2 Stroke: a major health problem and a leading killer PREVAIL STUDY RESULTS V2 November 13, 2006Stroke: a major health problem and a leading killerEpidemiologyWorldwide stroke prevalence was 7.1 million in 2000 and is rising1Incidence: 700,000 strokes/year (USA)2A major health burden in western countriesThird most common cause of death3The leading cause of disability in adults3Health care expendituresIn the USA, $ 57.9 billion for stroke-related medical costs and disability in 200621Guillot F, Moulard O. Circulation. 1998: 98(Suppl 1): American Heart Association Heart; Stroke Statistical Update. AHA, 2002; - ASA . 3Leys D, et al. Cerebrovasc Dis. 2001:11(Suppl 2):1-4.Dr D. Sherman's presentation at ASH December 8, 2006
3 Leading causes of death in 2005 No of deathsAll cardiovascular17.5 millionIschemic heart disease7.6 millionCerebrovascular disease5.7 millionAll cancerLung cancer1.3 millionStomach cancer1 millionLiver cancer662 000Colon cancer655 000Breast cancer502 000Source: WHO
4 Projections of stroke events in men and women in EU and EFTA countries, 2000 to 2025 (solely due to the demographic changes)European Fair Trade AssociationIceland, Norway, and Switzerland,Truelsen T, et al, WHO, 2004
5 Crude Stroke annual Incidence rates ΕπίπτωσηCrude Stroke annual Incidence ratesRegion Year Rate (95% CI)Perth, Australia 1995–96 1·6 (1·4–1·8)Frederiksberg, Denmark 1989–90 3·1 (2·7–3·4)South London, UK 1995–96 1·3 (1·2–1·4)Martinique, French West Indies 1998–99 1·6 (1· 5–1Oyabe, Japan –91 4·1 (3·8–4·4)Erlangen, Germany –98 1·3 (1·2–1·4)Arcadia, Greece 1993–95 3·4 (3·1–3·7)Belluno, Italy –93 2·2 (2·0–2·4)L’Aquila, Italy ·8 (2·6–2·9)Auckland, New Zeeland 1991–92 1·4 (1·3–1·5)Inherred, Norway 1994–96 3·1 (2·8–3·4)Novosibirsk, Russia ·3 (2·1–2·5)
6 ΕπίπτωσηKύρια ευρήματα μελέτης Αρκαδίας ( , >20 ετών, πληθυσμός )Ετήσια επίπτωση275 νέα πρωτοεμφανιζόμενα ΑΕΕ στην Αρκαδία / έτος256 νέα ΑΕΕ / πληθυσμού στην Ελλάδανέα ΑΕΕ το χρόνο σε όλη τη χώραΘνητότηταΘνητότητα 1ου μήνα (CFR) 26.6 %Θνητότητα 1ου έτους %Aνεξάρτητοι προγνωστικοί δείκτες: Ηλικία, επίπεδο συνείδησης, Κολπική μαρμαρυγή Vemmos K, et al Stroke 1999
7 ΕπίπτωσηAverage Annual Stroke Incidence (racial differences) Northern Manhattan Stroke Study - NOMAS300259250232222200172Average Annual Age-Adjusted IncidenceRate per 100,00015011810080WhiteTalking PointsThe data from the Northern Manhattan Stroke Study clearly indicate that stroke risk is different in different races. Black Americans have the highest risk followed by Hispanics. The lowest incident rate is found in white men and women.(10)BackgroundStroke mortality is reported to be greater in blacks than in whites, but stroke incidence data for blacks and Hispanics are sparse. The aim of this study was to determine and compare stroke incidence rates among whites, blacks, and Hispanics living in the same urban community. A population-based incidence study was conducted to identify all cases of first stroke occurring in Northern Manhattan, New York City, between July 1, 1993, and June 30, The population of this area was approximately 210,000 at that time, based on 1990 US Census data. Surveillance for hospitalized and non-hospitalized stroke consisted of daily screening of all admissions, discharges, and computed tomography logs at Columbia-Presbyterian Medical Center, the only hospital in the region, and review of discharge lists from outside hospitals, telephone surveys of random households, and contacts with community physicians, Visiting Nurses' Services, and community agencies. Stroke incidence increased with age and was greater in men than in women. The average annual age-adjusted stroke incidence rate at age ³ 20 years per 100,000 inhabitants was 223 for blacks, 196 for Hispanics, and 93 for whites. Blacks had a 2.4-fold and Hispanics a 2-fold increase in stroke incidence as compared to whites. Cerebral infarct accounted for 77% of all strokes, intracerebral hemorrhage for 17%, and subarachnoid hemorrhage for 6%. These data from the Northern Manhattan Stroke Study suggest that part of the reported excess stroke mortality among blacks in the United States may be a reflection of racial/ethnic differences in stroke incidence.(10)50BlackHispanicMenWomenSacco R, et al. Am J Epidemiol 1998;147:
