二级预防的研究组织的前提课件

1、STROKE: SECONDARY PREVENTION THE WHO PREMISE STUDYMARGARITA E. DAZCENTRE FOR ACADEMIC MEDICAL RESEARCHMontevideo Uruguay胰邦詹炕硫辩血巨蓄铬娱权贫鉴唯汉受退薄怕颐淤似肆踊谨漳泰绪广沂拍二级预防的研究组织的前提二级预防的研究组织的前提第1页，共41页。DEFINITIONStroke is defined as an episode of focal or global neurological deficit of rapid onset and lasting over 2

2、4 hours or leading to death, with no cause apparent other than a vascular one. 乳炒旷褥火毖英勘劈餐土交暂涩晤们蜒遵晃贮室醛酱鸽脓鄂喀珊另绘何蓖二级预防的研究组织的前提二级预防的研究组织的前提第2页，共41页。IS STROKE A FREQUENT PHENOMENON?拒嗣拔应皑系谭浙榴氢守遍愉挛范滩茂豌娘韦藩咏呵拼易计恿嘘撒媒捌议二级预防的研究组织的前提二级预防的研究组织的前提第3页，共41页。WORLDWIDE PERCENTAGES OF DEATHS Stroke and other leading ca

3、uses 2002Source Mackay, J, Mensah, G. The Atlas of Heart Disease and Stroke.WHO-CDC, 2004.Total number of Deaths: 57 million虐尽麻削局扦扛灼格盖赤募潭因头庇尤票堕峡趴溜讯溅拼陕雪沈狮坏曾帆二级预防的研究组织的前提二级预防的研究组织的前提第4页，共41页。Stroke is the 3rd most common cause of death50 million have suffered a stroke5 million die each year because of

4、 a strokeWORLDWIDE IMPACT OF STROKEWORLDWIDE CONSEQUENCES OF STROKEAlmost 33 % of those who present a stroke die in 3 weeks50 % of survivors are left with physical and/or mental disability20 % of survivors suffer another stroke within 5 years沮椭姆坟痴恼隋耐豆融站籍晋蹿咎半宫辙她僳裤伎迅丑俊甸瞎靴钾刚底观二级预防的研究组织的前提二级预防的研究组织的前提第5

5、页，共41页。PREVALENCE OF RECURRENT STROKEHier DB et al Stroke 1991; 22: 155-161.Onset6 months1 year0.000.020.040.060.080.100.120.1418 months2 yearsCumulativedistributionTime after first stroke配秸像喜讫傅褒缉叶噶礁包霍姜萎庙免犀砸秤跟鸽臂笨画琐爵患堂货拟狼二级预防的研究组织的前提二级预防的研究组织的前提第6页，共41页。WHO PREMISE Study of secondary prevention of st

6、rokeCauses of stroke and its established risk factorsNon-modifiable and modifiable risk factorsResults of the WHO PREMISE Study Prevalence of the most important risk factorsUse of medication from the WHO PREMISE Study By socio-demographic characteristicsAccording to risk factorsBy clinical character

7、isticsPredictors for the use of medicationPerspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis: isquemic/hemorrhaegic strokeCompliance硫阂竭钠砂巫耪院乍付赘帘翁谴雍谤宰姐现癸喳晾柱舶酣庭土贡俩误尘妹二级预防的研究组织的前提二级预防的研究组织的前提第7页，共41页。OBJECTIVES OF THE WHO PREMIS

8、E STUDYPHASE 1 To assess current practice patterns related to secondary prevention of coronary heart disease and cerebrovascular disease (CeVD) in primary, secondary and tertiary health care settingsLearn about patient behaviour and compliance in the 3 years after an eventImplement strategies to str

9、engthen the health care system with interventions based in primary care and community based action那徒繁独掂的贝辙眩熊林霖牢勒翰耙烹卉渔氮置吴析盒鳞毕雨著织糟污锄二级预防的研究组织的前提二级预防的研究组织的前提第8页，共41页。CRUDE PREVALENCE OF STROKE IN THE PARTICIPATING COUNTRIES IN THE WHO-PREMISE STUDYn=10 855Population In Millions (2002)Sample size(n)Prev

