Table of Contents

ABOUT DATAMONITOR HEALTHCARE 2
About the Cardiovascular pharmaceutical analysis team 2
CHAPTER 1 EXECUTIVE SUMMARY 4
Scope of the analysis 4
Contributing experts 4
Experts interviewed for this report (interviewed in October 2007) 4
Experts interviewed for Stakeholder Insight 2005: Acute Stroke, DMHC2058 (interviewed in 2005) 5
Experts interviewed for Pipeline Insight 2005: Antithrombotics, DMHC2084 (interviewed in 2005) 5
Experts interviewed for Pipeline Insight 2006: Acute Stroke, DMHC2167 (interviewed in February 2006) 5
Datamonitor insight into the stroke market 6
Related reports 7
CHAPTER 2 INTRODUCTION AND SCOPE 9
Coverage of the Stakeholder Insight survey 9
Country level "treatment trees" 12
Supporting data sets 12
CHAPTER 3 COUNTRY TREATMENT TREES 13
Introduction to the treatment trees 13
United States 14
Japan 19
France 24
Germany 29
Italy 34
Spain 39
United Kingdom 44
CHAPTER 4 EPIDEMIOLOGY AND PATIENT SEGMENTATION 49
Disease definition and classification 49
Symptoms 49
Ischemic stroke 50
Hemorrhagic stroke 52
Transient ischemic attack 55
Epidemiology of stroke 56
Epidemiology methodology 58
US 58
Japan 58
Europe 59
Key patient segmentations 60
Patient age 60
Comorbidities, complications and risk factors 61
CHAPTER 5 DIAGNOSIS AND TREATMENT OPTIONS 64
Presentation and diagnosis 64
Time to presentation 64
Diagnosis 67
Healthcare professionals involved in the diagnosis of stroke 67
Tests in emergency diagnosis of stroke 68
Secondary tests performed after initial diagnosis 73
Influences on diagnosis and treatment rates 75
The National Stroke Association 75
STOP Stroke Act 75
The Stroke Association 76
Treatment guidelines 77
Treatment of acute ischemic stroke 78
Treatment of hemorrhagic stroke 81
Stroke units 83
Treatment pathways 90
CHAPTER 6 PRESCRIBING TRENDS AND INFLUENCING FACTORS 92
Ischemic stroke treatment 92
Antiplatelets 100
Anticoagulants 102
Thrombolytics 104
Hemorrhagic stroke treatment 107
CHAPTER 7 IMPROVING TREATMENT OUTCOMES 111
Treatment outcomes 111
Length of stay 111
Mortality 113
Recovery 115
Recurrence of stroke 117
Unmet needs 119
Physician education: tackling physician competence and attitude 121
Patient education: raising stroke-symptom awareness 128
Infrastructural unmet needs: establishing, maintaining and expanding the network of dedicated stroke units. 131
Unmet clinical needs 135
Procoagulation 135
Neuroprotection 135
Revascularization 136
Safety 139
Efficacy 139
Extended time window of treatment 141
Ease of use 142
New product development 145
Prolyse 148
Clinical trials 148
Ancrod 148
Clinical trials 149
Danaparoid sodium 150
Clinical trials 150
Dabigatran etexilate 151
Clinical trials 152
Clazosentan 152
Clinical trials 152
Rivaroxaban 153
Clinical trials 153
Desmoteplase 154
Clinical trials 154
Conclusion 154
APPENDIX A BIBLIOGRAPHY 156
Epidemiology 156
General and clinical trial data 158
APPENDIX B 164
Physician research methodology 164
Physician sample breakdown 164
US 164
Japan 165
France 165
Germany 166
Italy 166
Spain 167
UK 167
APPENDIX C 168
The survey questionnaire 168
1. Patient Segmentation 168
2. Presentation And Referral 170
3. Diagnosis 173
4. Treatment 177
Treatment of ischemic stroke 179
Treatment of hemorrhagic stroke 187
5. Treatment Outcomes 190
Glossary 191
DISCLAIMER 193
List of Tables
Table 1: Incidence of first-ever stroke, 2007 57
Table 2: All stroke patients with comorbidities and risk factors in the seven major markets, 2007 61
Table 3: Causes of hemorrhagic stroke experienced by patients, 2007 63
Table 4: Type of medical professional diagnosing stroke, 2007 67
Table 5: Emergency diagnosis tests carried out in stroke patients, 2007 68
Table 6: Percentage of patients undergoing each test following initial diagnosis, 2007 74
Table 7: Antiplatelets given to ischemic stroke patients in the acute phase, 2007 100
Table 8: Antiplatelets given to ischemic stroke patients in the post-acute phase, 2007 101
Table 9: Anticoagulants given to ischemic stroke patients in the acute phase, 2007 102
Table 10: Anticoagulants given to ischemic stroke patients in the post-acute phase, 2007 103
Table 11: Types of therapy received by Ischemic stroke patients to prevent recurrence, 2007 105
Table 12: Late-stage drugs in development for stroke, 2007 147
US physician sample breakdown, 2007 164
