Transcript MMD 6223 Lecture B2 Coronary Artery Disease
ACV François Sestier, MD, PhD Abdelouahed Naslafkih, MD, PhD AQTV, Montréal, 14 Mai 2009 Programme de médecine d’assurance et expertise en sciences de la santé, Université de Montréal www.mae.umontreal.ca
OBJECTIFS
• Identifier la littérature médicale la
plus récente concernant la mortalité des LNH
• Calculer la mortalité observée en
utilisant une méthodologie actuarielle
Plan Epidemiologie Revue de littérature et méthodologie Conclusions
Epidemiologie
Risques d’ACV en 10 ans chez adultes de 55ans selon Framingham Heart Disease and Stroke Statistics—2008 Update A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2008;117;e25-e146
Incidence annuelle d’un 1er ACV, par race 1993–1999. Heart Disease and Stroke Statistics—2008 Update A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2008;117;e25-e146
Principaux types d’ACV
Projection (année 2005 à 2050) du nombre annuel d’un 1 er ACV en Suède selon 4 différents scenarios Hallström et al. Stroke. 2008;39:10-15
Plan Epidemiologie
Revue de littérature et méthodologie
Conclusions
Analyse de mortalité
• SMR (Standardized Mortality Ratio):
Mentionné dans quelques études SMR = MR x 100
• MR (Mortality Ratio):
Calculé
= Mortalité observée (décès, courbes de survie) vs. Mortalité attendue (calculée à partir des tables de mortalité
Publications 1. McGuire. Cer vasc Dis 2007 2. Slot. BMJ 2008 3. Kragsterman. Stroke 2006 4. Bravata 2003 5. Brønnum-Hansen 2001 6. Wijk. Lancet 2005 7. Kammersgaard . Age & Ageing 2004 8. Sugimoto. JPTS 2004 9. Paul 2005 10. de Jong . JCE 2003 11. Beer. Internal Medicine Journal 2007 12. Terént, Stroke. 2004 13. Anderson . Stroke. 2004 14. Sacco . Stroke 2008 15. Petty 2000 16. Carter. Stroke 2007 17. Modrego et al. J NS 2004 18. Hankeyl. Stroke. 2000 19. Kiyohara . Stroke. 2003 20. Marini . Stroke 1999 21. Waje-Andreassen . ANS 200..
22. Hardie. Stroke 2003 23. Principe. Stroke. 1998 24. Varona . J Neurol 2004
Articles
Patients 9598 7710 5508 5123 4162 2473 1197 1053 987 998 954 895 680 549 454 545 425 370 333 333 232 328 322 277 Age 72 72 70 78 65 63 75 71 76 71 74 71 75 76 73 15-44 41 76 55 15-45 5 10 4 5 10 11 10 10 10 FU 11 8 10 5 10 7 5 5 12 10
Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study 1-McGuire et al. Cerebrovasc Dis 2007;23:221-228 705 UK, 1995 705 incident ICH (53% women, mean age = 65 years ), and 8893 incident IS (47% women, mean age= 73 years ) Follow-up= 11 years Mortality :
The acute inhospital mortality was 45.7 and 30% for ICH and IS
At 11 years : mortality is 67% for ICH and 80.4% for IS
MR* ICH = 290% IS= 135%
* Expected mortality from LT England 1995-99, (% male+% female)
Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study McGuire et al. Cerebrovasc Dis 2007;23:221-228 MR = 290% MR= 135%
Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies 2- Slot et al. BMJ published online 29 Jan 2008
United Kingdom, 1981-2000 Three cohorts : Oxfordshire community stroke project (OCSP), Lothian stroke register (LSR), and the first international stroke trial (IST-1).
7710 patients (52% men, age 72
yrs) with ischaemic stroke followed up for a maximum of 19 years.
OCSP : 539 Patients, age =73 yrs LSR : 2054 Patients, age: 68 yrs IST-1: 5117 Patients, age 73 yrs
Lothian cohort:
Long term survival of patients in each category of functional status (Rankin score 0-5) from assessment at six months after index stroke
2 3 4 Rankin Score 0 1 5 All MR* 96% 138% 190% 390% 465% 525% 245% *
Life table England & Wales 2000-2002
Slot et al. BMJ published online 29 Jan 2008
International stroke trial cohort:
Long term survival of patients who were alive and independent from assessment at six months MR = dependent or MR* = 80% MR* = 160%
Slot et al. BMJ published online 29 Jan 2008 *
Life table England & Wales 2000-2002
Long-Term Survival After Carotid Endarterectomy for Asymptomatic Stenosis
3- Kragsterman et al. Stroke. 2006;37:2886-2891
The Swedish Vascular Registry (Swedvasc), 1994 -2003 5808 patients , 66% men mean age= 70 years Survival at 10 years Symptomatic: 45.5%
Asymptomatics : 53.8%
MR= 156%
vs.