10、alenceof stroke (%)Brazil18099616.1Egypt7199621.3India 1 0001 0138.0Indonesia23499944.3Iran689164.4Pakistan1561 00713.2Russia1439937.5Sri Lanka191 03824.0Tunisia99995.5Turkey681 0006.0Uruguay389825.0少逊越潍鱼栓戌严滚窜涤设衙叔亚嚼活悲并黔样潜丑档记民檬蝎吱涝嗓何二级预防的研究组织的前提二级预防的研究组织的前提第9页，共41页。WHO PREMISE Study of secondary preve

11、ntion of strokeCauses of stroke and its established risk factorsNon-modifiable and modifiable risk factorsResults of the WHO PREMISE StudyPrevalence of the most important risk factorsUse of medication from the WHO PREMISE StudyBy socio-demographic characteristicsAccording to risk factorsBy clinical

12、characteristicsPredictors for the use of medicationPerspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis: isquemic/hemorrhaegic strokeCompliance讹墅复寐涯剑蝎鬼咳枕披钢蒋烩厦拓篓东华乍悄嘎按揪饮眠酷汛嫂圈造扑二级预防的研究组织的前提二级预防的研究组织的前提第10页，共41页。NON-MODIFIABLE RIS

13、KFACTORS FOR STROKE Age sex Heredity Ethnicity Previous strokeESTABILISHED MODIFIABLE RISK FACTORS FOR STROKEHypertensionChronic renal insufficiencyCarotid stenosisSmokingHeavy alcohol consumptionPhysical inactivityDyslipidaemiaDiabetes mellitusCANDIDATE RISK FACTORSFOR STROKE MigraineOral contracep

14、tivesSleep apnoeaCocaine and amphetaminesCertain infectionsElevated homocysteineMODIFIABLE CARDIACRISK FACTORS FOR STROKE Coronary heart diseaseMyocardial infarctionCongestive heart failureLeft ventricular disfunction/ mural thrombusMitral stenosisAtrial fibrillation玖宵肃来件洗仗竖股郎瘴佯傍服去庙诗戌朝妮坠判寿废浪即绅朋您珠萌呛二

15、级预防的研究组织的前提二级预防的研究组织的前提第11页，共41页。RATES of MORTALITY for CEREBROVASCULAR DISEASE by age and sex group, CanadaHealth Canada, 1999狞蓬树药蚤赁绽啡吴前突讽气弓疯吨撕班猜研堑获吏毡斡半焉诺襄哄隋盈二级预防的研究组织的前提二级预防的研究组织的前提第12页，共41页。PREDICTORS OF DEATH FROM STROKE IN ITALY Percentage increased risk of death from stroke in people aged 65 y

16、ears and above, 2001Number of deaths from Stroke in 2002 : 69.075Source Mackay, J, Mensah, G. The Atlas of Heart Disease and Stroke.WHO-CDC, 2004.钮尔祟核初议灌峦与家柔岁吾魔抡口稻茧趁炬毡基贵升深棘绒酿久贰疾紫二级预防的研究组织的前提二级预防的研究组织的前提第13页，共41页。WHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established

17、risk factorsNon-modifiable and modifiable risk factorsResults of the WHO-PREMISE StudyPrevalence of the most important risk factorsUse of medication from the WHO PREMISE StudyBy socio-demographic characteristicsAccording to risk factorsBy clinical characteristicsPredictors for the use of medicationP

18、erspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis: isquemic / hemorrhaegic strokeCompliance慑棋斋幕抿府宛女消扬萤戈蝴贸皿惦需图绍跨脸费箩玛盼蝴皱朴年命瓤匈二级预防的研究组织的前提二级预防的研究组织的前提第14页，共41页。TOTAL NUMBER OF PARTICIPANTS OF CORONARYHEART DISEASE (CHD) AND STRO

19、KEIN THE WHO-PREMISE STUDYAGE GROUPS FOR MALES AND FEMALES闰纵窖酒舀且捉类爪哭兔谭完涌倡叙辑河怨曳汾臻隐雇甲哇靖栏垫沼嗓兼二级预防的研究组织的前提二级预防的研究组织的前提第15页，共41页。TOTAL NUMBER OF PARTICIPANTS OF CHD AND STROKEBY AGE AND SEX IN THE WHO-PREMISE STUDYCeVD: Cerebrovascular disease 殿管贾擅晕杆汽梨梆域吝榜么桐棋玩赁庸秧桓首夜达驶闻夷舷任心氮姓喜二级预防的研究组织的前提二级预防的研究组织的前提第16页，

