梗死后出血：抗凝和抗栓的选择

孙大夫，你好。你确实问了一个很纠结、临床上也非常棘手的现实病例。随着各种支架置入术的日益增多，在中国颈动脉剥脱远远少于颈动脉支架；搭桥远少于冠脉支架，可能这样的病人确实并不少见。这个病人是脑栓塞并出血转化，栓塞再通率较血栓形成要高，所以出血转化率更高。出血转化是血管再通的表现，传统观念认为不影响病人预后，但近几年研究表明出血转化影响病人预后的重要因素。你提供的这一例，血肿体积>梗死体积的30%，属出血转化IV级，最严重的类型了，因此视同脑出血病人来治疗。所以，这相当于一例PCI后支架（药物涂层支架）不足3个月，却合并了脑出血的房颤患者的后续治疗。

这个患者的CHA2DS2-VASc分数是7分（总分9分），是高危缺血性卒中患者；如果不合并此次明显出血转化的话，这种特殊复杂情况尚缺乏高等级的循证证据做出治疗推荐，更何况我们这个病人又掺杂严重出血并发症了。所以缺乏临床数据的前提下，我们要先向病人及家属做好充分病情沟通工作，再梗塞或再出血均是不希望发生的，但有时不可兼得。

（1）目前一定要按脑出血处理，停用抗栓治疗是合理的。她的出血风险是源于双抗和栓塞再通，并非抗凝药物。通常脑出血后恢复抗栓治疗是在6个月后，但由于她既是脑栓塞的高危患者，又有冠脉支架内血栓再形成的风险。因此可以将恢复抗栓治疗的时间提早。

（2）提到多早？脑出血后1～10周开始启动治疗均有报道。但无一个有确凿证据做为此类患者推荐的策略供临床医师直接选用。你们现在选择IIb/IIIa制剂，并未增加患者的血肿，可继续应用到2周；2周后，依据血栓弹力图结果，选择对血小板抑制率高的一种抗血小板剂（ASA通路>50%, ADP通路>30%有效，不知你们的结果如何？），再加用出血风险较小的抗血小板剂 西洛他唑 50mg bid，如无头痛等副作用，3天后可加量至100mg bid，与ASA或氯吡格雷中的一种联合应用。西洛他唑除抗血小板外，还有强心作用。这个病人BNP高，如心功能不好，还一举双得。

（3）谨慎观察出血情况，因她用的药物涂层支架，双抗要1年时间。

（4）超过1年后怎么办？因为目前抗凝药无论华法令还是新型抗凝药说明书，都将出血列为使用禁忌症。因此，此后还是选择一种对血小板抑制率最高的抗血小板剂，单抗最好。反过来说，以后可以与心脏介入医生交流一下，对于这种既房颤，又冠脉狭窄的病人，选裸支架最好，这样双抗时间可缩短至1个月，此后，可以选择一种抗血小板剂，加上XA因子直接抑制剂达比加群最好，后者有150mg bid 和110mg bid之分，为减少出血风险，选110mg bid可以。 同意你们的治疗。恢复双抗后，由其西洛他唑与杏丁中的潘生丁均系磷酸二酯酶抑制剂而发挥抗血小板作用。不建议2者同时用。 供参考，再沟通。

Cerebrovasc Dis. 2013;36(1):33-7. 

doi: 10.1159/000351151. Epub 2013 Jul 30. Long-term outcome after anticoagulation-associated intracerebral haemorrhage with or without restarting antithrombotic therapy. Gathier CS1, Algra A, Rinkel GJ, van der Worp HB. Author information Abstract BACKGROUND: For patients who survive intracerebral haemorrhage (ICH) during treatment with oral anticoagulation (OAC), the balance between the benefits and risks of restarting OAC is unclear. The decision to restart OAC or to start antiplatelet therapy in these patients therefore poses a dilemma for all physicians involved. We assessed the long-term outcome of patients who did or did not restart antithrombotic therapy after OAC-associated ICH. METHODS: We conducted a retrospective follow-up study of all patients discharged from our institution after OAC-associated ICH over a 10-year period. Data on the use of OAC or platelet inhibitors and the occurrence of vascular events during follow-up were assessed through questionnaires and patient files. The primary outcome was recurrent fatal or non-fatal stroke. Secondary outcomes were the occurrence of other haemorrhagic, thrombotic or thromboembolic events. With patients without antithrombotic treatment as reference, we calculated incidence ratios with corresponding 95% confidence intervals (CI) for treatment with OAC and for treatment with antiplatelet therapy. RESULTS: We included 38 patients, of whom 21 (55%) died during a mean follow-up of 3.5 years. The medication regime changed frequently during follow-up, illustrated by the fact that two thirds of the patients who had resumed OAC within 2 months of ICH terminated this at later points in time. Two recurrent strokes occurred during 35.4 patient-years without antithrombotic medication, 7 during 63.8 patient-years on antiplatelet medication (incidence ratio 1.9; 95% CI, 0.4-9.4), and 3 during 19.5 patient-years on OAC (incidence ratio 2.7; 95% CI, 0.5-16.3). There was only 1 recurrent ICH, which occurred during treatment with OAC. CONCLUSION: In this observational study, no significant difference in the primary outcome measure was found between the treatment groups, but there was a tendency towards a higher long-term risk of any stroke in patients who resumed OAC or started antiplatelet therapy. However, based on these results it is difficult to draw any concrete conclusions or make any strong recommendations. A randomized trial to assess the optimal long-term strategy after OAC-related ICH is warranted. Based on the point estimates of our study, such a trial should involve at least 300 patient-years of follow-up. 给你一篇文献，看出世界各地医生都在纠结中。超过1年后，单抗血小板剂，再栓塞风险高；单用抗凝剂，再栓风险低，但再出血风险相对高。所以大部分研究都是“鱼与熊掌不可兼得”，不能明确做出推荐。你有兴趣，可以看看。