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- 1. IDPS
- 2. Background The value of reducing blood pressure in the secondary prevention of stroke IDPS
- 3. BACKGROUND: Blood pressure and secondary stroke incidence Relative risk of Relative risk of stroke stroke 4.00 4.00 2.00 2.00 1.00 1.00 0.50 0.50 0.25 0.25 75 80 85 90 95 120 130 140 150 160 170 Usual diastolic BP (mm Hg) Usual systolic BP (mm Hg) UKTIA 2435 patients IDPS
- 4. Main results on stroke, cardiac events, dementia, and cognitive function IDPS
- 5. AIM To determine the balance of benefits and risks conferred by an ACE inhibitor (perindopril)-based blood pressure-lowering regimen among patients with a history of cerebrovascular disease and a wide range of blood pressures at entry. IDPS
- 6. Selection criteria In the past 5 years: cerebral hemorrhage ischemic stroke stroke of unknown type TIA or amaurosis fugax No major disability No entry blood pressure criteria IDPS
- 7. Methodology ACERTIL 4 mg ± indapamide* (2 or 2.5 mg) ACERTIL, ACERTIL 2 mg 4 mg Matching placebo(s) On top of their previous medication (including other BP-lowering agents) NB; mono or bi therapy at the discretion of the physician IDPS
- 8. Study outcomes Primary Total stroke Secondary Fatal or disabling stroke Major vascular events (nonfatal stroke, nonfatal MI, vascular death) Dementia (DSM IV) and cognitive function Disability and dependency IDPS
- 9. UK and Ireland Sweden 23 centers 23 centers Belgium 2 centers France Japan 24 33 centers centers China Italy 26 17 centers centers Australia 16 centers 10 countries New Zealand 172 centers 9 centers IDPS
- 10. Patient flow 7121 patients registered 484 ineligible 532 withdrew 6105 patients randomized 3051 assigned 3054 assigned active placebo 3049 vital status 3053 vital status known known Reference: Lancet. 2001;358:1033-1041. IDPS
- 11. Baseline characteristics Active* Placebo (n = 3051) (n = 3054) Demographics Female sex (%) 30 30 Age (y) 64 64 Asian ethnicity (%) 39 39 Blood pressure Systolic (mm Hg) 147 147 Diastolic (mm Hg) 86 86 Hypertension (%) 48 48 Cerebrovascular history Cerebral hemorrhage (%) 11 11 Cerebral infarction (%) 71 71 Stroke type unknown (%) 4 5 TIA/amaurosis fugax (%) 23 23 IDPS * Active treatment: Coversyl 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041.
- 12. Baseline characteristics Characteristic Coversyl arm Placebo Other medical history (%) Current smoker 20 20 Diabetes 13 12 Coronary heart disease 16 16 Blood pressure and hypertension status M Mean systolic blood pressure, mm Hg (SD) 147 (19) 147 (19) † ean diastolic blood pressure, mm Hg (SD) 86 (11) 86 (11) Hypertension (%) 48 48 Antihypertensive therapy (%) 50 51 †SBP ≥ 160 mm Hg or DBP ≥ 90 mm Hg Reference: Lancet . 2001;358:1033-1041. IDPS
- 13. Adherence during follow-up 100% 80% Adherence 60% Average adherence Active* 87% 40% Placebo 88% Placebo 20% Active P=0.07 0% 0 6 12 18 24 30 36 42 48 Follow-up (mo) * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 14. Safety and tolerability ACERTIL-based therapy was very well tolerated: Similar rate of withdrawal • from active therapy and placebo • in hypertensive and nonhypertensive patients Few withdrawals for hypotension or cough IDPS
