Classificazione e Fattori di rischio per l ictus ischemico. Claudio Borghi Dipartimento di Scienze Mediche e Chirurgiche Università di Bologna

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1 Classificazione e Fattori di rischio per l ictus ischemico Claudio Borghi Dipartimento di Scienze Mediche e Chirurgiche Università di Bologna

2 STROKE ISCHEMICO Classificazione fisiopatologica 1. Patologia dei grossi vasi (aterotrombotico) 2. Patologia dei piccoli vasi (infarto lacunare) 3. Cardioembolismo 4. Altre cause (cause rare) 5. Meccanismo Indeterminato Più fattori causali Accertamento insufficiente Criptogenetico TOAST Classification, Stroke 1993

3 Quali sono i fattori di rischio CV sui quali agire?

4 Number of strokes preventable in the USA by control of individual risk factors Gorelick PB et Al., JAMA 1999

5 Number of strokes preventable in the USA by control of individual risk factors Gorelick PB et Al., JAMA 1999

6 Stroke Mortality (Floating Absolute Risk and 95% CI) IHD Mortality (floating absolute risk and 95% CI) CHD and Stroke Mortality vs Usual BP by Age Systolic Blood Pressure Usual Systolic BP (mm Hg) Age at risk: years years years years years Age at risk: years years years years Diastolic Blood Pressure 70 Age at risk: years years years years years Age at risk: Usual Diastolic BP (mm Hg) years years years years CHD Stroke Prospective Studies Collaboration. Lancet. 2002;360:

7 Reduction in the rate of CHD and stroke for a BP reduction of 10 mm Hg SBP or 5 mm Hg DBP Law, MR et al. BMJ 2009;338:b1665

8 Relative risk of outcome event Associations of Blood Pressure Differences between Groups with Risks of Major Vascular Outcomes and Death A B C D E F G A B C D E F G A B C D E F G 1.50 Stroke Major CVD CHD CV death Heart failure Total mortality A: CA vs P B: ACEI vs P C: More vs less D: ARB vs C E: ACEI vs CA F: CA vs D G: ACEI vs D SBP difference between randomised groups (mmhg) Lancet 2003; 362: 1527

9 Effects of additional BP-related risk factors: - Central BP - Nightime BP - Visit-to-vist BP - Early Vascular Involvement (*)

10 Number of strokes preventable in the USA by control of individual risk factors Gorelick PB et Al., JAMA 1999

11 Adjusted risk of stroke and serum cholesterol in the Korean National Health System Prospective Study Ebrahim et al. BMJ 2006

12 Updated meta-analysis of major statin trials that assessed the effect of statins on fatal and non-fatal stroke Amarenco P, Labreuche J. Lancet Neurol 2009;8:453-63

13 Forrest plot of random-effects meta-analysis of randomized trials of statins and intracerebral hemorrhage Stroke 2012; 43(8):

14

15 Cumulative incidence for fatal and non-fatal stroke in the two blood pressure treatment groups. Sever P et al. Eur Heart J 2006;27:

16 Number of strokes preventable in the USA by control of individual risk factors Gorelick PB et Al., JAMA 1999

17 People with AF in the USA (millions) Prevalence of AF predicted to more than double by Projected incidence of AF assuming a continued increase in age-adjusted incidence as evident in Projected incidence of AF assuming no further increase in age-adjusted incidence Year 2050 Miyasaka Y et al. Circulation 2006;114:119 25

18 Stroke is a frequent complication of AF Stroke is the leading complication of AF AF is associated with a 5-fold higher stroke risk overall 1 AF doubles the risk of stroke when adjusted for other risk factors 2 AF is responsible for nearly one-third of all strokes, 6 and AF is the leading cause of embolic stroke 7 and the most relevant non-atherogenic cause 7 The risk of stroke in AF can be predicted by appropriate scores 3 (CHADS 2 and CHA 2 DS 2 VASc ) 1. Savelieva I et al. Ann Med 2007;39:371 91; 2. ACC/AHA/ESC guidelies: Fuster V et al. Circulation 2006;114:e & Eur Heart J 2006;27: ; 3. ESC Guidelines for the management of AF, Eur Heart J 2010; 4. Atrial Fibrillation Investigators. Arch Intern Med 1994;154: ; 5. Carlson M. Medscape Cardiology 2004;8; available at accessed Feb 2010; 6. Hannon N et al. Cerebrovasc Dis 2010;29:43 9; 7. Emmerich J et al. Eur Heart 2005); (Suppl C):C28 33; 7. Gorelik PB et al, JAMA 1999

19 CHA 2 DS 2 -VASc RISK SCORE Risk factor Score Congestive heart failure/lv dysfunction 1 Hypertension 1 Age 75 years 2 Diabetes mellitus 1 Stroke/TIA/thromboembolism 2 Vascular disease a 1 Age years 1 Sex category (i.e. female sex) 1 Maximum score patients with AF in general practice AUC (C-statistics): CHADS 2 score 0.66 CHA 2 DS 2 -VASc 0.67 van Staa TP et al. J Thromb Hemost 2011;9:39 48 a Prior myocardial infarction, peripheral artery disease, complex aortic plaque. LV = left ventricular; TIA = transient ischaemic attack ESC guidelines: Camm J et al. Eur Heart J 2010;31:

20 AF-related stroke is preventable Effect of VKA compared to placebo 2/3 of strokes due to AF are preventable with appropriate anticoagulant therapy with a vitamin-kantagonist (INR 2-3) 1 Anticoagulation with a vitamin-kantagonist (VKA) is recommended for patients with more than 1 moderate risk factor (age,hbp, CHF or LVD, Diabetes) Stroke Death A meta-analysis of 29 trials in 28,044 patients showed that adjusted-dose warfarin results in a reduction in ischaemic stroke and in all-cause mortality 1 67% 26% 1. Hart RG et al. Ann Intern Med. 2007;146: Fuster V, et al. JACC. 2006; 48:

21 Esistono nuovi potenziali fattori di rischio per l ictus?

22 Stroke incidence Stroke mortality

23 Pan, A. et al. JAMA 2011;306:

24

25 Feigin V L et al. Stroke. 2014;45:

26 Age-adjusted death rates for diseases of the heart, cerebrovascular disease, and chronic lower respiratory disease by year. USA to 2010 Lackland D et Al., Stroke 2013;45:

27

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