125%
Long-Term Mortality in Cerebrovascular Disease 4- Bravata et al. Stroke. 2003;34:699-704 USA 1995 Among 5123 patients , 4781 survived their hospitalization .
Median age = 78 yrs 57% women
5 years cumulative mortality rate Entire cohort = 52.6% Patient with carotid stenosis = 38.3% Patients with TIA = 49.6% Patients with acute Ischemic stroke =60% Expected mortality = 0.0694 (Life table US 1995-99, age 78 years, 43% male+575 female)
MR Entire cohort = 200% Carotid stenosis = 132% TIA = 185% Ischemic stroke = 240%
Long-Term Survival and Causes of Death After Stroke 5- Brønnum-Hansen et al. Stroke. 2001;32:2131-2136 Copenhagen County. WHO MONICA Project All stroke events during 1982–1991
4162 patients with a first stroke
Fatal and Nonfatal First Strokes in the Danish MONICA Population 1982–1991, by Sex and Age
SMRs by Sex and Age for Patients After a First Nonfatal Stroke
Age group 25-69 yr ≥70 yrs Year after stroke 0 - 1
1 - 5
5 - 10 10 - 15 0 - 1
1 - 5
5 - 10 10 - 15 Men 4.64
3.00
2.75
2.50
3.70
1.92
1.89
2.49
SMR
women 9.27
3.52
3.32
2.45
5.18
2.05
1.99
1.67
All 5.72
3.14
2.90
2.49
4.46
1.99
1.94
1.94
Brønnum-Hansen et al. Stroke. 2001;32:2131-2136
Ischemic Stroke Subtypes A Population-Based Study of Functional Outcome, Survival, and Recurrence 15- Petty et al. Stroke 2000;31:1062-1068
Rochester, Minnesota, 1985-1989
454 Patients
with a
first ischemic stroke
from the Rochester Epidemiology Project medical records linkage system
Follow-up = 5 years
Age Male % dead Observed mortality Expected mortality*
MR
Atherosclerotic
72 yrs 68% 32 0.0742
0.0506
Ischemic Stroke subtypes Cardioembolic
80 yrs 33% 80 0.2752
0.0892
Lacunar
73 yrs 43% 35.1
0.0828
0.0627
147% 310%
Unknown
75 yrs 34% 46.8
0.1185
0.0529
132% 225%
* Life table US 1995-99, (%male+% female)
Observed percentage surviving after incident ischemic stroke among 442 residents of Rochester, Minnesota, 1985 to 1989, with common ischemic stroke subtypes.
132% 147% 225% 310% Petty et al. Stroke 2000;31:1062-1068
Five-Year Survival After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke Study Hankey et al. Stroke. 2000;31:2080-2086 The relative risk of dying declined with increasing age ● Patients
<45 years had a 200-fold higher risk of dying than individuals of the same age and sex in the general population.
●
Patients older than 85 years had a relative risk of dying of 3.2 compared with individuals of the same age and sex in the general population.
Number of Deaths in Each Calendar Year After the Index Stroke Compared With the Expected Number of Strokes in the Same Population
Hankey et al.
Stroke. 2000;31:2080-2086
Number of Deaths After the First-Ever Stroke versus Expected Number of Deaths in the Same Population Stratified by Age
Hankey et al.
Stroke. 2000;31:2080-2086
Cerebral Ischemia in Young Adults 20- Marini et al. Stroke 1999;30:2320-2325
Italy 1984-1988
333
patients aged
15 to 44 years
who suffered from a first-ever ischemic stroke or TIA follow-up = 8 years Survival was worse in patients with stroke at entry (86.5%) than in those with TIA (97.1%). Mortality in both groups was significantly higher than in the general population.