- 15. Blood pressure differences All participants 160 Blood pressure (mm Hg) 140 120 Mean BP difference Active * 100 9.0/4.0 mm Hg Placebo 80 60 B R 1 3 6 9 12 18 24 30 36 42 48 54 Follow-up (mo) * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 16. Mean BP reductions SBP (SE) DBP (SE) Hypertensive 9.7 (0.4) 4.0 (0.3) Nonhypertensive 8.4 (0.4) 4.1 (0.2) Combination 11.8 (0.4) 4.8 (0.3) Single drug 5.2 (0.4) 2.8 (0.3) All participants 9.0 (0.3) 4.0 (0.2) Reference: Lancet. 2001;358:1033-1041. IDPS
- 17. Results on stroke outcomes IDPS
- 18. Stroke All participants 0.20 Placebo Proportion with event Active* 0.15 0.10 28% risk reduction 0.05 95% CI 17 - 38% P<0.0001 0.00 0 1 2 3 4 Follow-up time (y) * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 19. Stroke severity and subtype All participants Strokes Favors Favors Hazard ratio Active* Placebo active placebo (95%CI) • Fatal/disabling 93 149 0.62 (0.48-0.80) • Other stroke 179 238 0.74 (0.61-0.90) • Cerebral infarction 246 319 0.76 (0.65-0.90) • Cerebral hemorrhage 37 74 0.50 (0.33-0.74) • Stroke type unknown 42 51 0.82 (0.55-1.24) • Total 307 420 0.72 (0.62-0.83) 0.5 1.0 2.0 •Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg Hazard ratio (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 20. Stroke by medical history All participants Strokes Favors Favors Hazard ratio Active* Placebo active placebo (95%CI) Hypertensive 163 235 0.67 (0.55-0.81) Not hypertensive 144 185 0.73 (0.58-0.92) Diabetes 48 65 0.67 (0.46-0.98) No diabetes 259 355 0.72 (0.62-0.85) Cerebral infarction 236 307 0.76 (0.64-0.90) Cerebral hemorrhage 28 49 0.52 (0.33-0.83) TIA/amaurosis 33 49 0.66 (0.42-1.02) Total 307 420 0.72 (0.62- 0.83) 0.5 1.0 2.0 * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg Hazard ratio (or 2 mg in Japan) IDPS
- 21. Indications Treatment should be considered for patients with cerebrovascular disease, irrespective of : Type of stroke or TIA Initial BP (hypertensive or nonhypertensive) Other drugs and treatments Region/ ethnicity Age and gender IDPS
- 22. Results on cardiac outcomes IDPS
- 23. Major vascular events All participants Events Favors Favors Hazard ratio Active* Placebo active placebo (95%CI) Vascular death 181 198 0.91 (0.75-1.12) Nonfatal MI 60 96 0.62 (0.45-0.86) Nonfatal stroke 275 380 0.71 (0.61-0.83) Total 458 604 0.74 (0.66-0.84) 0.4 •Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg 1.0 2.0 (or 2 mg in Japan) Hazard Ratio Reference: Lancet. 2001;358:1033-1041. IDPS
- 24. Major vascular events 0.25 26% risk Proportion with event 0.20 reduction (95% CI 16-33%) P<0.0001 0.15 0.10 Placebo 0.05 Active ** 1 2 3 4 Follow-up time (y) PROGRESS Coll. Group Eur Heart J. 2003 24: 475- 484 IDPS
- 25. Major coronary events (CHD death or nonfatal myocardial infarction) 0.06 26% risk reduction Proportion with event 0.05 95% CI 6-42% P = 0.016 0.04 0.03 0.02 Placebo 0.01 Active * 1 2 3 4 Follow-up time (y) •Active treatment: Coversyl 4 mg +/- indapamide 2.5 mg •(or 2 mg in Japan) IDPS Reference: Lancet. 2001;358:1033-1041.