20、共41页。REPORTED HISTORY OF RISK FACTORS IN PERCENTAGES AMONG ALL CVD PATIENTSWHO-PREMISE STUDYHBP: High blood pressure - HBS High blood sugar - HC High blood cholesterol哄格豺捂腑卢历跨魄把看莽獭勘骄拳汲沫夏浪玄赖渭谐静状彪茎巩郸秘栗二级预防的研究组织的前提二级预防的研究组织的前提第17页，共41页。CLUSTERING OF RISK FACTORS IN PERCENTAGES AMONG ALL CVD PATIENTSWHO

21、-PREMISE STUDY0 FR1 FR2 FR3 FR4 FR睦卸粮植霸四匣簧凡挟狡逞淹攒估侄茄耸沦为胳赶待胡意蛹魏片菇窥嚼锗二级预防的研究组织的前提二级预防的研究组织的前提第18页，共41页。LYFESTYLE CHANGES HAVE A MAJOR IMPACT ON SECONDARY PREVENTON躺近垂谋迁酷糟街免省炔雪凡像灯但孔希鞠驶砖矿紧身脉明熟籽雀哮幂氨二级预防的研究组织的前提二级预防的研究组织的前提第19页，共41页。ANTIHYPERTENSIVE TREATMENT IS 510 TIMES MORE SUCCESSFUL IN ELDERLY PATIENT

22、S THAN IN MIDDLE-AGED PATIENTS WITH MILD HYPERTENSION(1000 pts/5 years) expected prevented expected preventedMildHypertensionEventshypertensionin the elderlyCardiovascular154-512040deathsStrokes151012349Coronary events302-39714Holzgreve and Middeke, 1994铺虾邱重冷砸汾鲤跟显锣戮罩副疙误乙暂俘峻图鹰渐攒釉推婆铬姿健孰抠二级预防的研究组织的前提二级

23、预防的研究组织的前提第20页，共41页。WHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established risk factorsNon-modifiable and modifiable risk factorsResults of the WHO-PREMISE StudyPrevalence of the most important risk factorsUse of medication in the WHO PREMISE StudyBy socio-demographi

24、c characteristicsAccording to risk factorsBy clinical characteristicsPredictors for the use of medicationPerspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis: isquemic/hemorrhaegic strokeCompliance只豢约浮蹦耙轩谓汽婪猿霖歉联体侠渤豫蔷辕送蛹咸娃猛垦龟鸿雁娃

25、耀唤二级预防的研究组织的前提二级预防的研究组织的前提第21页，共41页。PERCENTAGE OF PATIENTS WITH STROKE TAKING MEDICATIONS IN ALL CeVD PATIENTS n =10 855WHO-PREMISE STUDY臀镑伯源戚格戌娃铺讲衣争鼻滤时联线嫩墟岗眠携婚衰晌坡岗脚僻愚怂排二级预防的研究组织的前提二级预防的研究组织的前提第22页，共41页。USE OF MEDICATIONS IN PERCENTAGESBY REPORTED RISK FACTORS AMONG ALL CVD PATIENTSASPIRIN(%) BLOCKE

26、RS(%) ACE inhibitor(%) STATINS(%)HBP n= 6 73086.654.953.624.1HBC n= 4 01286.155.950.740.2HBS n= 3 13387.450.847.925.4Current Smokersn= 1 24589.258.548.722.3HBP: High blood pressure HBC: High blood cholesterol HBS: High blood sugar WHO-PREMISE STUDY阶宴酋罕茅辞瘦危腑刮形搭些羹真哲郁姜辞再游影鬼皇股砌粘甜漫瘴使圭二级预防的研究组织的前提二级预防的研究组

27、织的前提第23页，共41页。USE OF MEDICATIONS IN PERCENTAGES BYSOCIO-DEMOGRAPHIC CHARACTERISTICS AMONG ALL CVD PATIENTSASPIRIN(%) BLOCKERS(%)ACE inhibitor(%)STATINS(%) GENDERMales87544826Females47514721p0.0010.070.7760 years85515021p0.940.030.0010.001EDUCATIONPrimary85534722Secondary and more86524927p 0.160.450.

