Consequences of stroke and AF

Transcription

1 Consequences of stroke and AF Lorenzo G Mantovani Center of Pharmacoeconomics University of Naples Center for Public Health Research University of Milan Bicocca

2 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

3 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

4 YES Incidence 2-3 events per 1000 py s Italy 150k events per year* *Italian Source: Ministry of Health

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6 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money Is it value for money (theory)? Is it value for money (practice)?

7 YES Incident stroke first year cost Health care 5.5k Non health care 4.5k Indirect 1k 11k Euro s

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10 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

11 YES

12 AND VERY MUCH SO

13 AF=atrial fibrillation; OR=odds ratio; CI=confidence interval 1. Lin HJ, et al. Stroke 1996; 27: ; 2. Dulli DA, et al. Neuroepidemiology 2003; 22: Survival is poorer and stroke recurrence rates are higher following AF-related stroke Framingham (10-year follow up from 1981) 1-year post stroke recurrence 30-day post stroke mortality 1-year post stroke mortality AF patients (n=30) Non-AF patients (n=120) 23% 8% 30% 17% 63% 34%

14 Patients bedridden on admission (%) AF=atrial fibrillation; OR=odds ratio; CI=confidence interval Dulli DA, et al. Neuroepidemiology 2003; 22: Functional outcomes of stroke are significantly worse in patients with AF, and more patients remain bedridden % OR for bedridden state following stroke due to AF was 2.23 (95% CI: 1.87, 2.59) p< % 10 0 With AF (n=194) Without AF (n=867)

15 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

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17 1+ million prevalent subjects new cases per year

18 Atrial Fibrillation (AF) AF is the most common heart rhythm disturbance 1 It is estimated that 1 in 4 individuals aged 40 years will develop AF 1 In 2007, 6.3 million people in the US, Japan, Germany, Italy, Spain, France, and UK were living with diagnosed AF 2 Due to the aging population, this number is expected to double within 30 years 3 1. Lloyd-Jones DM et al. Circulation 2004;110: Decision Resources. Atrial Fibrillation Report. Dec Go AS et al. JAMA. 2001;285:

19 Rationale for Stroke Prevention in Patients With AF AF increases the risk for stroke 5-fold 1 The increase in risk for stroke is similar for paroxysmal, persistent, and permanent AF 2 Strokes associated with AF are usually more severe than those from other causes, conferring an increased risk for morbidity, mortality, and poor functional outcome 2 1. Wolf PA et al. Arch Intern Med. 1987;147(9): Savelieva I et al. Ann Med. 2007;39(5):

20 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

21 Stroke reduction of 19% (95% CI 2% to 34%)

22 Risk reduction of 62% (95% CI 48% to 72%) versus placebo

23 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

24 ONLY IN FEW

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26 Antithrombotic Therapy in AF ACC/AHA/ESC Guidelines 2006 High Risk Rheumatic valve, prior stroke, TIA or SE or 2 risk factors: Age >75 years Hypertension Diabetes mellitus CHF/impaired LV function Moderate Risk (CHADS2) 1 risk factor Age >75 years Hypertension Diabetes mellitus CHF/Impaired LV function Low Risk Age 75 years No additional risk factor VKA INR range VKA INR range or ASA mg/d ASA mg/d ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Europace. 2006; 8:

27 Oral anticoagulant therapy (%) Modest use of VKAs even in high-risk patients: European Heart Survey* CHADS 2 score Nieuwlaat et al. Eur Heart J 2006; Gage et al. JAMA 2001 *5,333 AF patients in 35 countries

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29 Stroke rate (% per year) Stroke risk in AF by CHADS 2 score C CHF 1 H Hypertension 1 A Age >75 1 D Diabetes mellitus 1 S 2 TIA/stroke n=120 n=463 n=523 n=337 n=220 n=65 n= CHADS 2 score Fuster et al. Eur Heart J 2006

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31 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

32 Now

33 Later?

34 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

35 Depends on price Italy: ? ? ? ?

36 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

37 According to TA agencies, YES

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39 Questions Is stroke frequent? Is stroke a burden? Is AF a cause of stroke? Is AF frequent? Can we prevent Stroke due to AF? (theory) Can we prevent Stroke due to AF? (practice) Who is candidate for new OAC? How many candidates do we have? Is it value for money (theory)? Is it value for money (practice)?

40 GARFIELD! Garfield will document in a standardised, comprehensive and solid way what happens to AF patients globally before during after Such evidence is and will be more and more crucial for policy makers 40

41 Reducing the Stroke Rate in AF Would be a Great Benefit 15 million strokes annually worldwide 20% of strokes due to AF 1,2 3 million are due to AF RRR of 64% with warfarin 3 2 million are preventable with warfarin therapy 50% of eligible patients treated with warfarin 4 1 million strokes could have been prevented 1 Arch Intern Med 1994; 2 Singer et al Chest 2008; 3 Hart et al Ann Intern Med 2007; 4 Connolly et al Circulation 2007

42 Research Policy