ACV

François Sestier, MD, PhDAbdelouahed 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.cawww.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

Epidemiologie

Revue de littérature et méthodologie

Conclusions

Plan

Epidemiologie

Risques d’ACV en 10 ans chez adultes de 55ans selon Framingham

Heart Disease and Stroke Statistics—2008 UpdateA Report From the American Heart Association Statistics Committee and Stroke Statistics

Subcommittee

Circulation 2008;117;e25-e146

Incidence annuelle d’un 1er ACV, par race1993–1999.

Heart Disease and Stroke Statistics—2008 UpdateA 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 1er ACV en Suède selon 4

différents scenarios

Hallström et al. Stroke. 2008;39:10-15

Epidemiologie

Revue de littérature et méthodologie

Conclusions

Plan

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 Patients Age FU1. McGuire. Cer vasc Dis 2007 9598 72 112. Slot. BMJ 2008 7710 72 8 3. Kragsterman. Stroke 2006 5508 70 104. Bravata 2003 5123 78 55. Brønnum-Hansen 2001 41626. Wijk. Lancet 2005 2473 65 107. Kammersgaard . Age & Ageing 2004 1197 78. Sugimoto. JPTS 2004 1053 639. Paul 2005 987 75 510. de Jong . JCE 2003 998 71 511. Beer. Internal Medicine Journal 2007 954 76 1212. Terént, Stroke. 2004 895 1013. Anderson . Stroke. 2004 680 7114. Sacco . Stroke 2008 549 7415. Petty 2000 454 516. Carter. Stroke 2007 545 71 1017. Modrego et al. J NS 2004 425 75 418. Hankeyl. Stroke. 2000 370 76 519. Kiyohara . Stroke. 2003 333 73 1020. Marini . Stroke 1999 333 15-4421. Waje-Andreassen . ANS 200.. 232 41 1122. Hardie. Stroke 2003 328 76 1023. Principe. Stroke. 1998 322 55 1024. Varona . J Neurol 2004 277 15-45 10

Articles

Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study1-McGuire et al. Cerebrovasc Dis 2007;23:221-228 705

UK, 1995705 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 ISAt 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 studyMcGuire et al. Cerebrovasc Dis 2007;23:221-228

MR = 290% MR= 135%

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

Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies2- Slot et al. BMJ published online 29 Jan 2008

Slot et al. BMJ published online 29 Jan 2008

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

RankinScore

MR*

0 96%1 138%2 190%3 390%4 465%5 525%All 245%

*Life table England & Wales 2000-2002

International stroke trial cohort: Long term survival of patients who were alive and dependent or independent from assessment at six months MR =

Slot et al. BMJ published online 29 Jan 2008

MR* = 80%

MR* = 160%

*Life table England & Wales 2000-2002

The Swedish Vascular Registry (Swedvasc), 1994 -2003

5808 patients, 66% menmean age= 70 years

Long-Term Survival After Carotid Endarterectomy for Asymptomatic Stenosis3- Kragsterman et al. Stroke. 2006;37:2886-2891

Survival at 10 years

Symptomatic: 45.5%

Asymptomatics : 53.8%

MR= 156% vs. 125%

USA 1995

Among 5123 patients, 4781 survived their hospitalization.Median age = 78 yrs57% women5 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)

MREntire cohort = 200%Carotid stenosis = 132%TIA = 185%Ischemic stroke = 240%

Long-Term Mortality in Cerebrovascular Disease4- Bravata et al. Stroke. 2003;34:699-704

Long-Term Survival and Causes of Death After Stroke5- Brønnum-Hansen et al. Stroke. 2001;32:2131-2136

Copenhagen County. WHO MONICA Project All stroke events during 1982–19914162 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

Brønnum-Hansen et al. Stroke. 2001;32:2131-2136

Age groupYear after stroke

SMR

Men women All

25-69 yr 0 - 1 4.64 9.27 5.721 - 5 3.00 3.52 3.145 - 10 2.75 3.32 2.9010 - 15 2.50 2.45 2.49

≥70 yrs 0 - 1 3.70 5.18 4.461 - 5 1.92 2.05 1.995 - 10 1.89 1.99 1.9410 - 15 2.49 1.67 1.94

Ischemic Stroke Subtypes A Population-Based Study of Functional Outcome, Survival, and Recurrence15- Petty et al. Stroke 2000;31:1062-1068

Rochester, Minnesota, 1985-1989454 Patients with a first ischemic stroke from the Rochester Epidemiology Project medical records linkage systemFollow-up = 5 years

Ischemic Stroke subtypesAtherosclerotic Cardioembolic Lacunar Unknown

Age 72 yrs 80 yrs 73 yrs 75 yrsMale 68% 33% 43% 34%% dead 32 80 35.1 46.8Observed mortality

0.0742 0.2752 0.0828 0.1185

Expected mortality*

0.0506 0.0892 0.0627 0.0529

MR 147% 310% 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.

