4/16/2015 Consulting Merck Novartis Astra Zeneca Joshua - PowerPoint PPT Presentation

4/16/2015 Consulting � � Merck � Novartis � Astra Zeneca Joshua Beckman, MD � Bristol Myers Squibb Stock � � Janacare � EMX Research Grant � � Bristol Myers Squibb Boards � � VIVA Phyiscian’s Group In the FHS, healthy individuals aged 60 years who did not have In the FHS, healthy individuals aged 60 years who did not have atherothrombosis were expected to live a further 20 years to the age of 80 atherothrombosis were expected to live a further 20 years to the age of 80 � Past: Management of Active Disease Comparatively, patients with a history of MI lived 9.2 fewer years Comparatively, patients with a history of MI lived 9.2 fewer years ▪ ▪ Those with a history of CVA lived 12 fewer years Those with a history of CVA lived 12 fewer years ▪ ▪ � Present: Management of Asymptomatic 20 20 Disease 9.2 Life Expectancy (Years) 12 Fewer � Future: Risk Stratification 15 years Fewer years 10 5 0 Healthy History of MI History of CVA MI=myocardial infarction; CVA=cerebrovascular accident. Adapted from Bakhai A. Pharmacoeconomics . 2004;22(suppl 4):11-18. 1

4/16/2015 Follow up of 1707 subjects diagnosed with TIA in ED Risk Factors for Events: OR 60% Age > 60 y 1.8 A. Statins Diabetes 2.0 B. Anticoagulants >10 Min TIA2.3 28% C. Antiplatelet agents Weakness 1.9 D. ACE inhibitors 12% Speech 1.5 0% Statins Anticoagulants Antiplatelet agents ACE inhibitors Johnston, SC. JAMA. 2000;284:2901-2906 6602 pts with recent TIA or CVA followed for 2 years 40 � � � 16 30 � � � 14 ARR Death/ CVA (%) 20 12 Stroke (%) 10 10 0 8 -10 6 0-2 2-4 4-12 >12 Time from event to randomization (weeks) 4 ASA DYP ASA-DYP Placebo 70-99% Stenosis 50-69% Stenosis J Neurol Sci 1996; 143(1-2):1 Rothwell, PM. Lancet 2004; 363:915 2

4/16/2015 Aspirin-Dipyridamole vs. Clopidogrel in Stroke Recurrence Prevention 1486 patients CVA within 48 hrs randomized to high-dose tinzaparin, medium-dose tinzaparin, or aspirin (300 mg daily; 491 patients) 20,332 pts with ischemic CVA within 90 days randomly assigned to 25 mg ASA + 200 mg of ER dipyridamole twice daily or 75 mg of clopidogrel daily Stroke Stroke/MI/Vascular Death Sacco RL et al. N Engl J Med 2008;359:1238-1251. Bath, PMW. Lancet 2001; 358 (9253):702-710 The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. 6105 Patients with Previous Stroke Treated with Regimen including ACEI or placebo 20 14% 15 Placebo 28% RRR Stroke % 10 10% Active Treatment 5 0 0 1 2 3 4 Years of Follow-Up SPARCL Investigators. N Engl J Med 2006;355:549-559. PROGRESS Collaborative Group. Lancet 2001:358; 1033 3

4/16/2015 Event Medical Rx 5 yr (%) CEA 5 yr (%) p Ipsilateral & perioperativeCVA & 11 5.1 .004 death Major CVA & Perioperative 6 3.4 .12 CVA/death IpsTIA/CVA, PeriopTIA/CVA 19.2 8.2 <.001 Any CVA/Periop death 17.5 12.4 .09 Any major CVA/Periop Death 9.1 6.4 .26 Any CVA/death 31.9 25.6 .08 Any major CVA/death 25.5 20.7 .16 ACAS Executive Committee JAMA 1995;273:1421-1428 Marquardt, L Stroke. 2010;41:e11-e17 ACST: 3120 pt with carotid stenosis >60%, no symptoms, randomized to CEA vs. medical management. Enrolled from 4/93 to 7/2003 CAS CEA p MI 7 (1.2%) 13 (2.2%) 0.2 Any Stroke or Death Major Stroke or Death 100 CEA 3.5% All Stroke 15 (2.5%) 8 (1.4%) 0.15 CEA 6.4% Event Free (%) 95 Major Stroke 3 (0.5%) 2 (0.3%) 0.66 Minor Stroke 12 (2.0%) 6 (1.0%) 0.15 Medical 6.1% 90 Medical 11.8% Stroke + Death 15 (2.5%) 8 (1.4%) 0.15 85 Stroke/Death/MI 21 (3.5%) 21 (3.5%) 0.96 Years of Follow-Up Years of Follow-Up ACST Collaborative Group. Lancet 2004; 363: 1491 Silver, FL. Stroke 2011, 42:675-680 4