Long-term prognostic factors of coronary artery disease patients after out-of-hospital cardiac arrest

Background

The long-term prognosis of survival in patients with out-of-hospital cardiac arrest (OHCA) with coronary artery disease (CAD) remains poor.

Methods

There were 2391 out-of-hospital cardiac arrest (OHCA) patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among them, 204 patients had CAD that caused OHCA (39%: multi-vessel disease, 19%: chronic total occlusion (CTO), 13%: vasospastic angina (VSA)). To predict mortality, we investigated patients' characteristics, pre-hospital information and findings of CAG.

Results

At 1-year later, 104 patients (51%) survived. Younger age (P<0.001), VF survivor (P<0.001), pre-hospital ROSC (P<0.001), bystander CPR (P=0.013), without ECMO (P<0.001), lower lactate level on admission (P<0.001), and higher geriatric nutritional risk index score (P<0.001) were associated with low 1-year mortality, while with ST-segment elevation (P=0.778), BMI level (P=0.344), and sex (0.401) were not. And in the findings of CAG, the past history of CAD (P=0.049), the higher number of coronary vessel disease (P=0.003) such as multi-vessel disease (P=0.022), higher SYNAX score (P=0.016), and larger infarct size (max CK level; P=0.013, max CK-MB level; P<0.001) were associated with high 1-year mortality. On the other hand, acute coronary syndrome (P=0.300), any coronary lesion (RCA (P=0.447), LAD (P=0.089), LCX (P=0.096), or LMT (P=0.842)), and with CTO lesion (P=0.140) were not associated. Zero-vessel disease (VSA, P=0.001) had lower mortality among the CAD patients. In the multivariate Cox proportional hazards model, age (hazards ratio; HR: 1.03, 95%confidence interval (CI) 1.00–1.06, P<0.001) and bystander CPR (HR: 0.36, 95% CI 0.20–0.65, P<0.001) were the independent predictors of mortality.

Conclusions

Younger age and pre-hospital support after OHCA with CAD were the predictors of low mortality. Pre-hospital information, systemic condition on arrival, or anatomical coronary complexity were important to predict low mortality.

Funding Acknowledgement

Type of funding sources: None.

Drug-coated balloon versus drug-eluting stent following orbital atherectomy for calcified coronary artery: one-year outcomes of a retrospective cohort study

Background

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. The effectiveness of drug-coated balloons (DCBs) and orbital atherectomy system (OAS) is unknown.

Methods

In this retrospective, single-center study, we compared the use of DCBs with second- and third-generation DESs following orbital atherectomy (OA) for calcified de novo coronary lesions. All patients underwent PCI with intravascular imaging. The primary endpoint was major cardiac event, that was a composite of cardiac death, death for unknown cause, non-fatal myocardial infarction, or target lesion revascularization at 1 year.

Results

Between June 2018 and December 2019, 107 patients with coronary lesions were enrolled in this study and divided into two groups: 23 patients in DCB group and 84 patients in DES group. The post-procedure segment percentage diameter stenosis was 23.1% (interquartile range [IQR], 17.7 to 32.5) with DCB versus 14.4% (IQR, 10.0 to 21.2) with DES (P<0.001). Overall adverse event rate for PCI procedure was low: one dissection with DES group, no persistent slow/no-flow, and no perforation with both group. The primary endpoint was not significantly different between 2 groups [DES: 6.0% (5/84), DCB: 0.0% (0/23), log-rank P=0.24].

Conclusions

In calcified coronary artery disease, using DCB following OA is as safe and effective as using DES following OA with respect to 1-year clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness and safety of apixaban vs warfarin among older venous thromboembolism patients: a subgroup analysis of age

Background

Venous thromboembolism (VTE) is the third most common cardiovascular condition in adult patients. Older patients are at an increased risk of VTE. However, they have been underrepresented in clinical trials and evidence on the safety and effectiveness of anticoagulants in older VTE patients, especially very elderly patients (≥80 years), is sparse.