- 26. Total coronary events (CHD death, nonfatal MI, coronary revascularization, unstable angina, 21% risk reduction 0.10 (95%CI 6-33%) Placebo P value = 0.008 Proportion with event Active 0.05 0.00 0 1 2 3 4 Follow-up time (y) IDPS
- 27. Heart failure (Death, hospitalization, or discontinuation) 0.06 26% risk reduction (95%CI 5-42%) Proportion with event 0.05 P value = 0.01 0.04 0.03 0.02 Placebo 0.01 Active * 0.00 0 1 2 3 4 Follow-up time (y) * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Eur Heart J. In press. IDPS
- 28. Comments and perspectives IDPS
- 29. Issue Why the difference between single-drug therapy (ACERTIL alone) and combination therapy (ACERTIL plus indapamide)? IDPS
- 30. Combination therapy (12/5 mm Hg) and single-drug therapy (5/3 mm Hg) Events Favors Favors Risk reduction Active* Placebo active placebo (95%CI) Stroke Combination 150 255 43% (30 to 54%) Single drug 157 165 5% (-19 to 23%) Total 307 420 28% (17 to 38%) Major vascular events Combination 231 367 40% (29 to 49%) Single drug 227 237 4% (-15 to 20%) Total 26% (16 to 34%) 458 604 Tests for homogeneity 0.5 1.0 2.0 (combination vs single drug): both < 0.001 Hazard ratio * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 31. Baseline characteristics Combination therapy Single drug therapy (n = 3544) (n = 2561) Demographic Female sex (%) 29 32 Age (years)* 63 65 Asian ethnicity (%) 38 39 Blood pressure Systolic (mm Hg)* 149 144 Diastolic (mm Hg)* 87 84 Hypertension (%)* 54 40 Reference: Lancet. 2001;358:1033-1041. IDPS
- 32. Issue Why no detectable effect with ACERTIL alone? • Study not designed to detect • Study not powered to detect / Number of subjects too small • Effect not proven or disproven (Wide CI) • Differences in patients’ baseline characteristics IDPS
- 33. Issue Is it safe to lower blood pressure, post-stroke, especially in normotensive subjects? IDPS
- 34. Adherence during follow-up 100% 80% Adherence 60% Average adherence Active* 87% 40% Placebo 88% Placebo 20% Active P=0.07 0% 0 6 12 18 24 30 36 42 48 Follow-up (mo) * Active treatment: ACERTIL 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Lancet. 2001;358:1033-1041. IDPS
- 35. Results on dementia and cognitive decline outcome IDPS
- 36. Stroke and dementia • Stroke is the leading cause of disability in adults 1 • Cerebrovascular disease is the second most common cause of dementia2 • Vascular dementia is one of the rare preventable dementias3 1. Barba R et al. Previous and incident dementia as risk factors for mortality in stroke patients. Stroke. 2002;33:1993-1998. 2. Leys D et al. Epidemiology of vascular dementia. Hemostasis. 1998;28:134-150. 3. Hachinski V. Preventable senility: a call for action against the vascular dementias. Lancet. 1992;340:654-648. IDPS
- 37. Major types of dementia • Alzheimer’s disease 53.7% • Vascular dementia 15.8%1 single or multiple infarcts2 small-vessel disease2 hypoperfusion2 hemorrhage2 1. Lobo A et al. Neurology. 2000;54(suppl 5):S4-S9. 2. Gold G. Les démences vasculaires. Med Hyg. 2002;60:1165-1167. IDPS
- 38. The cumulative incidence of dementia after stroke Incidence of dementia (%) 25 23% 20 15% 15 10% 10 7% 5 0 1 3 5 10 Timel (y) Incident of stroke increase the risk of dementia by 140% IDPS
- 39. Prevalence of vascular dementia in men and women in European countries 6 Cases/100 of population 4 Wom en Men 2 0 65- 69 70- 74 75- 79 80- 84 85- 89 90+ Age (y) IDPS
- 40. Baseline characteristics • 6105 patients with stroke or TIA • FU 3.9 years • MMSE / Screening for dementia each year Active Placebo (n = 3051) (n = 3054) Age, y (SD) 64 (10) 64 (10) Female (%) 30 30 Asian (%) 39 39 Median MMSE score 29 (27-30) 29 (27-30) MMSE < 26 (%) 15 15 ApoE4 allele carrier (%) 22 22 PROGRESS Coll Group Arch Int Med. 2003; 163:1069- IDPS
- 41. Cognitive outcomes Dementia 1. Screening MMSE <26 Questions about dementia MMSE missing 2. Diagnosis Specialist in each center; DSM-IV criteria Diagnosis reviewed centrally Cognitive decline = drop of 3pts or more of MMSE during FU Reference: Arch Int Med. In press. IDPS
