1 / 50

Asasantin Retard in Stroke Prevention : a Clinical and Business Perspective

Asasantin Retard in Stroke Prevention : a Clinical and Business Perspective. by Dr U Ahmed Consultant Physician, Management Consultant, Medico-Legal & Bioethics Consultant. Introduction - 1. Clinical Perspective Epidemiology of Stroke and TIAs Primary Prevention of Stroke

brandie
Download Presentation

Asasantin Retard in Stroke Prevention : a Clinical and Business Perspective

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Asasantin Retard in Stroke Prevention : a Clinical and Business Perspective by Dr U Ahmed Consultant Physician, Management Consultant, Medico-Legal & Bioethics Consultant

  2. Introduction - 1 Clinical Perspective • Epidemiology of Stroke and TIAs • Primary Prevention of Stroke • Secondary Prevention of Stroke • Role of Antiplatelet Agents • The Future

  3. Introduction - 2 Business Perspective Strategic Perspective • strategic issues / choices / levels / fit • strategy and competitive advantage Marketing perspective • marketing theory / transactions vs. relationship • marketing analysis / mix / plan / strategy

  4. Epidemiology of Stroke & TIA Stroke • incidence 2.4/1000-OCSP • 2400 strokes per year/1m • 1800 new & 600 recurrent • of this, 700 die at 1yr; 1700 for sec. Prev. • added each year to 12,000/1m with previous TIA, Stroke or both i.e. prevalent

  5. Epidemiology - 2 Stroke • therefore, new Stroke survivors each year is 1700 i.e. 1100 independent & 600 depend • added to 12,000/1m people with previous stroke (8000), TIA (3000) or both (1000) • of the 12,000-800 (7%) will have a stroke per year i.e. 600 recurrent strokes & 200 new

  6. Epidemiology - 3 Stroke • these 800 strokes i.e. 33% of the 2,400/1m/yr are those potentially avoidable by secondary prevention strategies targeted at the 12,000 prev. TIA/Stroke/both/1m/yr • TIA • 0.5/1000 inc.- 500/1m/yr new TIAs

  7. Prevention of Stroke • Risk Factor Modification • Management of TIAs • Antiplatelet Therapy • Anticoagulant Therapy • Other Medical Therapy -PROGRESS • Carotid Endarterectomy • NNTs

  8. Current Management of TIAs an overview Risk factors • non-modifiable • age • sex • family history • ethnicity • modifiable • hypertension, hypercholesterolaemia, • diabetes, smoking, alcohol, physical inactivity

  9. Other risk factors • oestrogens • Homocysteinuria • lipoprotein fractions • hypercoagulable states : antiphospholipid abs, protein S, C, factor V Leiden, antithrombin III defs

  10. Hypertension • SHEP • SYST – EUR – 42% stroke risk reduction in sys hyp • HOT • BHS Guidelines • PROGRESS • PATS; CAPPP, SYS REVIEW - 1997 & 2001, HOPE

  11. Diabetes mellitus • UKPDS - 44% stroke risk reduction with BP Rx • High stroke risk in 2HBS > 97 centile • Low BM reduce microvascular disease NOT macrovascular

  12. Life style factors • Smoking • Alcohol • Physical inactivity • Poor diet • Obesity

  13. Hyperlipidaemia • No RCTs for lipid in TIA or Stroke yet • On-going Trials – SPARCL, PROSPER, etc. • Meta-analysis of RCTs on Statins in IHD- e.g. 4S, WOSCOP etc. - 29% stroke risk reduction - 22% reduction in overall mortality

  14. Hyperlipidaemia, cont. • Secondary prevention trials – 32% stroke risk reduction • Primary prevention trials – 20% stroke risk reduction • ? Current consensus on Statins in TIA or Stroke - PHS, SPARCL, PROSPER

  15. Oestrogens • Pill • HRT in TIA / Stroke • Women Oestrogen Stroke Trial, Oestrogen & Progestegin Interventions Trial Other : • Homocysteine Trials – VISP, VITATOPS etc. (folate, B6, B12)

  16. MEDICAL THERAPYAntiplatelet agents Aspirin • cyclo-oxygenase inhibition; side effects -recent Meta-analysis • ? Optimal dose – 25mg to 1500mg per day ! • UK – TIA Aspirin Study – 300mg v. 1200mg – no difference

  17. Antiplatelet agents, cont. • Dutch TIA Study- Aspirin 30mg vs. 283mg : no difference in stroke risk reduction • ACE Study – lower better overall vascular risk reduction : 6.2% vs. 8.4% for Aspirin 130mg vs. 326mg respectively; no difference in Stroke Risk reduction • NASCET – Higher Dose Better : ?Relevance to TIA but not Endarterectomy • FDA/Consensus – Aspirin 50 to 325mg/day • High Risk patients benefit from Aspirin (HOT, TPT, PPP); not Low Risk (BDS, PHS)

