二级预防的研究组织的前提课件.ppt

1、Source Mackay,J,Mensah,G.The Atlas of Heart Disease and Stroke.WHO-CDC,2004.Total number of Deaths:57 millionOnset6 months1 year0.000.020.040.060.080.100.120.1418 months2 yearsCumulativedistributionWHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established risk factorsNo

2、n-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 characteristicsPredictors for the use of medicationPerspectives

3、of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis:isquemic/hemorrhaegic strokeComplianceWHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established risk factorsNon-modifiable and modifiable risk factorsResults

4、 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 medicationPerspectives of pharmacological interventionClinical trials wi

5、th universal treatmentSpecific treatment according to diagnosis:isquemic/hemorrhaegic strokeComplianceSource Mackay,J,Mensah,G.The Atlas of Heart Disease and Stroke.WHO-CDC,2004.WHO PREMISE Study of secondary prevention of strokeCauses of stroke and its established risk factorsNon-modifiable and mod

6、ifiable 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 medicationPerspectives of pharmacological int

7、erventionClinical trials with universal treatmentSpecific treatment according to diagnosis:isquemic/hemorrhaegic strokeCompliance010203040506070BREGINIDIRPKSLTK RUTNTOTALCountries%60 yearsAGE GROUPS FOR MALES AND FEMALES0102030405060CHD FemalesCHD MalesCeVD FemalesCeVD Males%60 yearsTOTAL NUMBER OF

8、PARTICIPANTS OF CHD AND STROKEBY AGE AND SEX CeVD:Cerebrovascular disease WHO-PREMISE STUDY0102030405060708090100BREGINIDIRPKSLTKRUTNTOTALCountries%H B PH B CH B SWHO-PREMISE STUDY010203040506070BREGINIDIRPKSLTKRUTNTOTALCountries%0 FR1 FR2 FR3 FR4 FRHolzgreve and Middeke,1994WHO PREMISE Study of sec

9、ondary 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-demographic characteristicsAccording to risk factorsBy

10、 clinical characteristicsPredictors for the use of medicationPerspectives of pharmacological interventionClinical trials with universal treatmentSpecific treatment according to diagnosis:isquemic/hemorrhaegic strokeComplianceWHO-PREMISE STUDYHBP:High blood pressure HBC:High blood cholesterol HBS:Hig

11、h blood sugar WHO-PREMISE STUDYWHO-PREMISE STUDYWHO 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 risk factorsUse of medication from the WHO P

12、REMISE StudyBy socio-demographic 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

13、 Total stroke 307/3051 420/3054 Major vascular events Total events 458/3051 604/3054 Events/patients Active*PlaceboFavorsactiveFavorsplaceboRisk reduction(95%CI)Stroke 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.Lancet 20

14、01;358:1033-41*Active:Perindopril 4 mg Indapamide 2,5 mgSource:EAFT(European Atrial Fibrillation Trial)Study GroupConsiderations of available information on the following items permit to outline high-priority research questions on the secondary prevention of stroke:Serum uric acid,diuretics and risk

15、 of ischaemic stroke in the Atherosclerosis Risk in Communities(ARIC)Study 13 413 individuals free of stroke or coronary artery disease 381 strokes occurred during the mean follow up of 12.6 years Subjects Uric acid quartiles at baseline (mg.dL-1)P for linear trend Up to 4.8 4.95.8 5.96.8 Above 6.9

16、No.of subjects 3243 2534 3183 2303 No.of events 51 45 85 86 Diuretic non-users Relative hazard 1.00 0.99 1.41 1.89(Sig.)0.01 No.of subjects 291 318 609 932 No.of events 16 14 29 55 Diuretic users Relative hazard 1.00 0.72 0.69 0.72 0.46 Hozawa A,Folsom A,Ibrahim H,et al.Atherosclerosis,Epub Oct 2005

17、 Serum uric acid,diuretic use and ischaemic stroke Oxidative stress appears to have a bearing on the occurrence of ischaemic stroke on stroke-related neurological damage Plasma uric acid has a dual purport Uric acid is a powerful endogenous antioxidant 2-4 units of oxidants(superoxide anion radical

18、and hydrogen peroxide)are formed per unit of uric acid produced through the action of xanthine oxidase Diuretics,even at low doses,reduce the renal excretion of uric acid The rise in plasma uric acid caused by diuretics and the attendant increase in total plasma antioxidant capacity blunt the increa

19、se in stroke risk possible due to excess uric acid and reactive species synthesis mediated by xanthine oxidase Reyes AJ.Cardiovasc Drugs Ther 2003;17:397414.Reyes AJ,Leary WP.J Hypertens 2003;21:17751777.Comparison of ximelagatran,warfarin and placebo in the prevention of stroke and systemic embolis

20、m in patients with non-valvular atrial fibrillation Source Compared treatments Incidence(n)Odds Ratio(95%CI)Meta-analysis*Warfarin Placebo 32/1225 89/1236 W:P 0.346(0.2290.522)(SPORTIF)*III and V trials Ximelagatran Warfarin 93/3665 91/3664 X:W 0.978(0.7301-311)Imputed placebo analysis Ximelagatran

21、Placebo 91/3664 89/1236 W:P 0.338(0.2040.560)Berry C,Norrie J,McMurray JJV.Cardiovasc Drugs Ther 2005;19:145151.Therapeutic objectives depend on each individuals risk factors and existing pathology.There is a wide consensus on:Treating patients with atrial fibrillation with anticoagulantsWhen antico

22、agulation is not possible due to socio-economic factors or clinically contraindicated-antiplatlet therapy should be usedLowering blood pressure is the most important risk factor goal to achieve Patients education and physicians dedication to improve treatment and prevention through non-pharmacologic and pharmacologic treatment is essential to improve compliance