Purpose

To evaluate the risk of recurrent VTE, major bleeding (MB), and clinically relevant non-major (CRNM) bleeding among older VTE patients initiating apixaban or warfarin according to two age sub-groups: 65–79 and ≥80 years.

Methods

Older VTE patients (aged ≥65 years) who initiated apixaban or warfarin were identified from the CMS Medicare database (September 2014–December 2017). To balance the characteristics between apixaban and warfarin patients, stabilized inverse probability treatment weighting (IPTW) was conducted. Post IPTW, a subgroup interaction analysis was conducted to evaluate if there was any difference in treatment effects between the two age subgroups (65–79 vs. ≥80) on recurrent VTE, MB, and CRNM bleeding. Cox proportional hazard models were used to conduct the interaction analysis, and the statistical significance of the interaction was set to p-value <0.10.

Results

A total of 22,135 apixaban and 45,840 warfarin patients with VTE aged ≥65 years were eligible for analysis. Post IPTW, patient characteristics were balanced between the apixaban and warfarin treatment cohorts. Apixaban patients had significantly lower risk of recurrent VTE, MB, and CRNM bleeding compared to warfarin patients (Figure). 42,551 (62.6%) were aged 65–79 years and 25,424 (37.4%) were aged ≥80 years. Among apixaban or warfarin patients, those aged 65–79 years had lower Charlson comorbidity index scores (mean 2.7 vs 3.2) and were less likely to have a diagnosis of anemia (34.7–34.9% vs 42.3–42.5%), cerebrovascular disease (14.7–15.7% vs 20.3–20.5%), or dementia (5.0–6.9% vs 20.4–24.6%) compared to patients aged ≥80 years. Across both age subgroups, incidence rates of recurrent VTE, MB and CRNM bleeding were lower for apixaban vs. warfarin. No significant interaction was observed between the treatment and age on recurrent VTE and MB (Figure). There was a significant interaction between treatment and age on CRNM bleeding. Apixaban trended towards a lower risk of CRNM bleeding across both age groups but the treatment effect on CRNM bleeding was larger for patients aged 65–79 years.

Conclusion

The treatment effects of apixaban vs. warfarin on recurrent VTE and MB were consistently observed across both older age groups in this analysis. More studies are needed to evaluate management of VTE in an older and especially the very elderly population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

Effectiveness and safety of apixaban vs warfarin among older venous thromboembolism patients stratified by race

Background

Race has been identified as a risk factor for venous thromboembolism (VTE), with Black individuals having a higher risk of VTE compared to Caucasians. Black patients have been underrepresented in clinical trials evaluating anticoagulants for VTE. There has been limited evidence about the effects of anticoagulants for Black patients with VTE in routine clinical practice.

Purpose

To evaluate the risk of recurrent VTE, major bleeding (MB), and clinically relevant non-major (CRNM) bleeding among VTE patients initiating apixaban or warfarin stratified by race.

Methods

Older VTE patients (≥65 years) who initiated apixaban or warfarin were selected from the CMS Medicare database (September 2014–December 2017). Stabilized inverse probability treatment weighting (IPTW) was used to balance the differences between apixaban and warfarin cohorts. After IPTW, subgroup interaction analysis was conducted to evaluate if treatment effects were different between Black and White patients in the Medicare population. Due to small sample size, other races were not included in the interaction analysis. Cox proportional hazard models were used to evaluate if there was significant interaction (p<0.10) between treatment and race on recurrent VTE, MB, or CRNM bleeding.