Japan physician sample breakdown, 2007 165
France physician sample breakdown, 2007 165
Germany physician sample breakdown, 2007 166
Italy physician sample breakdown, 2007 166
Spain physician sample breakdown, 2007 167
UK physician sample breakdown, 2007 167
List of Figures
Figure 1: Diagrammatic overview of the coverage of the Stakeholder Insight: Stroke survey, 2007 11
Figure 2: Summary of stroke treatment in the US, 2007 14
Figure 3: Ischemic stroke treatment in the US (I), 2007 15
Figure 4: Ischemic stroke treatment in the US (II), 2007 16
Figure 5: Ischemic stroke treatment in the US (III), 2007 17
Figure 6: Hemorrhagic stroke treatment in the US, 2007 18
Figure 7: Summary of stroke treatment in Japan, 2007 19
Figure 8: Ischemic stroke treatment in Japan (I), 2007 20
Figure 9: Ischemic stroke treatment in Japan (II), 2007 21
Figure 10: Ischemic stroke treatment in Japan (III), 2007 22
Figure 11: Hemorrhagic stroke treatment in Japan, 2007 23
Figure 12: Summary of stroke treatment in France, 2007 24
Figure 13: Ischemic stroke treatment in France (I), 2007 25
Figure 14: Ischemic stroke treatment in France (II), 2007 26
Figure 15: Ischemic stroke treatment in France (III), 2007 27
Figure 16: Hemorrhagic stroke treatment in France, 2007 28
Figure 17: Summary of stroke treatment in Germany, 2007 29
Figure 18: Ischemic stroke treatment in Germany (I), 2007 30
Figure 19: Ischemic stroke treatment in Germany (II), 2007 31
Figure 20: Ischemic stroke treatment in Germany (III), 2007 32
Figure 21: Hemorrhagic stroke treatment in Germany, 2007 33
Figure 22: Summary of stroke treatment in Italy, 2007 34
Figure 23: Ischemic stroke treatment in Italy (I), 2007 35
Figure 24: Ischemic stroke treatment in Italy (II), 2007 36
Figure 25: Ischemic stroke treatment in Italy (III), 2007 37
Figure 26: Hemorrhagic stroke treatment in Italy, 2007 38
Figure 27: Summary of stroke treatment in Spain, 2007 39
Figure 28: Ischemic stroke treatment in Spain (I), 2007 40
Figure 29: Ischemic stroke treatment in Spain (II), 2007 41
Figure 30: Ischemic stroke treatment in Spain (III), 2007 42
Figure 31: Hemorrhagic stroke treatment in Spain, 2007 43
Figure 32: Summary of stroke treatment in the UK, 2007 44
Figure 33: Ischemic stroke treatment in the UK (I), 2007 45
Figure 34: Ischemic stroke treatment in the UK (II), 2007 46
Figure 35: Ischemic stroke treatment in the UK (III), 2007 47
Figure 36: Hemorrhagic stroke treatment in the UK, 2007 48
Figure 37: Average age of stroke patients, 2007 60
Figure 38: Time to presentation after the onset of symptoms, 2007 65
Figure 39: Time taken to obtain emergency test results, 2007 71
Figure 40: Secondary diagnostic tests carried out in stroke patients, 2007 73
Figure 41: Overview of treatment guidelines for acute ischemic stroke 78
Figure 42: Overview of treatment guidelines for ICH 81
Figure 43: Organization of an acute neurological stroke unit 83
Figure 44: Share of respondents whose hospital has an acute stroke unit, seven major markets, 2007 85
Figure 45: Treatment Pathways, 2007 90
Figure 46: Percentage of patients that are referred from other hospitals or admitted as emergencies to stroke units, 2007 91
Figure 47: Percentage of ischemic stroke patients treated by each healthcare professional, 2007 93
Figure 48: Stroke patients receiving initial drug therapy in the ambulance or emergency room, 2007 95
Figure 49: Ischemic stroke patients treated with acute drug therapy, 2007 98
Figure 50: Ischemic stroke patients treated in the post-acute phase, 2007 99
Figure 51: Ischemic stroke patients receiving specified thrombolytic (%), 2007 104
Figure 52: Hemorrhagic stroke patients receiving each specified therapy, 2007 107
Figure 53: Hemorrhagic stroke patients undergoing surgery, 2007 108
Figure 54: Hemorrhagic stroke patients undergoing the specified surgical procedures, 2007 109
Figure 55: Average length of hospital stay, 2007 112
Figure 56: Stroke patients who die before receiving medical attention, 2007 113
Figure 57: Stroke patients who die in hospital, 2007 114
Figure 58: Level of recovery achieved by ischemic stroke patients, 2007 115
Figure 59: Hemorrhagic stroke patients making each type of recovery (%), 2007 116
Figure 60: Stroke patients referred for rehabilitation, 2007 117
Figure 61: Stroke patients that go on to have recurrent stroke (%), 2007 118