  18. Antiplatelet agents, cont. • Ticlopidine • Inhibits ADP-PLT Aggregation • Side effects : diarrhoea, TTP, Neutropaenia • CATS – 23.3% Stroke Risk Reduction (+ other Vascular events) • TASS – ASP 650mg bd vs. TCL 250mg bd – TCL Better reduction in Stroke & All-Cause Mortality by : 12% vs. 7% at 3 years; and Stroke Risk by 21% • Use : USA - Asp intolerance & Asp failures; cardiology - UK

  19. Antiplatelet agents, cont. • Clopidogrel : Use in Aspirin-intolerance & failures • Ticlopidine Structure; Inhibits ADP-PLT Aggregation • S.e : diarrhoea, rash, Git bleed • CAPRIE; CAPRA; CLOP + ASP Trials • Clop 75mg vs. Asp 325mg in Stroke, MI, PVD but not TIAs; 19,000 pts • Clop reduced COMPOSITE outcome risk by 8.7% in favour • NO Significant difference in Stroke Subgroup

  20. Antiplatelet agents, cont. • Dipyridamole (+Aspirin) • Phosphodiesterase inhibitor • Trials – 5 • French Toulouse Study : no difference; 440 TIA PTs; Asp vs. Dipy vs. Asp + Dipy • AICLA Study - 604 TIA/Stroke PTs given Asp vs. Asp + Dipy vs. Placebo – 42% Stroke Risk Reduction with Asp; no Added Benefit from Dipy

  21. Antiplatelet agents, cont. • ACCS – 890 Stroke/TIAs- given Asp vs. Asp + Dipy vs Placebo – Reduced Stroke Risk; no difference between Asp and Combination • ESPS -1- Placebo vs. Asp + Dipy – 33% Reduction in Risk of Stroke & Death – 38% Stroke Risk Reduction 2,500 Stroke/TIA pts

  22. Antiplatelet agents, cont. • ESPS-2 – Asp +Dipy MR vs. Asp vs. Dipy MR vs. Placebo • Asp 18% Stroke Risk Reduction • Dipy MR 16% Stroke Risk Reduction • Asp + Dipy MR 37% Stroke Risk Reduction • 23.1% Better Than Aspirin Alone • 24% Better Than Dipyr MR Alone • S.e. Headaches; Use-Asp intolerance & failures • ? Triple AntiPlatelet Therapy

  23. COST per YEAR Aspirin £ 2 Asp + Dipy MR £ 119 Clopidogrel £ 460 Ticlopidine £ 1,217 Efficacy - slide

  24. Anticoagulants - ?optimal INR; ?wafarin in Stroke • AF – Warfarin Rx of Choice; Other Indications -Cardio-embolic & Atherothrombotic - no RCTs yet - Warfarin Aspirin Recurrent Stroke Study, Euro-Austr Stroke Prev Trial • SPAF I, II, III and EAF Trial - Future ?Thrombin Inh e.g. SPORTIF III • Increased Stroke Risk in AF : • hypertension, pmh TIA/Stroke • poor LV function, systemic embolism • RHD, age >75 years • prosthetic valves

  25. SURGICAL RxCarotid Endarterectomy Asymptomatic • ACAS Trial : >60% stenosis; 1600 Pts; ARR 4.9% (11% vs. 6.1%); 5 yr FU • VAStudy : >50%stenosis; 444 Pts; ARR 12.6% (20.6% vs. 8%); 4 yr FU

  26. SURGICAL RxCarotid Endarterectomy cont. Symptomatic - NASCET - 70 - 99% Sten; 2226 Pts; ARR17% (26 vs. 9%); 2yr FU • ECST-70-99% stenosis; 3024Pts; ARR11.6% (26.5% vs.14.9%); 3yr FU; NNT8 • NASCET - 70 - 99%stenosis; 2226Pts; ARR17%(26% vs. 9%); 2yr FU; Benefit in 50-69% • Risk-factor modelling; Role of IAD

  27. Angioplasty • CAVATAS • Posterior Circulation TIAs - angioplasty -Vertebral Artery • surgery • TIA CLINIC

  28. NNTs - 1 Acute Stroke Treatment • Stroke Unit - 18 • Aspirin - 83 (Rx of Acute Stroke) • Thrombolysis - 16

  29. NNTs - 2 Stroke Prevention • Anti-hypertensive Rx - 45 • Smoking Cessation - 43 • Statins - 59 • Aspirin - 100 • Clopidogrel - 62 • Aspirin + Dipyridamole MR - 53