MR
TIA = 280% Stroke = 1450%
Long-term prognosis of ischemic stroke in young adults 24- Varona et al. J Neurol (2004) 251 : 1507–1514 survival at 10 years in young adult patients (15–45 years)with stroke vs. the general population Spain 1974-2001 : 272 young adults (15–45years)
MR = 858%
Selected Articles
Publications 1. McGuire. Cer vasc Dis 2007 2. Slot. BMJ 2008 3. Kragsterman. Stroke 2006 4. Bravata 2003 5. Brønnum-Hansen 2001 6. Wijk. Lancet 2005 7. Kammersgaard . Age & Ageing 2004 8. Sugimoto. JPTS 2004 9. Paul 2005 10. de Jong . JCE 2003 11. Beer. Internal Medicine Journal 2007 12. Terént, Stroke. 2004 13. Anderson . Stroke. 2004 14. Sacco . Stroke 2008 15. Petty 2000 16. Carter. Stroke 2007 17. Modrego et al. J NS 2004 18. Hankeyl. Stroke. 2000 19. Kiyohara . Stroke. 2003 20. Marini . Stroke 1999 21. Waje-Andreassen . ANS 200..
23. Hardie. Stroke 2003 23. Principe. Stroke. 1998 24. Varona . J Neurol 2004 Patients 9598 7710 5508 5123 4162 2473 1197 1053 987 998 954 895 680 549 454 545 425 370 333 333 232 328 322 277 Age 72 72 70 78 65 63 75 71 76 71 74 71 75 76 73 15-44 41 76 55 15-45 FU 11 8 10 5 10 7 5 5 12 10 5 10 4 5 10 11 10 10 10
Age All types < 40 40-50 50-60 60-65 65-70 <70 >70 70-75 75-80
2000 (18) 1077 (21) 660 (18)
475 (8)
245 (2) 475 (8) 300 (5) 200 (5) 200 (13)
195(13) 200(18)
300 (10)
120(11)
140 (17) 160(9) 200 (18) 232 (7)
80-85 +85
122 (7)
All ages
230 (22) 270(5) MS= Minor stroke; CS= Carotid Stenosis
MORTALITY RATIOS Ischemic IS-all
858 (24)
135(1) 380(16)
240 (4)
ATH 147
(15)
310
(10)
CE 285
(10)
310
(15)
Lac ICH 225(8) 475(8)
225 (8)
290
(10) 647 (8)
290(1) 132
(15) 270 (14) 165 (14)
TIA , MS
280 (20) 195 (23) 335 (8) 165 (6)
185(4) CS
156 (3) 125 (3)
132(4)
Age All types IS-all DEC MORTALITY RATIOS Ischemic ATH DEC CE DEC Lac DEC ICH DEC TIA , MS CS < 40 40-50 DEC DEC DEC DEC DEC DEC DEC DEC 300 DEC DEC 50-60 60-65 65-70 70-75 75-80 80-85 >85 DEC 475 300 200 175 150 125 DEC 225 175 150 150 125 125 DEC 225 200 175 150 125 125 DEC DEC 475 300 300 300 200 300 225 175 150 150 125 125 DEC DEC 300 175 175 175 150 300 300 175 175 175 150 125 300 225 175 150 150 125 125
IS = Ischemic stroke; ATH = Atherosclerotic; CE= Cardio embolic; Lac = Lacunar,; ICH= Intracerbral Haemorrhage; TIA= Transient isch aemic attack; MS= Minor stroke; CS= Carotid Stenosis
Lothian stroke register :
2054 Patients with I.S., age: 68 yrs Survival in each category of functional status (Rankin score 0-5) Assessment at six months after index stroke Rankin Score 0 1 2 3 4 5 All 2-Slot et al. BMJ published online 29 Jan 2008 MR* 96% 138% 190% 390% 465% 525% 245% *
Life table England & Wales 2000-2002
ACV: conclusions
• ACV ischémiques: MR x 2 si score de Rankin 4-5(2)
Dependance pour AVQ+50; Pas de dependance -50(2)
• ACV : refus < 60 yo?? 50yo?? 45yo?? • ACV: années écoulées
Différer la 1ère année (18) MR stable 2 à 5 ans x 2.3 (13-18) MR 6 à 15 ans x 1.5 (13-19) MR > 15 ans x 1.2 (13)
• ACV: MR x 2 si MVP, incontinence, 2ième épisode(18) • ICT : pas de diminution du risque avec le temps(23)