Results

A total of 22,135 apixaban and 45,840 warfarin patients with VTE were included in the analysis. Post-IPTW, patient characteristics were balanced between apixaban and warfarin treatment cohorts. Apixaban patients had significantly lower risk of recurrent VTE, MB, and CRNM bleeding compared to warfarin patients (Figure). When stratified by race, 57,008 (83.9%) were White, 7,832 (11.5%) Black, and 3,135 (4.6%) other races. For both treatment cohorts, age was similar between Black (77.0–77.2 years) and White (77.4–77.5 years) patients. However, Black patients were more likely to have an inpatient VTE event (77.3–77.8% vs. 63.1–63.3%), a provoked VTE event (78.6–79.5% vs 69.4–69.6%), and a higher comorbidity index score (mean 4.1 vs. 2.7) compared to White patients with VTE. The incidence rates per 100 person-years of recurrent VTE (2.0–3.3 vs 1.4–2.2) and MB (7.4–10.1 vs 3.5–5.3) were also numerically higher for Black patients compared to White patients. Across both race groups, apixaban patients had a lower incidence rate of recurrent VTE, MB and CRNM bleeding compared to warfarin patients. No significant interaction was observed between treatment and race for recurrent VTE, MB, or CRNM bleeding (Figure). The findings within each race group were consistent with those of the overall VTE population.

Conclusion

Among older VTE patients, disparities were observed in VTE characteristics and clinical outcomes between Black and White patients. Across both race groups, apixaban had lower risk of recurrent VTE, MB, and CRNM bleeding compared to warfarin patients. Further studies are needed to identify optimal management strategies for Black patients with VTE.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer IncBristol-Myers Squibb Company

Effectiveness and safety of apixaban vs warfarin among venous thromboembolism patients using five US databases: a subgroup analysis of chronic liver disease

Background

Venous thromboembolism (VTE) is a serious disease in the United States affecting approximately 1 in 1000 patients each year. Patients with chronic liver disease (CLD) are at an increased risk of VTE and major bleeding (MB). Currently, insufficient clinical and real-world evidence exists on the efficacy/effectiveness and safety of apixaban or warfarin in VTE patients with CLD.

Purpose

To evaluate the risk of recurrent VTE, MB, and clinically relevant non-major (CRNM) bleeding among VTE patients initiating apixaban or warfarin stratified by CLD status.

Methods

VTE patients ≥18 years of age (≥65 years for Medicare) initiating apixaban or warfarin were identified from CMS Medicare and four commercial claims databases. To balance the characteristics between apixaban and warfarin patients, stabilized inverse probability treatment weighting (IPTW) was conducted. Post-IPTW, subgroup interaction analysis was conducted to evaluate whether treatment effects of apixaban vs. warfarin were consistent across patients with and without a diagnosis of CLD. Cox proportional hazard models were used to evaluate the interaction of the treatment (apixaban vs. warfarin) and CLD on recurrent VTE, MB, and CRNM bleeding. The statistical significance of the interaction was set to p-value <0.10.

Results

A total of 60,786 apixaban and 94,333 warfarin patients with VTE were eligible for analysis. Post-IPTW, all patient characteristics were balanced between the apixaban and warfarin treatment cohorts. Apixaban treated patients had significantly lower risk of recurrent VTE, MB, and CRNM bleeding compared to warfarin patients (Figure). In the IPTW weighted population, 4,766 (7.8%) apixaban patients and 6,320 (6.7%) warfarin patients had a diagnosis of CLD. For the apixaban or warfarin patients, those with a diagnosis of CLD were generally younger (mean 64.0–65.2 vs 66.9 years), had higher Charlson comorbidity index scores (mean 3.8–3.9 vs 2.1) and were more likely to have an inpatient VTE event (67.8–69.5% vs 53.0–53.2%) or provoked VTE events (66.2–67.8% vs 55.4–55.5%) compared to patients without a diagnosis of CLD. The incidence rate of recurrent VTE, MB, and CRNM bleeding was higher among VTE patients with CLD than without CLD and was also higher for patients treated with warfarin compared to those treated with apixaban regardless of CLD status (Figure). There were no significant interactions observed between treatment and CLD status for recurrent VTE, MB or CRNM (Figure).

Conclusion

Treatment with apixaban had a lower risk of recurrent VTE, MB, and CRNM bleeding compared to treatment with warfarin. The benefits of apixaban were consistently observed among subgroups of VTE patients with and without CLD. Additional studies are needed to evaluate VTE patients with CLD.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer, Inc.

