Castelfranco Veneto. La prevenzione primaria dell ictus

Transcription

1 Castelfranco Veneto 19 Novembre 2004 La prevenzione primaria dell ictus Achille C. Pessina Dipartimento di Medicina Clinica e Sperimentale Università di Padova

2 American Heart Association-2004 Update

3 Percentage Breakdown of Deaths From Cardiovascular Diseases United States: 2001 CHD (54%) Other (13%) Congenital CV Defects (0.4%) Rheumatic Heart Disease (0.4%) Disaeses of the arteries (4%) High Blood Pressure (5%) CHF (6%) Stroke (18%) American Heart Association-2004 Update

4 THE BURDEN OF STROKE 4.4 mil. people die of the consequences of stroke each year; ie 9% of all deaths (Global Bureau od Disease Study, Lancet 1997; 349: ) In western Countries 10-12% of all deaths (Lancet 1992; 339:342-44) Risk doubling every decade over age 50 (Lancet 1997; 349: )

5 Prevalence of Stroke by Age and Gender United States: Percent of Population men women > 75 Decades of age American Heart Association-2003 Update

6 14-YR ADJUSTED RELATIVE RISK (RR) FOR (RR) STROKE MORTALITY The CArdiovascular STudy in the ELderly (CASTEL) * <0.001 vs. 1 st quinile; vs. 1 st quintile Cut-off (yrs) < >80 Quintiles of age * Mazza A.et al; Eur J Epid 2001

7 Ictus... una questione di emergenza nuovi casi ogni anno 510 casi ogni giorno 42 casi ogni ora 1 ICTUS OGNI 3 MINUTI L ictus è più frequente dell infarto SPREAD 2001

8 Mortalità per cause cardiovascolari in Italia nel periodo IMA M F Malattie Cerebrovascolari M F Malattie del S. Cardiocircolatorio M F

9 Ictus e Attacco Ischemico Transitorio ricoveri per acuti/anno (2% del totale) 2 milioni di giornate di degenza/anno (2,9% del totale) 645 milioni di euro/anno Centro di Farmacoeconomia, Università di Milano su dati del Ministero della Salute 2002

10 STROKE OUTCOME AND RECURRENCE 20% of pts die within 30 days after a stroke 40% of pts die within 1 year (Stroke 2000; 31: ) 30% of sorvivors disabled 10% require institutional care (Stroke 2001; 32: ) 15-30% depression 6-14% further stroke within 1 year 20-37% further stroke within 5 years (Stroke 2001; 32: )

11 Asia Pacific Cohort Studies Collaboration Usual SBP and primary stroke Stroke Risk ( 95% CI) ( participants, strokes, 3.2M person-years) -10mmHg 70 + yrs - 27% yrs - 38% < 60 yrs - 55% Usual SBP (mmhg) J Hypertens. 2003; 21:707

12 14-YR ADJUSTED RELATIVE RISK (RR) FOR STROKE MORTALITY The CArdiovascular STudy in the ELderly (CASTEL) RR 4 * <0.001 vs. 1 st quintile; ** <0.01 vs. 1 st quintile ** * Cut-off (mmhg) < >88 Quintiles of Pulse Pressure Mazza A. et al; Eur J Epid 2001

13 Primary Prevention of Hypertension (population-based strategy) Systolic BP distribution After Intervention Before Intervention Reduction in BP % Reduction in Mortality (mmhg) Stroke CHD Total Whelton P. et al. JAMA 2002; 288:1882

14 Prognostic effect of observation and intervention in a general population (age years at screening) Stroke survival Phase A p< Years of follow-up Only screening Active observation Direct intervention Phase B The Castel clinical trial - Casiglia et al, 2002

15 Relationship between Odds Ratios (calculated for experimental vs reference treatment) for CV events and corresponding differences in SBP Difference (reference minus experimental) in SBP (mmhg) Staessen JA J Hypertens 2003; 21:

16 LIFE: Comparable BP Reduction Atenolol mmhg Systolic Losartan mmhg mmhg Mean Arterial Diastolic Atenolol mmhg Losartan mmhg Losartan 81.3 mmhg Atenolol 80.9 mmhg Study Month Dahlöf B et al Lancet 2002;359:

17 LIFE: Fatal and non-fatal stroke Proportion of patients with first event (%) Atenolol Losartan Adjusted Risk Reduction 24.9%, p=0.001 Unadjusted Risk Reduction 25.8%, p= Study Month Dahlöf B et al Lancet 2002;359:

18 Relative risks with 95% CI for CV events and total mortality in SCOPE and LIFE study Relative risk Lithell H et al. J Hypertens 2003; 21:

19 Favourable Non-Haemodynamic Actions of AIIRB Endothelial dysfunction Vascular remodelling Cardiovascular matrix synthesis Arterial stiffness Arterial wave reflection Central aortic pressure LV systolic stress Williams B et al Am J Cardiol 2001;87: 10C-17C

20 Kaplan Meier curves for stroke (VALUE study) Modified from Julius S. et al. Lancet 2004;363:

21 VALUE: Blood Pressure Reduction in the two treatment groups (Difference between groups <0.000 at every time point. Overall SBP difference=2.23 mmhg, DBP difference=1.59 mmhg) Modified from Julius S. et al. Lancet 2004;363:

22 VALUE: Outcome e differenze nella PAS a scadenze specifiche: Ictus Intervallo di Tempo (mesi) D PAS (mmhg) ICTUS Odds Ratios e 95% IC Studio complessivo Fine dello studio A Favore di valsartan A Favore di amlodipina Julius S et al. Lancet. Giugno 2004;363.

23 VALUE: Outcome e differenze nella PAS a scadenze specifiche: Infarto del Miocardio Intervallo di Tempo (mesi) Studio Complessivo Fine dello Studio D PAS (mmhg) Infarto del Miocardio Odds Ratios e 95% IC A Favore di valsartan A Favore di amlodipina Julius S et al. Lancet. Giugno 2004;363.

24 Comparison of more intensive BP lowering strategy vs. less intensive strategy (1) Favours more intensive Favours less intensive Lancet 2000; 356:

25 4S(Simvastatina) Lancet,1994 CARE(Pravastatina) NEJM,1996 LIPID(Pravastatina) NEJM, 1998 MIRACL(Atorvastatina) JAMA, 2001 HIPS (Simavastatina) Lancet, 2002 Greace (Atorvastatina) Curr Res Med Open, 2002 PROSPER (Pravastatina) Lancet, 2002 WOSCOPS (Pravastatina) NEJM, 1995 ALLHAT-LLT (Pravastatina) JAMA, 2002 ASCOT-LLA(Atorvastatina) Lancet, 2003

26 80 70 Trattamento Intensivo Terapia Convenzionale p= 0,006 p<0,001 p= 0,19 p= 0,001 p= 0,21 60 Pazienti (%) Emoglobina Glicata <6,5% Colesterolo <175 mg/dl Trigliceridi <150 mg/dl PAS <130 mmhg PAD <80 mmhg

27 60 50 Terapia Convenzionale Trattamento Intensivo p= 0,007

28 A Strategy to Reduce Cardiovascular Disease by More Than 80% NJ WALD,professor MR LAW, professor Dept. of Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and the London Queen Mary s School of Medicine and Dentistry University of London. BMJ 2003; 326:1419