8 Feigin V, Lancet Neurology 2003 ΕπίπτωσηAnnual incidence by age per 1000 population of all types of stroke combined in selected studiesFeigin V, Lancet Neurology 2003
9 Σύγκριση επίπτωσης μεταξύ διαφόρων μελετών για τις ηλικίες 45-84 ανά 100 000 πληθυσμού Ισχαιμικό Εγκεφαλική Υπαραχνοειδήςέμφρακτο αιμορραγία αιμορραγίαDijon, France ( ) (20-32) (1-7)Arcadia, Greece 249 ( ) (36-66) 11 (4-17Perth, Australia ( ) (22-55) 19 (6-32)Umbria, Italy ( ) (25-55) 17 (7-27)Rochester, Minnesota 318 ( ) (22-47) 17 (8-26)Oxfordshire, England 312 ( ) (29-50) 17 (10-25)Frederiksberg, Denmark 339 ( ) (14-52) 6 (0-17)Söderhamn, Sweden 349 ( ) (23-75) 12 (0-26)* Standardized incidence rates for groups aged years to the European populationVemmos K et all, Stroke 1999Επίπτωση
10 Feigin V, Lancet Neurology 2003 ΕπίπτωσηAge-standardised annual incidence per 1000 population of all strokes combined in people aged 55 years (Segi 1996 world population)Feigin V, Lancet Neurology 2003
11 ΕπίπτωσηRates of acute vascular events in men and women in the OXVASC study -population (91 106) between 2002 and 2005-EventTotal, nMen, rateWomen, rateTotal, rateAll cerebrovascular events combined9182.993.753.36All coronary vascular events8563.892.333.13All peripheral vascular events1880.790.570.69rates are per 1000 population per yearRothwell PM et al. Lancet 2005
12 ΕπίπτωσηAge-specific rates of acute cerebrovascular and coronary vascular events in the Oxford, UK (OXVASC study)StrokeCoronaryAge groupN=889rateN=82745-54461.31712.0355-641083.691334.5465-7423211.122110.5775-8431923.3627920.4485 or older18444.8312329.97rates are per 1000 population per yearstudy included some participants under age of 45Rothwell PM et al. Lancet 2005
13 Feigin V, Lancet Neurology 2003 ΕπιπολασμόςAge-standardised prevalence of stroke per 1000 population in selected studies of people aged 65 yearsFeigin V, Lancet Neurology 2003
15 Case-fatality within 1 month of stroke onset by major stroke type ΘνητότηταCase-fatality within 1 month of stroke onset by major stroke typeIS=ischaemic stroke; PICH=primary intracerebral haemorrhage; SAH=subarachnoid haemorrhage; UND=undefined.Feigin V, Lancet Neurology 2003
16 ΘνητότηταOne year survival in patients with first-ever stroke “The Arcadia Stroke Registry”ΚενοτοπιώδηΑθηροσκληρωτικάΚαρδιοεμβολικάΑιμορραγίεςVemmos et al, J Neurol Neurosurg Psychiatry 2000;69:
17 Long-term Mortality Following Ischemic Stroke ΘνητότηταLong-term Mortality Following Ischemic StrokeDeaths from stroke or MI among patients with a first cerebral infarction (n = 764)3027.0%2520Percentage1510.1%105Talking PointsThis was a population-based study conducted in Rochester, Minnesota in which people suffering a stroke were then followed up to a maximum of 18 years to determine cause of death.(56)Stroke DeathsMI DeathsIn data acquired over an 18-year observation period, for those with an initial stroke, the risk of death from stroke is more than 2.5 times the risk of death from MIPetty GW, et al. Neurology 1998;50:
18 Prognosis of Ischemic Stroke German Stroke Data Bank ΠρόγνωσηPrognosis of Ischemic Stroke German Stroke Data BankSlight disabilities (mRS 0-2)Follow-up after 90 daysModerate disabilities (mRS 3)Severe disabilities (mRS 4-5)14.70%18.60%Deceasedn = 5,0179.40%Talking PointsStroke mortality and morbidity after acute cerebral infarction according to data from the German Stroke Data Bank (n=5,017) are as follows:57.2% of the patients recovered completely or suffered only minor sequelae; however, these patients should be on some type of stroke prevention therapy. 9.4% suffered from moderate disability. In 18.6% of the patients, stroke caused severe impairment, and 14.7% of the patients died.(7)Score Description of modified Rankin Scale (mRS)0 No symptoms at all1 No significant disability despite symptoms; able to carry out all usual duties and activities2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance3 Moderate disability; requiring some help, but able to walk without assistance4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistanceSevere disability; bedridden, incontinent and requiring constant nursing care and attentionDead57.20%Grau AJ, et al. Stroke 2001;32:
