LongTerm Management of Patients at Risk of Atherothrombosis Section 2 The Burden of Atherothrombosis

1
Long-Term Management of Patients at Risk of
Atherothrombosis

Section 2The Burden of Atherothrombosis
2
Epidemiology of Atherothrombotic Manifestations
in the US

First attack only PAD patients in North America
(USA and Canada) symptomatic (37.5) and
asymptomatic (62.5)
1. American Heart Association. 2002 Heart and
Stroke Facts Statistical Update. 2. Ouriel K
et al. Lancet 2001 358 125764. 3. Weitz JI et
al. Circulation 1996 94 302649.
3
Epidemiology of Atherothrombotic Manifestations
in Europe1

According to patient age, sex and country of
originSpain, Italy, FranceUK, Germany,
Netherlands
1. Guillot F, Moulard O. Circulation 1998
98(abstr suppl 1) 1421.
4
Increasing Worldwide Prevalence of
Atherothrombotic Manifestations1
Prevalence 2000 2005
205.0 million (?5.1 since 1997)
222.2 million (?13.9 since 1997)
Populations aged 50 year old
9.1 million (?12.8 since 1997)
10.7 million (?32.7 since 1997)
Myocardial infarction
7.1 million (?11.8 since 1997)
8.4 million (?31.6 since 1997)
Ischemic stroke

Projected populations of people aged over 50
years, and estimated prevalence of myocardial
infarction and ischemic stroke cumulated in 14
countries Belgium, Canada, Denmark, Finland,
France, Germany,Italy, Netherlands, Norway,
Spain, Sweden, Switzerland, UK, USA
1. Guillot F, Moulard O. Circulation 1998
98(abstr suppl 1) 1421.
5
Hospitalizations in the US due to ACS1
1. Cairns J et al. Can J Cardiol 1996 12
127992.
6
European Survey of Acute Coronary Syndromesthe
ENACT Study1
Patient records from 3,092 ACS patients in the
EU (1999)

• Ratio of unstable angina (UA) to MI was 1.21.0
  overall and was similar in all European countries
• In patients with diagnosis of UA on admission, 9
  evolved to definite MI despite current treatment

17 Western European countries
1. Fox KA et al. Eur Heart J 2000 21 14409.
7
Epidemiology and Long-term Outcome of
Cerebrovascular Disease1

• Incident cases/year (per 1 million inhabitants)
• 500 transient ischemic attacks
• 2,400 strokes (75 first ever strokes)
• in 3 months 480 (20) deaths
• in 1 year 700 (29) deaths 600 (25) dependent
  survivors 1,100 (46) independent survivors
• Prevalent cases (per 1 million inhabitants)
• 12,000 patients, of whom 800 (7) have recurrent
  stroke every year

1. Hankey GJ, Warlow C. Lancet 1999 354 145763.
8
Causes of Death During Different Time Intervals
after First-Ever Stroke1
1. Hankey GJ. Stroke 2000 31 20806.
9
5-Year Mortality Risk in Cerebrovascular Patients1
1. Sacco RL et al. Neurology 1994 44 62634.
10
Long-term Outcome of Peripheral Arterial Disease
(PAD)1

• Causes of death
• 55 coronary artery disease
• 10 cerebrovascular disease
• 25 non-vascular

100
80
Survival
60
Patients ()
Myocardial
infarction
40
Intervention
20
Amputation
0
0
1
2
3
4
5
6
7
8
9
10
Time (years)

• 1. Ouriel K. Lancet 2001 358 125764.

