 5 oral anticoagulation; PFO 5 patent foramen ovale; PICO 5 population, intervention, comparator, and outcome; PMBV 5 percutaneous mitral balloon valvotomy; PVE 5 prosthetic valve endocarditis; PVT 5 prosthetic valve thrombosis; RCT 5 randomized controlled trial; RR 5 relative risk; TEE 5 transesophageal echocardiography;
TIA 5 transient ischemic attack; UFH 5 unfractionated heparin; VKA 5 vitamin K antagonist
Antithrombotic and Thrombolytic Therapy for Valvular Disease
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
Richard P. Whitlock , MD ; Jack C. Sun , MD ; Stephen E. Fremes , MD , FCCP ; Fraser D. Rubens , MD ; and Kevin H. Teoh , MD
Downloaded From: http://journal.publications.chestnet.org/ on 09/18/2014
これらの推奨の根拠となる研究は存在しない（推奨の根拠は