Epidemiology current status: heart and brain Veikko Salomaa, MD, PhD Research Professor 22.5.2012 Heart and brain/ Veikko Salomaa 1
Veikko Salomaa, MD, PhD Research Professor National Institute for Health and Welfare THL, Finland X 2
Mortality statistics Each year CVD causes over 4.3 million deaths in Europe and over 2.0 million deaths in the European Union (Source: European Heart Network, CVD statistics 2008). CVD causes nearly half of all deaths in Europe (48%) and in the EU (42%) CHD is the single most common cause of death in Europe accounting for 1.92 million deaths each year. Over one in five women (22%) and over one in five men (21%) die from the disease Stroke is the second single most common cause of death in Europe accounting for 1.24 million deaths in Europe each year. Over one in six women (17%) and one in ten men (11%) die from the disease. 22.5.2012 3
m m Cardiovascular Disease Statistics 2008 EHN European Heart Network 4
m m Cardiovascular Disease Statistics 2008 EHN European Heart Network 5
Mostly common antecedents CHD and stroke share a common atherosclerotic background. Most classic risk factors are the same for both: Age and male sex are the main non-modifiable risk factors High BP, high LDL-cholesterol, smoking and DM are the main modifiable risk factors Among patients with a heart disease, especially arrhythmias, activation of the coagulation system contributes importantly to the risk of stroke 22.5.2012 6
Glynn et al. AJE 2005;162:975-982 7
Incidence of stroke (per 100,000) during a five year follow-up after the first manifestation of CHD in 2000-2004, compared with the unselected population ACS PTCA CABG Unselected population Men 1291 1026 784 386 Women 1283 1067 761 227 Age group 45-74 y. at the time of the CHD event Source: Finnish Cardiovascular Disease Register, which includes all CVD events in Finland 22.5.2012 8
Incidence of ACS (per 100,000) during a five year follow-up after the first stroke in 2000-2004, compared with the unselected population ACS Unselected population Men 1135 660 Women 446 225 Age group 45-74 y. at the time of the stroke event Source: Finnish Cardiovascular Disease Register, which includes all CVD events in Finland 22.5.2012 9
Estimated 10-year stroke risk in adults 55 years of age according to levels of various risk factors (Framingham Heart Study). Roger VL et al. Circulation 2012;125:e2-e220. Copyright American Heart Association.
Healey JS et al. NEJM 2012;366:2 11
Atrial fibrillation AF is the most common significant cardiac arrhythmia, it raises the risk of ischemic stroke about 5-fold (Singer and Go, Arch Int Med 2012) Warfarin therapy reduces this risk by two thirds but does not abolish it totally. Risk assessment scores, such as CHA 2 DS 2 -VASc, can be used for assessing the risk of stroke in AF patients. Generally, however, anticoagulation is underutilized. 22.5.2012 12
The Task Force for the Management of Atrial Fibrillation of the ESC. Guidelines. Europace 2010;12:1360-1420. 13
Cardiovascular Disease Statistics 2008 EHN European Heart Network Olsson LG et al. Int J Cardiol 2012 doi:10.1016/j.ijcard.2012.03.057 14
New anticoagulants Recent trials have tested new anticoagulants in the prevention of stroke among patients with non-valvular AF RE-LY trial: Dabigatran ROCKET AF trial: Rivaroxaban ARISTOTLE trial: Apixaban At least as effective and safe as warfarin and simpler to use Caveats: An antidote does not exist Effect on blood coagulation is not easy to measure Costs are higher than the costs of warfarin 22.5.2012 15
Patel MR et al. NEJM 2011;365:883-91 16
Summary Heart and stroke are closely connected and a major adverse event in one greatly increases the risk in the other Patients who survived their first ACS have >3 times higher risk of stroke among men and >5 times higher risk stroke among women compared with the unselected population After PTCA men have almost 3 times and women almost 5 times higher risk of stroke that the unselected population AF increases the risk of stroke by 5 fold. This excess risk can be substantially reduced by anticoagulation, either by warfarin or by one of the novel anticoagulants 22.5.2012 17