  30. NNTs -3 • Anticoagulants - 12 • Carotid Endarterectomy - 26 (symptomatic) See ACETATES - for DETAILS !

  31. Business Perspective Strategy Perspective • Strategic issues/- Strategic choices - determine scope of activities - evaluate success of activities - acquire & allocate resources & capability - create effective match challenges in env - manage networks c & b/w stakeholders

  32. Business Perspective - 2 Strategy perspective • Levels of strategy- corporate/bus/intern units • Strategic success / fit - corporate success based on effective match b/w external relationships of a firm and its own distinctive capabilities (Kay,1993)

  33. Business Perspective - 3 Strategy Perspective • Competitive advantage - your most dangerous competitors are those that are most like you. The difference b/w you and your competitors is the basis of your advantage (Henderson,1989)

  34. Business Perspective - 4 Strategy Perspective • Strategic stretch - creating a chasm b/w an organisation’s resources / capabilities / ambition - bridging the chasm through leveraging resources & capabilities (Hamel & Prahalad, 1993)

  35. Business Perspective - 5 Strategy Perspective • Resources - input into production process; few are productive on their own. Productive activity requires the co-operation & co-ordination of a team of resources • Capability - capacity of a team of resources to perform activities is a source of competitive advantage (Grant,1991)

  36. Business Perspective - 6 Leveraging Resources • concentrate resources on strategic goals • accumulate resources efficiently • complement types of resources - add value • conserve resources - avoid waste ! • recover resources from market - in minimum time !

  37. Business Perspective - 7 • Competitive Advantage - potential / superior rate of profit • Sources of Competitive Advantage - strategic assets e.g. knowledge / exclusivity - distinctive capabilities e.g. innovation - differentiation : image, support, price, design - cost leadership : economies of scale, learning, efficiency

  38. Business Perspective - 8 Exploiting Competitive Advantage • Sustainability : durable, transparent, transferable, replicable • Appropriateness • Responding to Opportunity for Comp Adv - Key resource : Information - Key Capability : Flexibility of Response

  39. Marketing Perspective • Marketing • Marketing Theory • Transaction / Relationship Marketing • Marketing Analysis • Marketing Mix • Marketing Plan • Marketing Strategy

  40. Marketing • Management process responsible for matching resources with opportunities at a profit, by identifying, anticipating, influencing, & satisfying customer demand (UKCIM) • Social & managerial process by which individuals & groups obtain what they need through creating & exchanging value(Kotl)

  41. Marketing Theory Perfect Markets vs. Imperfect Markets • many buyers&sellers • perfect knowledge • homogenous products - customers indifferent b/w sellers • no barriers to movement of goods or factors of production

  42. Marketing Types Transaction vs. Relationship Marketing • relational • mutual benefit • long-term • strategic • cost effective • reputation

  43. Marketing Analysis Systematic understanding of the existing & potential markets for products & services, providing this info to MX and making recommendations on how the customers’ requirements might best be served /met.

  44. Marketing Analysis What do you analyse? • Buying decisions of your product / service • Who do you analyse? • Customers : decisions, needs, aspirations, expectations • Competitors : performance, goals, capability • Yourself : offering, performance, capability • How do you analyse? Research & Audit

  45. Market Research/Audit • Systematic problem-analysis, model-building & fact-finding for the purpose of improved decision-making & control in the marketing of goods & services. (Birn,1992) • Analyses of internal reporting systems relating to all aspects of sales / purchases, distribution & invoicing can highlight problems & opportunities

  46. Market Research Why ? • To reduce uncertainty • To monitor performance • To contribute to strategic processes - by helping organisations understand the relationship to their environment • How? Quantitative e.g. exp vs. Qual - surveys

  47. Competitor Analysis • Info on - goals, strategies, beliefs, capabilities, nature / changes, strengths, weaknesses, marketing operations • Methods - value chain analysis, SWOT, organisational culture & structure, managerial features, strategic factors

  48. Marketing Mix/Plan • 7 Ps : Product, Price, Promotion, Place, People, Process, Physical Evidence • Marketing Plan : the process by which resources are allocated to meet specific marketing objectives - knit together strategic & day-to-day elements of marketing

  49. Marketing Plan • McDonald 9-point Plan • mission, performance survey, financial prospecting, market overview, SWOT analyses, portfolio summary ( segment planning), assumptions underpinning plan, setting objectives & strategies, financial budgets

  50. Marketing Strategy • Monitor : industry, competition, environment • Evaluate : market opportunities & threats • Identify : competitive options & strategies • Development : detailed marketing plan / implementation & review • Methods : SWOT, STEEP, Ansoff, Porter- cdf

More Related