- 42. Cognitive outcomes (ctd.) • Dementia 1580 patients screened positive during FU Expert assessment for 98% 410 patients demented 108 preceded by a recurrent stroke • Cognitive decline 610 patients (25 per 1000 PY) Reference: Arch Int Med. In press. IDPS
- 43. Effect of treatment on dementia Events Favors Favors Risk reduction Active* Placebo active placebo (95%CI) Dementia Post-stroke 43 65 34% (3 to 55%) Without stroke 150 152 1% (-24 to 22%) Total 193 217 12% (-8 to 28%) 0.5 1.0 2.0 Odds ratio * Active treatment: Coversyl 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) Reference: Arch Int Med. In press. IDPS
- 44. Effect of treatment on cognitive decline Events Favors Favors Risk reduction Active* Placebo active placebo (95%CI) Cognitive decline With stroke 48 86 45% (21 to 61%) Without stroke 228 248 9% (-10 to 84%) Total 276 334 19% (4 to 32%) 0.5 1.0 2.0 Odds ratio * Active treatment: Coversyl 4 mg +/- indapamide 2.5 mg (or 2 mg in Japan) IDPS
- 45. Conclusion • 28% reduction in the all strokes • 50% reduction in the risk of hemorrhagic stroke • 25% reduction in the risk of cerebral ischemia Reference: Lancet . 2001;358:1033-1041 IDPS
- 46. Conclusion • 26% reduction in the risk of major cardiovascular events • 26% reduction in the risk of major coronary events • 33% reduction in myocardial infarction • All benefits achieved against a background of standard care that included antiplatelet and antihypertensive therapy Reference: Lancet . 2001;358:1033-1041. IDPS
- 47. Recommendations for initiation Acute stroke Initiate treatment at the time of discharge or post-discharge follow up History of stroke or TIA Primary care physician to initiate treatment at the patient’s next visit IDPS
- 48. ACERTIL offers optimal cardiovascular protection in all hypertensive patients IDPS
Editor's Notes
- UKTIA = United Kingdom Transient Ischaemic Attack* Before PROGRESS there was no evidence that the lowering of blood pressure decreased secondary stroke incidence. Nevertheless,a few studies suggested lowering BP does an impact in the secondary prevention of stroke (for example the UKTIA study). PROGRESS was designed to clearly establish this fact. * Ref : Study group of the UKTIA aspirin trial final results J Neurol Neurosurg Psychiatry.1991. 54:1444-1554.
- Patients were eligible for entry into the PROGRESS study if they had a history of cerebrovascular disease in the last 5 years. This meant that the patients enrolled into the study included not only people who had experienced a stroke recently, but also people who had suffered a stroke as long ago as up to 5 years prior to the study. Patients needed to present no major disability. There were no blood pressure entry criteria, and the importance of this is that it enabled not only hypertensive patients, but also normotensive patients with a history of stroke to be included in the study.
- Randomization was done between either active treatment or placebo. This was done in a double-blind fashion. They were then randomized to treatment with either Coversyl 4 mg alone or Coversyl 4 mg + indapamide 2.5 mg. The decision as to whether a patient was allocated Coversyl alone or in combination (or alternatively single or combination placebo) was made at the discretion of the doctor entering the patient into the study, ie patients were NOT randomized between monotherapy and combination therapy. It is important to remember that patients received the active treatment or the matching placebo on top of their previous medication, including other blood pressure-lowering therapy. Patients were then followed up over a period of 4 years.
- The primary end point of PROGRESS was total stroke (whether fatal or nonfatal). Secondary end points included fatal or disabling strokes, major vascular events (nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death), dementia and cognitive function, and disability and dependency.
