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Acute Management in Ischemic Stroke

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Stroke in ThailandStroke in Thailand

� Bangkok metropolis (1983) = 690 : 100,000 age over 20(Viriyavejakul A, et al. 6th Excerpta Medical No.22; 1983: 10)

� Stroke in the elderly (1998); overall 1.12%

Central 1.99 North 0.6

South 1.5 Northeast 0.6

(Viriyavejakul A, et al. J Med Assoc Thai 1998; 81: 497-505)

�Thai Epidemiology Stroke Study (TES Study 2004): Stroke in age 45-80 years = 2.46%

Prevalence

CINP Asia pacific Regional Meetng March 14-17, 2006, Pattaya, Thailand Abstracts P54-55

Economics Burden of Stroke� ���������� stroke

� 690 �� !"�#�$���� 1 &'(�((*.(,.(-,(./ ,����-(0�/)� 2(3��!$�4(���567 �58(9� �7:;<#=� #�$��> 138,000 �� � :;<#=� 5#B(CDE�FE�(�( 9,660 �� !"�#G � �"�2�<F"� 04D�0��!��&H$0���<��#�$��> 1 &'(I�0!"��(!"�#G �-J5#B(5�-( 13,800 H<�(I�0

� 5#B(';K5'7 0��5*�LM�-F � "�� -N�

ASAEducation

Cost effective?

Digital gangreen

Vasculitis

Routine labEchocardiogramESR, ANA, CoagulogramProtein C, SAntithrombin III

Vascular work upDuplex U/SMRACTA

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A B

C D

Acute Treatment� Aspirin

� F�����*e�L� International Stroke Trial &H$ Chinese Acute Stroke Trial

� �7:;<#=� ��� 40,000 �(

� ,I�"�'����gHJ �4!�����!� &H$ dependency F�� 47.1% 5#B( 45.8% absolute risk reduction 1.2%

ASA in Acute Stroke

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Thrombolytic Therapy : benefit

Thrombolytic therapy and ICH

Anticoagulant in Stroke

Acute Treatment� Outcome ����4�L�07NHJ���!� &H$��� dependents 1 �� � Aspirin

� !4�� "������E�(�(� Death or dependency 47.0%� ASA 45.8%� Absolute risk reduction (ARR) 1.2%� Number needed to treat (NNT) 100/1.2 = 83 �� � �"�2�<F"� 83 x 0.5 x 28 = 1, 160 I�0

� Thrombolytic therapy � ARR 6.3% NNT 16 �"�2�<F"� 800,000 I�0

Ref : Hankey GJ and Warlow CP, 1999

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Treatment HT and Stroke

Secondary Prevention:Antiplateletstherapy

ASA for Secondary Prevention

Dipyridamole plus ASA and ASA alone

Ticlopidine, Clopidogrel and ASA

Warfarin in Non-valvular Atrial Fibrillation

� Heart Protection Study #$%&'()$%*$+ ,- the Lancet

� /0 stroke incidence 102#/34-256 0.28% (;5<=

� /0 vascular >?* 1.1 % (;5<=

� 1*;@AB-4CD cholesterol level

SIMVASTATIN: STROKE INCIDENCE

(10269) (10267)

SIMVASTATIN PLACEBO Rate ratio & 95% CI

STATIN better PLACEBO better

Type

290 409Ischaemic

51 53Haemorrhagic

103 134Unknown

Severity

96 119Fatal

42 51Severe

107 155Moderate

138 189Mild

61 71Unknown

(4.3%) (5.7% )25% SE 5reduction

444 585

(2P<0.00001)

ALL STROKES

0.4 0.6 0.8 1.0 1.2 1.4

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'��# ����4�L�07NvJ<:H� Acute treatment

� ASA� Thrombolytic therapy

� Secondary prevention� Blood pressure lowering drug� Smoking cessation� Statins for hypercholesterolemia� ASA, ticlopidine, clopidogrel, ASA+dipyridamole� Anticoagulants for atrial fibrillation

Secondary prevention

� Blood pressure lowering drug (50%)� ARR 2.2% NNT 45 ��

� �"�2�<F"� HCTZ 5#B(5�-( 4,100 I�0!"�#G Atenolol 5#B(5�-( 49,000 I�0!"�#GACEI 5#B(5�-( 180,000 I�0!"�#GACEI generic 65,700 I�0!"�#G

Perinopril+indapamide 377,000 I�0!"�#G

� Smoking cessation (30%)� ARR 2.3%� NNT !"�#G 43 �� � �"�2�<F"�

� �J5�� 0 I�0 � #�$8 4J5�-(�"�I�8�7NvJ< 12,700 I�0

!"�#G

Secondary prevention

� Statin (40%)� ARR 1.7% NNT 59 �� � �"�2�<F"� Zocor 40 mg 5#B(5�-( 360,000 I�0

Simvastatin 40 mg 5#B(5�-( 94,000 I�0� ASA (75%)

� ARR 1.0% NNT 100 �"�2�<F"� 5#B(5�-( 36,500 I�0� Clopidogrel

� ARR 1.6% NNT 62 �"�2�<F"� 5#B(5�-( 2,263,000 I�0

Secondary prevention

� ASA+Dipyridamole� ARR 1.9 % NNT 53� �"�2�<F"� ASA+Dipyridamole 5#B(5�-( 754,000 I�0!"�#G

� Anticoagulants (20%)� ARR 8.0% NNT 12 � �"�2�<F"� anticoagulants 5#B(5�-( 26,000 I�0!"�#G

Secondary prevention

'��# �"�2�<F"� 2(����4�L�&H$#y���4( Stroke

� Acute stroke treatment I�0!"���4D�� ASA 1,160� Thrombolysis by rtPA 800,000

� Secondary prevention I�0!"�#G� Smoking cessation 0(12,700)� Diuretics for hypertension 4,100� Anticoagulants for atrial fibrillation 26,000� ASA for all in sinus rhythm 36,500

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'��# �"�2�<F"� 2(����4�L�&H$#y���4( Stroke

� ACEI for hypertension I�0!"�#G� Original 180,000� Generic 65,700

� ASA+dipyridamole for all sinus 754,000� Statins for hypercholesterolemia

� Original 360,000� Generic 94,000

� Clopidogrel for all sinus rhythm 2,263,000

Recommendation

� Modify risk factors 4�5#B('-N�07N'E��4K07N'�J !<(0�(!NE�� 5�"( �������E�H4��� , �J��8��v��4(

� Acute treatment� ASA

� 28<04(07 3� 2( 48 ��� �(�J gr V stat �4I#�$0�(

Secondary prevention in thrombotic stroke

� Secondary prevention in thrombotic stroke� �JI�8�7N� HJ����J4(zH8-! 5�"( HCTZ� Aspirin � Aspirin plus dipyridamole

� Secondary prevention in embolic stroke� Warfarin

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