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ACV

ACV. François Sestier , MD, PhD Abdelouahed 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.ca. OBJECTIFS.

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ACV

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  1. ACV François Sestier, MD, PhD AbdelouahedNaslafkih, 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.ca

  2. OBJECTIFS • Identifier la littérature médicale la plus récente concernant la mortalité des LNH • Calculer la mortalité observée en utilisant une méthodologie actuarielle

  3. Epidemiologie Revue de littérature et méthodologie Conclusions Plan

  4. Epidemiologie

  5. Risques d’ACV en 10 ans chez adultes de 55ans 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;e25-e146

  6. Incidence annuelle d’un 1er 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;e25-e146

  7. Principaux types d’ACV

  8. 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

  9. EpidemiologieRevue de littérature et méthodologie Conclusions Plan

  10. 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

  11. Articles

  12. Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study 1-McGuire 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)

  13. Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study McGuire et al. Cerebrovasc Dis 2007;23:221-228 MR = 290% MR= 135%

  14. 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

  15. 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 *Life table England & Wales 2000-2002 Slot et al. BMJ published online 29 Jan 2008

  16. 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

  17. 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%

  18. 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%

  19. 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

  20. SMRs by Sex and Age for Patients After a First Nonfatal Stroke Brønnum-Hansen et al. Stroke. 2001;32:2131-2136

  21. Ischemic Stroke SubtypesA 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 * Life table US 1995-99, (%male+% female)

  22. 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

  23. 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 dyingthan 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.

  24. 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

  25. 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

  26. 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%

  27. 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 (15–45years) MR = 858%

  28. Selected Articles

  29. 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

  30. 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

  31. 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 *Life table England & Wales 2000-2002 2-Slot et al. BMJ published online 29 Jan 2008

  32. 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)

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

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