- The PROGRESS trial was a true landmark study, internationally conducted, in 10 countries worldwide and involved 172 continents, with a large proportion of Asian patients.
- The quality of the data was superb, with an independent data monitoring committee, and from this slide it can be seen that even with such a large number of randomized patients spread all over the globe, at the end of the 4-year follow up, only 3 patients were lost to follow-up. This helped to ensure the accuracy of any findings from the study.
- As might be expected from a randomized study with such a large population, there are almost no differences between the baseline characteristics of the active compared with the placebo groups. The average age of patients in the study was 64, with 30% being of female sex, and 61% being caucasian, in both the active and placebo groups. The levels of blood pressure were equivalent in both groups. Both normotensive as well as hypertensive patients were included in the PROGRESS trial in similar proportions. This is important, since the PROGRESS study medication was ADDED to any existing antihypertensive medication, to see whether there was any additional benefit. The majority of patients in both groups had a history of stroke as opposed to TIA, and of the subtypes of stroke, cerebral infarction was the commonest form, reflecting the higher incidence worldwide of ischaemic stroke compared with hemorrhagic stroke.
- When considering a medication that could prevent recurrent stroke, any effective medication would have to be taken lifelong. If the patient finds the medication unacceptable (for example due to side effects) then they are unlikely to adhere to this treatment for a long period of time. One of the most remarkable aspects of the PROGRESS study was the outstanding tolerance to active treatment. This is demonstrated by the graph on this slide demonstrating no significant difference between adherence to active treatment, and adherence to placebo over the 4 years of follow-up.
- In addition to an excellent adherence to the treatment, there were similar rates of withdrawal in the two groups, but also in hypertensive as well as normotensive patients. Moreover, of particular note is the low incidence of cough and hypotension in the active treatment group. These are two side effects often cited as reasons for discontinuation of ACE inhibitor therapy, but here we can see that in PROGRESS, the rate of these adverse effects with Coversyl-based therapy is very low. The low incidence of hypotension is particularly reassuring when it is remembered that 50% of these patients were normotensive at entry into the study. This confirms the safety of Coversyl in post-stroke patients.
- This graph shows the mean reductions in both systolic and diastolic blood pressure in the active and placebo groups throughout the course of the study. It can be seen that there is a clear, consistent, and enduring reduction of blood pressure over the 4-year period in the group treated with Coversyl-based therapy. This is important, as the intention of the study was to examine whether blood pressure-lowering with a Coversyl-based regimen leads to a reduction in recurrent stroke. Remember that this graph shows mean reduction of blood pressure in all patients, and so this impressive and enduring reduction of blood pressure was seen in a mix of both hypertensive and normotensive patients.
- As can be seen on this chart, the mean blood pressure reduction is consistent in both hypertensives and nonhypertensives. As can be expected, patients receiving the combination therapy of Coversyl and indapamide shown a larger decrease in blood pressure. The large difference is also explained by the fact that patients who received the combination therapy had a significantly higher blood pressure level at entry than those receiving the monotherapy.
- Here is a graph showing the main result of the PROGRESS study. It can be clearly seen that treatment with a Coversyl-based regimen led to a reduction in relative risk of recurrent stroke of 28%. This is highly significant. The curves can be seen to separate very early, in the first year of treatment, meaning in theory that if a patient were started on Coversyl-based therapy, the beneficial effects for that patient would start almost immediately. Furthermore, it can be seen from the fact that the graphs are continuing to diverge throughout the course of the study, that the beneficial effect on recurrent stroke of treatment with Coversyl-based therapy increases during the course of treatment.
- Here it can be seen that there was a significant effect of Coversyl-based therapy on reduction of recurrent stroke, whatever the subtype: Coversyl-based therapy significantly reduced the risk of ischemic stroke (the commonest type of stroke) and cerebral hemorrhage (by an incredible 50% - particularly important since there are almost no pharmacological treatments available for this condition). Coversyl-based therapy also reduced the risk of fatal or disabling stroke as well as nonfatal or disabling stroke. (ie, Coversyl-based therapy reduced the number of people having severe strokes without increasing the numbers of people having a more minor stroke).