19 The Athens Stroke Outcome Project Νοσοκομειακή έκβαση 3105 ασθενών με οξύ πρώτο εγκεφαλικό επεισόδιο (Rankin score)The Athens Stroke Outcome Project
20 Hospital discharges, cerebrovascular diseases per 100000 Stroke trendsHospital discharges, cerebrovascular diseases perSource: WHO/Europe, European HFA Database, November 2007FranceGermanyGreeceItalySpain
21 Stroke trendsAverage annual incidence rates (trends) of stroke per population from (Rochester, Minnesota)Brown RD, Stroke 1996
22 Stroke trendsFramingham Study: Age-adjusted annual incidence of first stroke over time in men and women (per 1000 person-years)Group1950–19771978–19891990–2004p for trendMen188.8.131.52.02Women5.85.10.01Carandang R et al. JAMA 2006; 296:
23 Stroke trendsAge and sex-specific incidence rates (trends) for all types of stroke combined in Arcadia for the years 1994 and 2004MENWOMEN367.4 ( ) ( )316.1 ( ) ( )Vemmos et al, Stroke 1999, and ESC May 2005Vemmos et al, Stroke 1999, and ESC May 2005
24 Stroke trendsFramingham Study: 30-day mortality from stroke in men and women over time (%)Group1950–19771990–2004pMen23140.01Women21200.32Carandang R et al. JAMA 2006; 296:
25 Stroke trendsTrends in Case Fatality Rate (28 days) in Arcadia for the years 1994 and 20041994: 26.6% (95% CI, )2004: 25.5% (95% CI, )%Vemmos et al, Stroke 1999, and ESC May 2005
26 The Burden of Stroke Continues After the Acute Event Stroke progression during hospitalization 24%Mortality30 days 8–20%1 year –25%5 years –60%Complete or partial dependence 27–53%Dementia persisting at 1 year 34%Post-stroke rehabilitation has improved, but the consequences of stroke are still severe. In many patients, the stroke progresses during hospitalization.1A high percentage of stroke survivors die within 30 days after sustaining a stroke, and approximately half of stroke survivors die within five years of a first stroke; almost half of these deaths can be attributed to a vascular cause.1For people who survive a stroke, persistent disability, dementia, and decreased quality of life are common. 1ReferenceSacco RL. Neurology 1997; 49 (Suppl 4): S39–S44Source: Sacco. Neurology. 1997; 49 (Suppl 4): S39–S44
27 Effects on quality of life Stroke has a major impact on quality of lifeBest possible health state1Asthma [0.79]2*Mild stroke [0.75]1†Lower back pain [0.66]2*- 0.5Moderate/severe stroke [0.39]1†Recurrent stroke [0.12]1†Effects on quality of lifeEstimates of quality of life scores after stroke have been made for various categories of disability: a mild event was scored at 0.75; a moderate to severe event was scored at 0.39; and a recurrent event was scored at 0.12 (0 = dead and 1 = perfect health).1Stroke has a considerable impact on patients’ quality of life: even a mild stroke has a similar impact on quality of life as asthma.1,2ReferencesGage BF. JAMA 1995; 274: 1839–1845.Burstrom K et al. Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 2001; 10: 621–635.DeathPLEASE NOTE THAT THESE RESULTS WERE OBTAINED FROM TWO DIFFERENT STUDIES*Based on the health-related quality of life results using the mean EQ-5D self-classifier index values and mean rating scale scores†Patients were questioned using a computer-based utility-assessment tool and the quality of life impact calculated using the time trade-off method to elicit utilities1. Gage BF et al. JAMA 1995; 274: 1839–1845.2. Burstrom K et al. Qual Life Res 2001; 10: 621–635.