11
Peripheral Arterial Disease (PAD) and All-Cause
Mortality1
1.00
Normal Subjects
0.75
Asymptomatic LV-PAD
0.50
Survival
Symptomatic LV-PAD
0.25
Severe Symptomatic LV-PAD
0.00
0
2
4
6
8
10
12
Year
Kaplan-Meier survival curves based on mortality
from all-causes Large-vessel PAD
1. Criqui MH. Vasc Med 2001 6(suppl 1) 37.
12
Mortality in Patients with Severe Peripheral
Arterial Disease (PAD)
Relative 5-Year Mortality
1. Criqui MH. Vasc Med 2001 6(suppl 1) 37. 2.
McKenna M et al. Atherosclerosis 1991 87
11928. 3. Ries LAG et al. (eds). SEER Cancer
Statistics Review, 19731997. US National Cancer
Institute 2000.
13
Risk of a Second Vascular Event
Sudden death defined as death documented within
1 hour and attributed to coronary heart disease
(CHD) Includes only fatal MI and other CHD
death does not include non-fatal MI
1. Adult Treatment Panel II. Circulation 1994
89133363. 2. Kannel WB. J Cardiovasc Risk 1994
1 3339. 3. Wilterdink JI, Easton JD. Arch
Neurol1992 49 85763. 4. Criqui MH et al. N
Engl J Med 1992 326 3816.
14
Economic Impact of Coronary Heart Disease (CHD)
and Stroke1
Direct versus Indirect Costs (US)
70
60

• Direct costs
• Hospital/nursing home
• Physicians/other professionals
• Drugs
• Home health care

50
40
Costs (billion US)
30

• Indirect costs
• Loss of productivity due to morbidity or
  mortality

20
10
0
CHD
Stroke
1. American Heart Association. 2002 Heart and
Stroke Facts, Statistical Update.
15
Stroke Mean Cost as a Function of Long-Term Care
Destination1
Chronic long-termin-hospital care
56,114
33,208
Nursing home
33,062
Rehabilitation
Destination
22,297
Convalescent home
11,722
New housing
11,375
Return home
0
10,000
20,000
30,000
40,000
50,000
60,000
Euros
Excluding new acute hospitalization
1. Spieler J-F et al. Cerebrovasc Dis 2002 13
13241.
16
Acute Coronary Syndrome Average Cost in
Different European Countries (at 6 Months)1
France
Spain
Italy
UK
Germany
Netherlands
Initial hospital stay accounts for 80 of the
costs
1. Brown RE et al. Eur Heart J 2002 23 508.
17
Myocardial Infarction, Ischemic Stroke,and
Event-Free PAD Cost over 2 Years1

35,000
30,000
Estimated cost for
angioplasty or surgery
25,000
Follow-up and rehabilitation
20,000
treatment phase
Cost over 2 years from time of
presentation (US)
15,000
Acute
10,000
5,000
0
MI
Stroke
Event-free PAD
Including concomitant medication. Cost
estimates based on Medicare reimbursement rates
(US, 1997) and reference 1.
1. Hunink MG et al. J Vasc Surg 1994 19 63241.

18
Burden of AtherothrombosisSummary

• Atherothrombosis is a prevalent and deadly
  disease
• Manifestations of atherothrombosis (including
  acute cardiovascular disease, ischemic heart
  disease and stroke) constitute the leading cause
  of death in developed countries, causing over
  half of all deaths annually in North America and
  Europe1
• Myocardial infarction (MI) and stroke alone are
  responsible for a significant health burden1
• Peripheral arterial disease (PAD) greatly
  increases the risk to patients of coronary artery
  and cerebrovascular disease2
• The economic burden of MI, stroke and PAD is
  considerable.3

1. The World Health Report 2001. Geneva WHO
2001. 2. Criqui MH. Vasc Med 2001 6(suppl 1)
37. 3. American Heart Association. 2002 Heart
and Stroke Facts, Statistical Update.
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Disclaimer

• This slide kit presents data to support the
  rationale for the use of ADP-receptor antagonists
  in registered and non-registered indications.
• The slide kit has been prepared for medical and
  scientific purposes, and cannot be considered as
  an inducement to use clopidogrel in
  non-registered indications.
• Neither Sanofi-Synthélabo nor Bristol-Myers
  Squibb recommends the use of clopidogrel in any
  manner inconsistent with that described in the
  full prescribing information.