Petty et al. Stroke 2000;31:1062-1068

132%

147%

225%

310%

Five-Year Survival After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke StudyHankey 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 StrokeCompared 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 Adults20- Marini et al. Stroke 1999;30:2320-2325

Italy 1984-1988333 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 adults24- Varona et al. J Neurol (2004) 251 : 1507–1514survival at 10 years in young adult patients (15–45 years)with

stroke vs. the general populationSpain 1974-2001 : 272 young adults (15–45years)

MR = 858%

Publications Patients Age FU1. McGuire. Cer vasc Dis 2007 9598 72 112. Slot. BMJ 2008 7710 72 8 3. Kragsterman. Stroke 2006 5508 70 104. Bravata 2003 5123 78 55. Brønnum-Hansen 2001 41626. Wijk. Lancet 2005 2473 65 107. Kammersgaard . Age & Ageing 2004 1197 78. Sugimoto. JPTS 2004 1053 639. Paul 2005 987 75 510. de Jong . JCE 2003 998 71 511. Beer. Internal Medicine Journal 2007 954 76 1212. Terént, Stroke. 2004 895 1013. Anderson . Stroke. 2004 680 7114. Sacco . Stroke 2008 549 7415. Petty 2000 454 516. Carter. Stroke 2007 545 71 1017. Modrego et al. J NS 2004 425 75 418. Hankeyl. Stroke. 2000 370 76 519. Kiyohara . Stroke. 2003 333 73 1020. Marini . Stroke 1999 333 15-4421. Waje-Andreassen . ANS 200.. 232 41 1123. Hardie. Stroke 2003 328 76 1023. Principe. Stroke. 1998 322 55 1024. Varona . J Neurol 2004 277 15-45 10

Selected Articles

Age All typesIschemic

ICH TIA , MS CSIS-all ATH CE Lac

< 40

40-50

2000 (18)

1077 (21)

858 (24)

280 (20)

50-60

660 (18) 195 (23)

60-65

475 (8) 225(8)225 (8)

647 (8) 335 (8)

65-70

245 (2)

475 (8)475(8)

290 (10)

290(1) 165 (6)

<70 300 (5)

>70200 (5)

200 (13)

70-75

195(13)

200(18)

300 (10)

135(1)

380(16)

147 (15)

310 (10)

285 (10)

132 (15)

270 (14)

165 (14)

156 (3)125 (3)

75-80

120(11)

140 (17)

160(9)

200 (18)

240 (4) 185(4) 132(4)

80-85

232 (7)310 (15)

+85 122 (7)

All ages

230 (22)270(5)

MORTALITY RATIOS

IS = Ischemic stroke; ATH = Atherosclerotic; CE= Cardio embolic; Lac = Lacunar,; ICH= Intracerbral Haemorrhage; TIA= Transient isch aemic attack; MS= Minor stroke; CS= Carotid Stenosis

Age All types

Ischemic

ICH TIA , MS CS

IS-all ATH CE Lac

< 40 DEC DEC DEC DEC DEC DEC DEC DEC

40-50 DEC DEC DEC DEC DEC DEC 300 DEC

50-60 DEC DEC DEC DEC 300 DEC 300 300

60-65 475 225 225 DEC 225 DEC 300 225

65-70 300 175 200 475 175 300 175 175

70-75 200 150 175 300 150 175 175 150

75-80 175 150 150 300 150 175 175 150

80-85 150 125 125 300 125 175 150 125

>85 125 125 125 200 125 150 125 125

MORTALITY RATIOS

IS = Ischemic stroke; ATH = Atherosclerotic; CE= Cardio embolic; Lac = Lacunar,; ICH= Intracerbral Haemorrhage; TIA= Transient isch aemic attack; MS= Minor stroke; CS= Carotid Stenosis

2-Slot et al. BMJ published online 29 Jan 2008

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

RankinScore

MR*

0 96%1 138%2 190%3 390%4 465%5 525%All 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)

Tel: 1-877-343-7606Tel: 1-877-343-7606Fax : 1-514-343-7074Fax : 1-514-343-7074

E-mail: E-mail: françois.sestier@umontreal.cafrançois.sestier@umontreal.ca