28 How bad is a major stroke? Worse than deathEquivalent to being wellPatients (%)Equivalent to deathHow bad is a major stroke?A study by Samsa et al. (1998) examined attitudes towards hypothetical major stroke. Preferences were assessed by using the time trade off (TTO). Although responses were varied, 45% of respondents in the study considered major stroke to be a worse outcome than death.ReferenceSamsa GP et al. Am Heart J 1998; 136: 703–713.Patient attitudes to hypothetical major stroke1. Samsa GP et al. Am Heart J 1998; 136: 703–713.
29 Σημαντικά προβλήματα που αντιμετωπίζουν ασθενείς με εγκεφαλικό μετά το νοσοκομείο (n=6000) Br J Gen Pract 2003;53:803–807
30 Ischaemic stroke survivors aged >65 years in the USA 1/4 were resident in a nursing home1/3 required help with walking1/4 were dependent in activities of daily livingKelley-Hayes et al. 2003
31 Global economic costs of stroke Short termLong termOthersEmergency transportationDiagnosisIn-patient staySurgeryDrugsOutpatient visitsTransportationGP visitsPhysiotherapyOccupational therapySpeech/language therapyDrugsTests and investigationsOrthoses/incontinence padsInstitutional careIncome lost by informal carersIncome lost due to deathIncome lost due to disabilityBenefit payments
33 Δεδομένα από τη διεθνή βιβλιογραφία για το κόστος του ΑΕΕ Αγγλία, Σκωτία, Ολλανδία: 3-4% των δαπανών υγείαςIsard 1992, Bergman 1995, Evers 19970,27% του ΑΕΠ στις αναπτυγμένες χώρεςΗΠΑ:1990: $40,6 δις1998: $43,3 δις2001: $45,4 δις2009: $68,9 διςΤaylor 1996ΑSA, Heart Disease and Stroke Statistics,2001ΑSA, Heart Disease and Stroke Statistics , 2009 update
35 The High Cost of Stroke Annual Total (2001) Per Event* $28.0 billion $46,667$29,000$75,667Direct costs(care and treatment)Indirect costs(lost productivity)Talking PointsBased on direct costs alone, stroke is very expensive and ranks among the most expensive illnesses in the United States.(18)Direct costs may be expected to rise with:- Increasing annual stroke rates(17)- Increased use of available treatment options- InflationIndirect cost is a controversial concept that reflects the drain on society's productivity and resources outside of direct medical care.(18) Even without indirect costs, stroke is very expensive.BackgroundAccording to the most recent estimates of the American Heart Association, the United States will have spent more than $45.4 billion on stroke-related costs in 2001.(19) These costs have risen considerably over the last years.(18,19) Most of these expenditures are directly related to medical care, including those for physicians and nurses, hospital stays, nursing home or transitional care units, pharmaceuticals, rehabilitation, etc.(18) Indirect costs related to the lost productivity of the stroke victims or their caregivers are more difficult to define and quantify but nonetheless contribute to the overall economic burden of stroke.(18,19)Total*Based on 600,000 strokes per yearAmerican Heart Association, 2001 Heart and Stroke Statistical Update.