Promoting healthy trajectories for urban middle school youth through county-funded, parks-based after-school programming

Ongoing pressure for public schools to prioritize academics has increased attention on after-school settings as a critical space for social-emotional learning (SEL). After-school programs are uniquely positioned to build protective and promotive factors that contribute to positive future orientation, especially within communities where systemic inequities create barriers to high school graduation, higher education, employment, and earnings. This study examines Fit2Lead Youth Enrichment and Sports (YES), a county-funded, parks-based after-school collaboration for middle schoolers that merges mental health and recreation to promote healthy trajectories. Eight Miami neighborhood parks were selected based on county data indicating high rates of violence. An open trial design (N = 9 parks, 198 youth; ages 9-15; 40.5% female; 66.5% Black/African American, 24.9% Hispanic/Latinx, and 76.3% low-income) tested hypotheses that participation for adolescents exposed to community violence would disrupt a commonly reported decline in self-regulation and self-efficacy, and mitigate risk for anxiety and depression. Youth completed questionnaires at the beginning and end of one school year. Paired t-tests revealed no changes from pre to post, and no differences by baseline levels of youth and parent mental health. Findings highlight the promise of prevention programs to disrupt downward trajectories for youth during the risky time of early adolescence.

Effectiveness and safety of apixaban, LMWH, and warfarin among high-risk subgroups of VTE patients with active cancer

OBJECTIVE

This pooled claims database study evaluated the risk of recurrent Venous Thromboembolism (VTE) and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban, low-molecular weight heparin (LMWH), or warfarin stratified by high-risk subgroups.

METHODS

Patients diagnosed with VTE in the setting of active cancer who initiated apixaban, LMWH, or warfarin were identified using four US commercial claims databases from 01SEP2014 to the end of the study period (MarketScan: 01MAR2014-30JUNE2017; Optum and Humana: 01MAR2014-31DEC2017; PharMetrics: 01MAR2014-31MAR2018). Stabilized inverse probability treatment weighting (IPTW) was used to balance treatment cohorts. Cox proportional hazard models were used to evaluate the risk of recurrent VTE and MB for each subgroup stratification: VTE risk level based on cancer types, metastatic diagnosis, cancer treatment, chemotherapy, gastrointestinal cancer, and index VTE event type (PE vs. DVT). Statistical significance (p < .10) of the interaction between treatment effects and subgroups was evaluated.

RESULTS

Eligible subjects included 3393 apixaban, 6108 LMWH, and 4585 warfarin patients. After IPTW, all patient characteristics were balanced. Analyses stratified by the VTE risk level, metastatic diagnosis, cancer treatment, chemotherapy, gastrointestinal cancer and index VTE event type showed generally consistent results according to the respective subgroup (most of the p values for interaction >0.10). Two significant interactions were observed between apixaban vs. LMWH and VTE risk level (interaction p = .051) and metastatic diagnosis (interaction p < .001) for recurrent VTE; one significant interactions were observed between apixaban vs. LMWH and cancer treatment for MB (interaction p = .074). Additionally, for warfarin vs. LMWH, two significant interactions were observed between treatment and VTE risk level (interaction p = .005) and metastatic diagnosis (interaction p = .002) for recurrent VTE.

CONCLUSIONS

Across these high-risk subgroups of VTE cancer patients, treatment outcomes associated with apixaban were generally positive compared to LMWH and warfarin.

P–758 The efficacy, safety and proven security of microSecure vitrification offers “peace of mind” and reliability during a global pandemic

Study question

Under deadly pandemic conditions involving the novel SARS-CoV–2 corona virus, could biopsied blastocysts be safely cryopreserved, stored and utilized for subsequent warming cycles?

Summary answer

Blastocysts were securely stored, effectively warmed and safely transferred to yield normal pregnancy outcomes under uncertain laboratory conditions subject to unprecedented policy changes.