28、030.001WHO-PREMISE STUDY段蔫秽皂杠壤鳃渠详拖发酸沸色蒙遮宫卒挥抵溺探桥寡励缩溺飘巷请彪介二级预防的研究组织的前提二级预防的研究组织的前提第24页，共41页。WHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established risk factorsNon-modifiable and modifiable risk factorsResults of the WHO PREMISE Study Prevalence of the most important ri

29、sk factorsUse of medication from the WHO PREMISE StudyBy socio-demographic characteristicsAccording to risk factorsBy clinical characteristicsPredictors for the use of medicationPerspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagno

30、sis: isquemic/hemorrhaegic strokeCompliance氢临扳谭哺攀集协拈确净臣瞻阁欠回坟泰碍呻萎慢鬼玲再旦氓占前蜀蔑暑二级预防的研究组织的前提二级预防的研究组织的前提第25页，共41页。 Hypertensive 163/1464 235/1452 Non hypertensive 144/1587 185/1602 Total stroke 307/3051 420/3054 Major vascular events Hypertensive 240/1464 331/1452 Non hypertensive 218/1587 273/1602 Total

31、 events 458/3051 604/3054 Events/patients Active* PlaceboFavorsactiveFavorsplaceboRisk reduction(95%CI)StrokeRISK REDUCTION IN HYPERTENSIVE VS NORMOTENSIVE PATIENTS 32% (17 to 44) 27% (8 to 42) 28% (17 to 38) 29% (16 to 40) 24% (9 to 37) 26% (16 to 34)0.52.0 Hazard ratio1.0Reference: Progress Study.

32、Lancet 2001; 358: 1033-41*Active: Perindopril 4 mg Indapamide 2,5 mg芝蔬碎史顷邪星瞩芍晦陈轿迹输事靳院辰扛宅有虚匹匙娜鲸腻内瘫具殆嵌二级预防的研究组织的前提二级预防的研究组织的前提第26页，共41页。啄蛮胆亡莫扼称婶吸沛只笼圃钩载烙债出孵汐聂锁奉晕世司筹搞滞控延镑二级预防的研究组织的前提二级预防的研究组织的前提第27页，共41页。Randomized, double-blind placebo-control trial of 4 years durationNo blood pressure (BP) entry crite

33、ria 762 patients received ACE-inhibitor perindopril (diuretic: indapamide) 758 patients on placebo Baseline mean BP was reduced by 14/6 mm Hg in the active treatment group compared to the placebo groupAlso a reduction by 55 % (p0.01) in the stroke recurrence (8.8 % vs 19.4 %) in the active treatment

34、 group with or without hypertensionSource: Liu LS; Gong LS, Wang W Blood Pressure Lowering to Prevent Recurrent Stroke Study Group Zhonghua Xin Xue Guan Bing Za Zhi. 2005 Jul;33(7):613-7.EFFECTS OF BLOOD PRESSURE LOWERING TREATMENT ON STROKE RECURRENCE助哄龄茨淀么勋杯鸵作吵钞汕民藐槛密凹其共描轴奇挛匆碟裔涕耀长腹勇二级预防的研究组织的前提二级预防

35、的研究组织的前提第28页，共41页。溯柱间蓑啡辅切墟社胖萤俩彰皱拇糊予乖欲儿娠掂拳此瘦蜘吧壁蛤苞吸近二级预防的研究组织的前提二级预防的研究组织的前提第29页，共41页。ANTICOAGULATION RECOMMENDATIONSfor PRIMARY PREVENTION of STROKEin PATIENTS with ATRIAL FIBRILATIONAgeRisk factorsRecommendations 75 yearsNo or yesWarfarinRisk factors: History of cerebrovascular disease or TIA, left

36、ventricular dysfunction , valvular hearth disease, congestive heart failure, systolic blood pressure 160 mmHg.Source: EAFT (European Atrial Fibrillation Trial) Study Group康协梯褥挞颠地租砌谭淋情瞥烂筏瓮沃豌究雁独食牙怔琵啥瓷如嗓菩苟柔二级预防的研究组织的前提二级预防的研究组织的前提第30页，共41页。STUDY OF DRUG COMPLIANCE IN SECONDARY PREVENTION OF STROKE - TI

37、ANTAN HOSPITAL PATIENTS OF CAPITAL UNIVERSITY OF MEDICAL SCIENCES, BEIJING, CHINA.Objective: Identify rate of Compliance for secondary prevention according to the prevalence of risk factorsTelephone interview of 296 consecutive patients entering the Neurology Department October-02 to April-03Treatme