36 Μεταβολές άμεσου οικονομικού κόστους εγκεφαλικών για περίοδο 18 μηνών Μεταβολές άμεσου οικονομικού κόστους εγκεφαλικών για περίοδο 18 μηνώνCerebrovasc Dis 2004;17:134–142
37 Pharmaceuticals Only Account for 2% of Cost of Stroke Care Annual cost of stroke in USA = US$49.4 billion1Hospital/nursing homePhysicians/other professionalsPharmaceuticals/other medical durablesHome healthcareLost productivity1. American Heart Association Heart and Stroke Statistical Update. AHA, 2002
39 Stroke: Mean Cost as a Function of Long-Term Care Destination*1 Chronic long-term in-hospital care56,114Nursing home33,20833,062RehabilitationDestinationConvalescent home22,297New housing11,722In France, a recent study has shown the cost differential between the various destinations of stroke patients after discharge, with chronic long-term in-hospital and nursing home care representing the most significant burden.The mean cost per patient was 19,513 Euros, which extrapolates to a cost for France of 2.9 billion Euros per year, assuming that the incidence of stroke is 150,000 each year.The study concluded that not only the level of handicap, but socioeconomic variables were important in determining the destination of stroke patients after discharge.Return home11,37510,00020,00030,00040,00050,00060,000Euros*Excluding new acute hospitalization1. Spieler J-F et al. Cerebrovasc Dis 2002; 13: 132–41.Reference:1. Spieler J-F et al. Cerebrovasc Dis 2002; 13: 132–41.
40 Άμεσο οικονομικό κόστος εγκεφαλικών ανάλογα με την αναπηρία για περίοδο 18 μηνών (Rankin score, Euro ανά ασθενή)Cerebrovasc Dis 2004;17:134–142
41 Συνδυασμός θανάτων και χρόνου που χάνεται από την μη εργασία λόγω της αναπηρίας ανά πληθυσμού (4η στη σειρά νόσος)Atlas of Heart Disease and Stroke, Mackay J, Mensah G (eds). Geneva: WHO; 2004
42 Συμπεράσματα-1Τα εγκεφαλικά επεισόδια είναι μια καταστροφική νόσος που ευθύνεται για μεγάλο ποσοστό θνητότητας και αναπηρίαςΗ επίπτωση και ο επιπολασμός κυμαίνονται ευρέως μεταξύ των χωρών και ενδεχομένως θα αυξηθεί τα επόμενα χρόνιαΗ θνητότητα από εγκεφαλικά παραμένει υψηλή και δεν μειώνεται τα τελευταία χρόνιαΕίναι το 1ο αίτιο αναπηρίας σε ηλικιωμένα άτομαΤουλάχιστον το 50% του συνόλου των ατόμων που παθαίνουν εγκεφαλικό χρειάζονται αποκατάστασηTalking PointsThe causes of stroke are more heterogeneous than those associated with MI- Up to 20 % of all strokes are primary hemorrhages- Only 20% of ischemic strokes are due to large artery atherosclerosis; 30-40% are of unknown cause(10,53)Hemorrhage is a common and devastating complication of ischemic stroke, but not of MI (54,55)Strokes occur in older patients than MI- The mean age of stroke patients is (10,53)Stroke patients are at greater risk of major hemorrhagic complications in the future than MI patients - Stroke patients are twice as likely to have major bleeding in the future as MI patients (41)Stroke patients are at higher risk of recurrent stroke than MI (16,41)
43 Συμπεράσματα-2Τα εγκεφαλικά είναι μια εξαιρετικά επιβαρυντική οικονομικά νόσος, (καταναλώνεται το 2-4% του προϋπολογισμού για την υγεία)Το κόστος επιβαρύνει τον ασθενή, την οικογένεια, την κοινωνία, το προϋπολογισμό του κράτουςΤο υψηλό κόστος είναι αποτέλεσμα της μεγάλης αναλογίας χρόνιας αναπηρίας που αφήνει η νόσοςΗ μεγαλύτερη κατανάλωση πόρων γίνεται αφού ο ασθενής εξέλθει από το νοσοκομείο
44 Underfunding of Stroke Research A Europe-Wide Problem “for every £20 spent on cardiology research, only £1 is spent on stroke research”!!Stroke. 2004;35:
45 ΓιατρούςΕπαγγελματίες ΥγείαςΑσθενείς και οικογένεια
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