- This slide shows the breakdown of reduction in stroke in hypertensives and normotensives, diabetics, and nondiabetics or per subtype of stroke at the entry. As can be clearly seen that in the PROGRESS study, benefit was seen regardless of the patient’s type. All patients, whatever their blood pressure at entry, benefit from Coversyl-based therapy treatment. This suggests the idea that when one is considering the target blood pressure in stroke patients, whatever the level, its too high! (since even normotensive patients who had their BP reduced with Coversyl-based therapy were shown to experience clear benefits).
- This slide now emphazises that, as all patients benefited from the treatment, it should be considered irrespectively of the type of stroke or TIA, the initial BP at entry, the concomitant drugs, region and ethnicity, or age and gender.
- One of the prespecified secondary end points of the PROGRESS study was total major cardiovascular events (stroke, MI, or death from cardiovascular disease). In this table it can be clearly seen that treatment with Coversyl-based therapy significantly reduced total major cardiovascular events by 26%, and this result was driven by a particularly large reduction in numbers of nonfatal myocardial infarction, reduced by 38%. This is important since it shows that Coversyl-based therapy has protective effects on the brain as seen previously, but also at the level of the heart. Another interesting point that can be taken from this, is the fact that the reduction in myocardial infarction seen in the PROGRESS study is about twice as great as could be expected (from previous trials 1 ) from blood pressure reduction alone. This suggests that there is something specific to Coversyl-based therapy beyond simply blood pressure reduction that has helped to achieve these great results. 1. Collins R, MacMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull. 1994; 50: 272-298.
- Finally, this graph to show the effect on Coversyl-based therapy on major vascular events, reduced by 26% over the 4 years of follow-up.
- This graph clearly shows the effect of Coversyl-based therapy on major coronary events as defined per CHD death or nonfatal MI. As seen previously on stroke, Coversyl-based therapy reduced the major coronary events, and benefits are seen right at the initiation of the treatment, as the curves separate very early.
- Another striking benefit of Coversyl in providing optimal protection at the level of the heart is the effect seen in heart failure as defined by death for HF, hospitalization for HF, and discontinuation because of HF. Coversyl-based therapy reduces the onset of heart failure by 26%, and once more these benefits are seen early during the follow-up as seen on the graph.
- One of the main questions that was addressed when considering the results of the PROGRESS trial was the difference in results seen in patients receiving either Coversyl alone or the combination therapy (Coversyl + indapamide).
- Indeed, when looking at the results per subgroup, the results obtained among patients receiving the combination of Coversyl and indapamide provide higher efficacy in terms of stroke (43%) as well as on major vascular events (40%). However, among patients receiving Coversyl alone, the magnitude of the results on stroke or major vascular events did not reach significance.
- However, one should be very cautious when considering these results. It would be unfounded to draw final conclusions on the efficacy of Coversyl alone compared with the combination, as patients were not randomized to receive either the monotherapy or the combination. Indeed, patients receiving combination were significantly younger and had higher blood pressure at entry. Moreover, as the group of patients receiving Coversyl alone was statistically not powerful enough, it is impossible to draw conclusions from these results.
- So to summarize this point, the results with Coversyl alone were not detectable: - as the study was not designed or/and powered to detect the effect in such a small group; - moreover, the effects of Coversyl alone are nor proven nor disproven and a benefit up to 23% reduction on stroke can be expected; - there were significant differences in patients’ baseline characteristics receiving monotherapy or combination therapy. In conclusion, as results with the combination provide higher benefits, the recommendation from the investigators is to follow the same plan as in the protocol, that is to use Coversyl in all patients and combine indapamide whenever possible.
- Finally, another question that may cause concern is to know whether it is safe to lower blood pressure in post-stroke patients, especially among those who are normotensive.