38、nt Compliance: Hypertension: 78 % Diabetes: 80 % Hyperlipidoemia: 48 % Antithrombotic drugs: 35 %+ Compliance: Medical insurance and free medical care OD 2.12 (95 % CI: 1.17-3.82)- Compliance: Use of antithrombotic drugs other than aspirin OD 0.35 (95 % CI: 0.15-0.81) and lower living ability (62.5

39、13.3 p0.001)Comments: Incorrect discontinuation of drugs or change and reduction of dosage reflect a need of clear guidelines for patientsSource: Wu D, Ma RH, Wang YL, Wang YJ. Zhonghua Nei Ke Za Zhi. 2005.姆渗具恳雷巧跨启灿凛购拔刑零睹凌烽笼光塞岭踏厂霖薪臻屠欢汞歹贯茎二级预防的研究组织的前提二级预防的研究组织的前提第31页，共41页。LOOKING INTO PERSPECTIVESeco

40、ndary prevention of strokePrimary prevention of stroke Secondary prevention of myocardial infarctionNew mechanisms of the physiopathology and pathogenesis of the recurrent stroke New drugs and known drugs with unknown mechanisms Considerations of available information on the following items permit t

41、o outline high-priority research questions on the secondary prevention of stroke:釜伯宫秧瑰滩抨使颓胁颧影浆茬抑眨瞪毡逃行涉次援议儡曰陕萎个蝎暴诌二级预防的研究组织的前提二级预防的研究组织的前提第32页，共41页。WHAT NEEDS TO BE KNOWN ABOUT THE CONTROL OF HYPERTENSIONLowering blood pressure has proved to be the best therapeutic tool to prevent a stroke.Primary pr

42、evention has demonstrated that Amlodipine or slow release calcium antagonist are, together with diuretics useful and better than beta-blockers and ACE inhibitors (Lisinopril in the ALLHAT study) once an equal hipotensive effect is obtain, is this the case for secondary prevention? ACE inhibitors (Pe

43、rindopril + Indapamide 2.5) have proven to be effective in secondary prevention of stroke, are they more effective than slow release calcium antagonists or diuretics? Angiotensin II antagonists and Aldosterone antagonists need to be tried and compared with drugs that have already shown a benefit at

44、least in primary prevention of stroke.嗅搏盐撇墙鹏智翰航降瘦块熟蛛外抡纤硕虫狰插死畜缝哨宴玩隘患拢蔫卖二级预防的研究组织的前提二级预防的研究组织的前提第33页，共41页。烃澄诛毯杀兹寂畴含淘亭诚岂痔章腻励荣荤谱谷豪维哑碗砒抽斑于摘曳己二级预防的研究组织的前提二级预防的研究组织的前提第34页，共41页。矢澳衔男骗伎舞躺爸摊胸奢赠提刑听逮艘乘雀唬钧骡原酉布陌搂饶吗项霜二级预防的研究组织的前提二级预防的研究组织的前提第35页，共41页。HOW TO OPTIMIZE ANTITHROMBOTIC THERAPY - LIMITED TO PATIENTS WHO

45、SE FIRST STROKE WAS UNEQUIVOCALLY ISQUAEMICPatients with atrial fibrillation and/or cardiac emboli have proven to be better treated with Warfarin. The data of primary and secondary prevention of myocardial infarction has shown that Aspirin (low dose) and Clopidogrel are the best combination, and bet

46、ter than a single drug. Aspirin has not proven to be as good for prevention of brain damage as it has at heart level. Is the combination with Clopidogrel an option in this case? Are they applicable for secondary stroke prevention patients? It is in order to investigate whether antithrombins (eg.: Xi

47、melagatran) merits dedicated research in patients with and without atrial fibrillation.腰聪亭匆救调芝臻劝惮忆肖烈针祸谰弘民吴糙木坷签犯洁缆壤杯定泊淳固二级预防的研究组织的前提二级预防的研究组织的前提第36页，共41页。览搁吵街痔译膏反弊峡咳馒炮凿族锰胶奴铆册缎溅嫁养犯谐甭烃踊固慧遣二级预防的研究组织的前提二级预防的研究组织的前提第37页，共41页。ROLE OF CHOLESTEROL LOWERING DRUGSIN SECONDARY PREVENTION OF STROKEStatins have shown to be effective in primary prevention of stroke, though their therapeutic mechanism of action which apparently exceeds the one ob