clinical overview l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Clinical Overview PowerPoint Presentation
Download Presentation
Clinical Overview

Loading in 2 Seconds...

play fullscreen
1 / 21

Clinical Overview - PowerPoint PPT Presentation


  • 309 Views
  • Uploaded on

Clinical Overview. Gregory W. Albers, MD. Director, Stanford Stroke Center Stanford University Palo Alto, California. Ischemic Stroke. 85% of strokes are ischemic Most ischemic strokes caused by atherosclerosis of extracranial or intracranial arteries

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Clinical Overview' - Anita


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
clinical overview

Clinical Overview

Gregory W. Albers, MD

Director, Stanford Stroke Center Stanford University

Palo Alto, California

ischemic stroke
Ischemic Stroke
  • 85% of strokes are ischemic
  • Most ischemic strokes caused by atherosclerosis of extracranial or intracranial arteries
    • Embolic or thrombotic occlusion of cerebral blood vessels by aggregated platelets, fibrin, and debris from atheromatous plaques
the most frequent sites of arterial and cardiac abnormalities causing ischemic stroke
The Most Frequent Sites of Arterial and Cardiac Abnormalities Causing Ischemic Stroke

IntracranialAtherosclerosis

PenetratingArtery Disease

Carotid Plaque WithArteriogenic Emboli

Flow ReducingCarotid Stenosis

Aortic ArchPlaque

Atrial Fibrillation

Valve Disease

CardiogenicEmboli

Left VentricularThrombi

Albers et al, Chest, 1998.

transient ischemic attack
Transient Ischemic Attack
  • Transient occlusion of an intracranial arterydue to thromboembolism
  • Symptoms resolve following rapid fragmentation and dissolution of the microemboli/thrombus
stroke morbidity and mortality
Stroke Morbidity and Mortality
  • Leading cause of serious, long-term disability
  • Third leading cause of death in the U.S.;second leading cause worldwide
  • Accounts for >50% of all hospitalizationsfor acute neurologic disease
stroke incidence
Stroke Incidence
  • >700,000 new or recurrent strokes per year
  • ~ 4 million Americans are living with neurologic deficits due to stroke
the high cost of stroke
The High Cost of Stroke

Annual Total

1998

Per Event*

Direct Costs $28B $38,714(care and treatment)

Indirect Costs $15B $20,520(lost productivity)

Total $43B $59,234

*Based on 731,000 strokes/yr

American Heart Association. 1998 Heart and Stroke Statistical Update. Dallas, TX:AHA, 1997.

Broderick J et al. Stroke. 1998;29:415–421.

secondary prevention of ischemic stroke
Secondary Preventionof Ischemic Stroke
  • Carotid endarterectomy: >50% stenosis
  • Anticoagulation therapy: Cardioembolic stroke
  • Antiplatelet therapy: Most common therapy
antiplatelet agents for stroke prevention
Antiplatelet Agentsfor Stroke Prevention
  • Aspirin
  • Ticlopidine
  • Clopidogrel
  • Dipyridamole
efficacy of antiplatelet agents for prevention of stroke mi or vascular death
Efficacy of Antiplatelet Agentsfor Prevention of Stroke, MI,or Vascular Death

Risk Reductions

Patient Relative Risk Odds

Population Therapy Reduction (%) Reduction (%)

All Vascular All antiplatelet 22 27Diseases regimens

Stroke/TIA All antiplatelet 17 22 regimens

Stroke/TIA Aspirin 13 16

Source: Antiplatelet Trialists’ Collaboration, 1994: Algra and Van Gijn 1996.

slide11
Efficacy of Antiplatelet Agents vs Placebo for Prevention of Stroke, MI, or Vascular Death in Stroke/TIA Patients

Relative Risk Antiplatelet Agent No. of Studies Reduction (%)

Aspirin (all doses) 10 13

Ticlopidine 1 23

Dipyridamole + ASA 4 30

All Antiplatelet Agents 18 17

Source: Algra and Van Gijn 1996; Gent et al.1989; Tijssen, 1998; Antiplatelet Trialists’ Collaboration, 1994.

slide12
Relative Risk Reductions for VascularDeath, Stroke, MI from ASA Trials vs Placebo in Stroke/TIA Patients

ASA  100 mg

(2 Studies)

RR = 13%

ASA 300 mg

(1 Study)

RR = 9%

RR = 14%

ASA  900 mg

(7 Studies)

