Sanofi_edit_Layout 1 28/10/2009 10:14 Page 57
Assessing Therapeutic Options and Individualising Treatment According to Patient Needs
Stroke Risk Scores Predict One-year Risk of Table 2: Stroke Factors in The Health Improvement
Recurrence and Cardiovascular Events
Network Study
The Essen Stroke Risk Score (ESRS), developed by Joachim Röther,
was derived from Clopidogrel versus Aspirin in Patients at Risk of
Odds Ratio (95% CI)
Adjusted For Fully Adjusted
Ischaemic Events (CAPRIE) population and validated in the
Matching Variables
European Stroke Prevention Study 2 (ESPS-2) population. The aim of Diabetes 2.06 (1.92–2.13) 1.90 (1.76–2.05)
the ESRS was to predict one-year risk of recurrent stroke and other Hypertension 1.59 (1.51–1.67) 1.46 (1.39–1.54)
cardiovascular events. It is calculated using age, presence of
BP medications 1.50 (1.43–1.58) 1.24 (1.18–1.31)
hypertension, diabetes, prior MI, cardiovascular disease (CVD), PAD, BP = blood pressure; CI = confidence interval. All The Health Improvement Network (THIN)
smoking status and prior TIA/stroke. The study showed that as the
practices combined n= 44,434: 20,172 males; 24,262 females; 22,217 cases with stroke.
22
Adapted from Lewis et al., 2007.
ESRS increases, so do the risks of suffering a stroke and all
cardiovascular events combined. With the highest ESRS of more
Figure 2: Long-term Mortality Due to Vascular Causes in
Stroke Patients
than six, the risk of having an event is 8–10% in one year.
30
40
Extending the REACH Registry
35
34
Projections on REACH Data Provide an
30
29
34
International Perspective on Vascular Disease,
Risk and Management Methods
25
The primary objective of the REACH registry is to gain an international
20
19 19
17
perspective of patients with or at risk of vascular disease and to see
15
how they were managed: what their event rates are over time, what
10
medications they take and what their outcomes are. It was designed
8
7
8
to overcome limitations of previous surveys and be the most globally
5
inclusive and geographically extensive registry of patients at high risk
0
Northern Manhattan Perth Stroke Oxfordshire
of atherothrombotic events, including a broad spectrum of patient Stroke Study Study Stroke Project
types in a ‘real-world’ setting.
31
It started with 68,375 patients, with
Deaths occuring between 1 month and 5 years (%)
Incident stroke Recurrent stroke Cardiovascular event
95% retention at one year. At one year, the primary end-point of Adapted from Hartmann et al., 2007, Hankey et al., 2000 and Dennis et al., 1993.
stroke, MI or VD had a rate of 4.2% for the whole population and 4.7%
for the symptomatic population: double the rate for the group that
Table 3: One-year Cardiovascular Event Rates in REACH
only had multiple risk factors (see Table 3). If hospitalisation for an
atherothrombotic event is included, this figure exceeds 14% in the
Population (%)
Total Symptomatic Multiple RF Only
symptomatic group (see Table 3).
32
Extrapolated over patients
(n=64,977) (n=53,390) (n=11,766)
worldwide, this amounts to millions of events each year. Death (all-cause) 2.6 2.8 1.5
CV death 1.7 1.8 0.8
REACH Contrasts Event Rates in Single versus
Non-fatal MI 1.1 1.2 0.8
Multiple Vascular Beds
Non-fatal stroke 1.7 1.9 0.8
The REACH data can also be used to compare event rates in people
CV death/MI/stroke 4.2 4.7 2.2
with disease in one vascular bed with multiple vascular territories.
CV death/MI/stroke/ 12.8 14.4 5.3
hospitalisation for
Using the same end-points of stroke/MI/VD, the rates are 4.1% for a
atherothrombotic
single bed and 7.1% for multiple beds. With hospitalisations added
events
in, the event rate jumps from 12.6% in one bed to >21% in multiple
RF = risk factors; MI = myocardial infarction; CV = cardiovascular.
beds. Overall, the risk of a major adverse cardiovascular event 32
Adapted from Steg et al., 2007.
increases in line with symptomatic arterial bed involvement (see
Figure 3: One-year Event Rates and Number of
Figure 3).
32
Data from REACH
33
out to three years show event rates
Disease Locations
continuing to climb in the population, with approximately one-
quarter of all subjects suffering a cardiovascular event or
10
9.2
hospitalisation. Again, disease in more than one vascular bed was
9
significantly more likely to lead to an event than disease in just one
8
bed.
33
This is a tremendous public health burden that needs to be
7
6.8
brought under control.
6
ate (%)
5
Summary and Conclusions
3.9
4.4
4.1
Event r
4
Patients with stroke and TIA have extremely high rates of vascular risk
3
2.7 2.9
factors. Having symptomatic disease in more than one vascular bed 2
1.6 1.6 1.8
2.2
1.5
significantly increases the risk of having subsequent events. Improved 1
0.8 0.8
1.1
0.8
and more aggressive use of current medications – and continued 0
CV death Non-fatal MI Non-fatal CV death/
investigation of new ones – is important if future vascular events
stroke MI/stroke
are to be prevented. The best way to treat stroke is to prevent
Number of disease locations
stroke. The prevention of vascular events is therefore the best
0 123
approach to treatment.
32
MI = myocardial infarction; CV = cardiovascular. Adapted from Steg et al., 2007.n
EUROPEAN NEUROLOGICAL REVIEW 57