- Once more some results of the PROGRESS trial provide us with conclusive evidence that is it safe to initiate a Coversyl-based therapy in stroke patients, even in those who are normotensive. Indeed, when looking at the adherence to the treatment during the follow-up, no difference were seen among patients receiving Coversyl-based therapy or the placebo, being striking proof of its excellent hemodynamic tolerance.
- Firstly let’s go through some epidemiological information regarding the importance of dementia, especially among stroke patients. Stroke and dementia are very closely correlated, as cerebrovascular disease is the second cause of dementia. Moreover, vascular dementia is one of the rare preventable dementia, which confirm the value of including it as an end point in the PROGRESS trial. Finally, to firmly establish the strong link between stroke and dementia, one sixth of stroke patients are suffering from dementia.
- If we try to define dementia as simply as possible, we would define it as a “loss of normal cognitive function” or in other words the “loss of capacity in thinking, learning, and memory.” Dementia has two main causes that can be interconnected to varying degrees: Alzheimer’s disease (being the commonest form) and vascular dementia. Vascular dementia is of sudden onset, follows stroke, can have varying consequences, and the following causes are considered to explain its onset: - single or multiple infarct, - small-vessel disease, - cerebral hypoperfusion, - cerebral hemorrhage.
- Looking now briefly at the burden of dementia in patients who have already experienced a stroke, we realize that its incidence increases impressively during the years after the stroke. Considering the increase in life expectancy and the better management of stroke (increasing survival), the incidence of dementia will logically increase in the coming years.
- This slide confirms the increase in dementia with regard to the population’s age. Both sexes will be more and more prone to develop dementia while increasing in age.
- In the PROGRESS trial, all patients underwent an MMSE evaluation each year to detect either cognitive decline and/or a dementia. On the chart are represented the patients’ baselines characteristics. As expected in a trial of this size, patients’ characteristics were homogeneous.
- The screening process for dementia was done in the PROGRESS trial by an MMSE evaluation and questions about dementia. Then if a case of dementia was suspected, the diagnosis was made by a specialist, based on the DSM-IV criteria, and all cases were reviewed centrally. Patients needed to have a drop of 3 points on the MMSE scale during the follow-up to have a cognitive decline.
- Among patients screened for dementia, 1580 of them had a positive screening during the follow-up and 410 of them were diagnosed as demented. Finally, among them, 108 cases of dementia were preceded by a recurrent stroke (post-stroke dementia). Apart from that, and still when considering all patients, 610 patients suffered from cognitive decline.
- Considering now the overall results on dementia, Coversyl-based therapy significantly reduces stroke-related dementia by 34% (despite a very wide CI). In patients who did not experience another stroke during the follow-up, results were not discernable and in patients overall, the strong trend for reducing the dementia did not reach significance (even though a benefit of up to 28% RR can not be excluded). To put these results in perspective with the previous ones seen on stroke, Coversyl-based therapy reduced the onset of stroke, and if patients experienced another stroke during the follow-up, Coversyl-based therapy reduces the onset of dementia.
- In terms of cognitive decline, Coversyl-based therapy reduces the onset of cognitive decline in all patients by 19%. Furthermore, in patients who experienced another stroke during the follow-up, the reduction in cognitive decline was even more impressive, reaching a RR of 45%.
- PROGRESS provides evidence of the undoubted benefits of Coversyl-based therapy in stroke patients. The next challenge is to implement these results, and to build a set of guidelines for treatment. In PROGRESS the protocol stated that patients could be started on active therapy once they were stable. In a practical sense this implies that for an acute stroke patient, treatment could reasonably be started at the time of discharge from their acute event, or alternatively at the first follow-up post discharge. For the large number of patients who have previously experienced a stroke or TIA (but with no acute event), the primary care physician could commence therapy at the patient’s next visit. PROGRESS demonstrated benefits in patients who had suffered a cerebrovascular event from as soon as a few months, up to as long as several years after their primary event. This makes prevention of recurrent stroke with Coversyl-based therapy equally important for those who have recently suffered a stroke as for those who have had a stroke several years ago - its never too late to start therapy!