Low vs Med: P = 0.75Low vs High: P = 0.99Med vs High: P = 0.71

ALL

(10 Studies)

RR = 13%

0.4

60%

0.6

40%

0.8

20%

1

0%

1.2

-20%

1.4

-40%

1.6

-60%

RR and 95% CI

Algra and van Gijn (1996) J Neurol Neurosurg Psychiatr 60:197–199.

ace trial aspirin efficacy by dose prevention of vascular events following carotid endarterectomy
ACE TRIALAspirin Efficacy by DosePrevention of Vascular Events Following Carotid Endarterectomy

10

P = 0.030

P = 0.120

9

8.4%

8

Low-Dose (N = 1395)

(81 or 325 mg)

7.1%

7

6.2%

5.7%

6

High-Dose (N = 1409)

(650 or 1300 mg)

Event Rate (%)

5

4

3

2

1

0

Stroke or Death

at 3 Months

Stroke, MI, or Death at 3 Months

Taylor DW, Thorpe KE, for the ACE Trial Study Group. Presented at The Challenge of Stroke;The Lancet Conference; October 15–16, 1998. Montreal, Quebec, Canada; 1998.

fda recommends low dose aspirin
FDA RecommendsLow-Dose Aspirin
  • FDA reviewed trials of aspirin vs placebo
  • The “positive findings at lower dosagesare sufficient reason to lower the dosageof aspirin...for subjects with TIAand ischemic stroke.”
  • For “ischemic stroke and TIA: 50 to 325 mg [aspirin] once a day. Continue therapy indefinitely.”

FDA, Federal Register. 1998.63:56802–56819.

new aspirin dosing guidelines for secondary stroke prevention
New Aspirin Dosing Guidelines for Secondary Stroke Prevention
  • FDA
    • New professional labeling for aspirin recommends 50 to 325 mg/day
  • American College of Chest Physicians
    • Aspirin at 50 to 325 mg/day as an initial choice
  • American Heart Association
    • [50–325 mg/day proposed]
available antiplatelet agents
Available Antiplatelet Agents
  • Ticlopidine
    • Advantages
      • Proven efficacy in patients having sufferedan ischemic stroke (compared with placebo)
      • Proven efficacy in patients having suffered a TIAor minor stroke (compared with high-dose ASA)
    • Disadvantages
      • Risk of neutropenia
      • Risk of thrombotic thrombocytopenic purpura (TTP)
      • Require CBC monitoring
      • Diarrhea/Rash
available antiplatelet agents cont d
Available Antiplatelet Agents (Cont’d)
  • Clopidogrel
    • Advantages
      • Proven efficacy compared with ASA in patients with stroke, MI, or PAD
      • Well-tolerated
    • Disadvantages
      • Efficacy for TIA not proven
      • Not more efficacious than ASA in the stroke and myocardial infarction subgroups
efficacy of antiplatelet agents in patients with cerebrovascular disease
Efficacy of Antiplatelet Agents in Patients With Cerebrovascular Disease

Relative Risk Reduction vs Aspirin

25

23%*

22%*

20

21%*

Relative RiskReduction (%)

15

10

9%

8%

7%

5

0

Stroke

Stroke/MI/Vascular Death†

Clopidogrel (CAPRIE, N = 6431)

Ticlopidine (TASS, N = 3069)

ER-DP + ASA (ESPS-2, N = 3299)

* Statistically significant.

† Represents stroke/MI/Sudden Death for ESPS-2.

accp antiplatelet guidelines
ACCP Antiplatelet Guidelines
  • “Every patient who has experienced a [non-cardioembolic] stroke or TIA...should receive an antiplatelet agent.…”
  • “Aspirin, clopidogrel...ticlopidine..., and the combinationof aspirin and dipyridamole are all acceptable options for initial therapy.”
  • “Clopidogrel is recommended in favor of ticlopidine because it has a lower incidence of significant adverse effects.”
  • “The combination of dipyridamole and aspirin b.i.d. may be more effective than clopidogrel and has a similarly favorable adverse effect profile.”

Albers GW et al. Chest. 1998;114:683S–698S.

summary and conclusions
Summary and Conclusions
  • Antiplatelet agents are effective in the secondary prevention of non-fatal stroke and death
  • Currently approved antiplatelet regimens providea modest reduction in risk
  • More effective and safe treatment options for stroke prevention and its devastating consequences are needed