ACV Franois Sestier MD Ph D Abdelouahed Naslafkih

ACV François Sestier, MD, Ph. D Abdelouahed Naslafkih, MD, Ph. D 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 55 ans 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; e 25 -e 146

Incidence annuelle d’un 1 er 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; e 25 -e 146

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

Articles Publications 1. Mc. Guire. 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 Patients 9598 7710 5508 5123 4162 2473 1197 1053 987 998 954 895 680 549 454 545 425 370 333 232 328 322 277 Age 72 72 70 78 FU 11 8 10 5 65 10 7 63 75 71 76 5 5 12 10 71 74 71 75 76 73 15 -44 41 76 55 15 -45 5 10 4 5 10 11 10 10 10

Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11 -year cohort study 1 -Mc. Guire 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 Mc. Guire 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 Rankin Score 0 1 2 3 4 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 dependent or independent from assessment at six months MR = 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 SMR Men 4. 64 3. 00 2. 75 2. 50 3. 70 1. 92 1. 89 2. 49 women 9. 27 3. 52 3. 32 2. 45 5. 18 2. 05 1. 99 1. 67 Brønnum-Hansen et al. Stroke. 2001; 32: 2131 -2136 All 5. 72 3. 14 2. 90 2. 49 4. 46 1. 99 1. 94

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 Ischemic Stroke subtypes Age Male % dead Observed mortality Expected mortality* MR Atherosclerotic Cardioembolic Lacunar Unknown 72 yrs 68% 32 0. 0742 0. 0506 80 yrs 33% 80 0. 2752 0. 0892 73 yrs 43% 35. 1 0. 0828 0. 0627 75 yrs 34% 46. 8 0. 1185 0. 0529 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. 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– 45 years) MR = 858%

Selected Articles Publications 1. Mc. Guire. 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 987 998 954 895 680 549 454 545 425 370 333 232 328 322 277 Age 72 72 70 78 FU 11 8 10 5 65 10 7 63 75 71 76 5 5 12 10 71 74 71 75 76 73 15 -44 41 76 55 15 -45 5 10 4 5 10 11 10 10 10

Age All types MORTALITY RATIOS Ischemic IS-all ATH CE Lac ICH TIA , MS CS < 40 40 -50 2000 (18) 1077 (21) 50 -60 660 (18) 60 -65 475 (8) 65 -70 <70 >70 280 (20) 195 (23) 225(8) 245 (2) 475 (8) 225 (8) 475(8) 290 (10) 285 (10) 132 (15) 647 (8) 290(1) 335 (8) 165 (6) 300 (5) 200 (13) 195(13) 70 -75 858 (24) 200(18) 300 (10) 135(1) 380(16) 147 (15) 310 (10) 270 (14) 156 (3) 125 (3) 165 (14) 120(11) 75 -80 140 (17) 160(9) 240 (4) 185(4) 132(4) 200 (18) 80 -85 232 (7) +85 122 (7) 310 (15) All 230 (22) ages 270(5) CE= Cardio embolic; Lac = Lacunar, ; ICH= Intracerbral Haemorrhage; TIA= Transient isch aemic attack; IS = Ischemic stroke; ATH = Atherosclerotic;

MORTALITY RATIOS Ischemic Age All types IS-all ATH CE Lac ICH TIA , MS CS < 40 DEC DEC 40 -50 DEC DEC DEC 300 DEC 50 -60 DEC DEC 300 60 -65 475 225 DEC 300 225 65 -70 300 175 200 475 175 300 175 70 -75 200 150 175 300 150 175 150 75 -80 175 150 300 150 175 150 80 -85 150 125 300 125 175 150 125 >85 125 125 200 125 150 125 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 MR* 96% 138% 190% 390% 465% 525% 245% *Life table England & Wales 2000 -2002 2 -Slot et al. BMJ published online 29 Jan 2008

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? ? 50 yo? ? 45 yo? ? • 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, 2 ième épisode(18) • ICT : pas de diminution du risque avec le temps(23)

Tel: 1 -877 -343 -7606 Fax : 1 -514 -343 -7074 E-mail: françois. sestier@umontreal. ca