每日一题_2022.09.14

A 41-year-old man with a mechanical aortic valve who is on warfarin therapy is brought to the emergency department by emergency medical services after the acute onset of right-sided weakness. One hour ago, he had no symptoms. His temperature is 36.9°C (98.4°F), heart rate 90 beats/min, blood pressure 183/95 mm Hg, and respiratory rate 18 breaths/min. On examination, he has a left gaze preference, right homonymous hemianopia, right facial droop, right arm plegia, and right leg paresis. He is mute. Noncontrast head CT is normal. INR is 1.3.

Which of the following treatments should the patient receive as early as possible, and for what reason?

A. Endovascular therapy with a stent retriever because his clinical syndrome is consistent with a large vessel occlusion

B. Endovascular therapy with a stent retriever because he is on warfarin and therefore IV recombinant tissue plasminogen activator (rtPA) is contraindicated

C. Endovascular therapy with a stent retriever because his systolic blood pressure is 183 mm Hg and therefore IV rtPA is contraindicated

D. IV rtPA because there is no contraindication to it

答案解析：

最近公布的美国心脏协会指南指出，即使正在考虑血管内治疗，符合 IV 重组组织纤溶酶原激活剂 (rtPA) 的患者也应该接受它（I 类，A 级证据）。 除了 IV rtPA 外，大血管闭塞的患者可能有资格接受血管内治疗，但不应停止 IV rtPA。 患者的 INR 仅为 1.3。 INR 大于 1.7 是 IV rtPA 的禁忌症，收缩压大于 185 mm Hg 也是如此。

正确答案：D