What is known already

By April 2020, every IVF lab worldwide was implementing deep cleaning/disinfecting procedures in their laboratory and patient-contact areas, thorough hand-washing policies and mandatory PPE to reduce the chance of contact transmission and spread of the potentially deadly SARS-CoV–2 coronavirus. Furthermore, we know that safeguards like oil overlay culture dishes and pipetting dilution factors provide insurance against possible contamination. However, knowing that the trophectoderm of blastocysts possessed the ACE–2 binding receptor, potential concern existed regarding the continuation of laser zona opening and biopsy procedures that could possibly expose cryopreserved embryos to the coronavirus in liquid nitrogen storage (vapor or liquid).

Study design, size, duration

Between March 8 and December 22, 2020, 508 patients performed FET cycles involving the use of single (n = 490) or dual (n = 18) euploid microSecure vitrified blastocysts. In this retrospective analysis, we compared clinical pregnancy outcomes to a 5 year dataset (2015–2019) encompassing 2768 single and 272 dual embryo transfer FET cycles. All blastocysts were vitrified using a closed microSecure system and Innovative Cryoenterprise (ICE; NJ, USA) non-DMSO, glycerol-EG solutions. Differences were assessed by Chi-square analysis (p < 0.05).

Participants/materials, setting, methods

Deep cleaning was performed with Simple Green Pro3+ Virucide in non-lab areas (e.g., ET rooms, waiting room) and 6% H2O2 & OoSafe solutions to disinfect lab surfaces and equipment. Group embryo cultures were performed in MCO–5M humidified incubators under low oxygen tri-gas conditions with varying CO2 levels (5.3–6.0%; pH = 7.3–7.35) using 25µl droplets of LifeGlobal medium+7.5%LGPS+1%sodium hyaluronate, before changing to 10µl droplet/GPS dishes post-biopsy. FET cycles involved 4-step sucrose dilutions and transvaginal ultrasound-guided embryo transfers.

Main results and the role of chance

While ICSI fertilization rates were unchanged in 2020 (79.4% 2PN vs 77.3%), blastocyst utilization rates tended to be slightly lower than past years (56.4% vs 59.9%) but within an acceptable range. Of 529 blastocysts warmed, 527 (99.7%) survived completely for transfer, being comparable to the 99.4% experienced over 5 years. Furthermore, there was no differences detected in single embryo transfer pregnancy outcomes. The implantation and ongoing clinical pregnancy/live birth rates were 69% and 66.53% compared to 70.4% and 65.1%, respectively. Under pandemic conditions we did not observe an increase in biochemical pregnancies (10.3%) nor spontaneous miscarriage rates (7.8%). Although it is possible that our rigorous disinfection practices could have attributed to lower blastocyst production, the viability of those embryos was not compromised. Importantly, we were able to feel comfortable performing micromanipulation and cryopreservation procedures throughout the year knowing that we were effectively eliminating possible vertical transmission of coronavirus to an exposed trophectoderm layer in cryostorage by applying mircoSecure vitrification. Post-FET clinical check-ups revealed no patient reporting any fever or other Covid–19 symptoms in the weeks following their transfers. We are fortunate to say that our Lab staff, physicians and patients have remained healthy throughout 2020.

Limitations, reasons for caution

Blastocyst survival and viability are independent of possible viral exposure. Previously, the risk of disease transmission via liquid nitrogen or vapor exposure was considered highly unlikely (Pomeroy et al., 2010), but that was at a time when embryos were primarily zona-enclosed. Today’s ART standards have us re-evaluating safer approaches.

Wider implications of the findings: We have effectively mitigated avoiding performing zona opening procedures by employing our standard practice of aseptic, closed vitrification. In combination with standard preventative measures (PPE, hand hygiene, distance awareness) and routine deep cleaning practices, we sustained a contamination-free environment and healthy patients, capable of sustaining high levels of pregnancy success.

Trial registration number

Not applicable

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

A study on accumulator analysis for the valve performance evaluation system of nuclear power plants

To evaluate the valves used in the nuclear power plants are working properly under the required conditions, the performance and capacity test should be performed. In the test system, the accumulator was employed to control the large amount of high pressure and high temperature steam generated in the boiler precisely. In the accumulating process, the steam is often condensed. In order to prevent condensation, it is needed to install heaters and preheat the accumulator. However, if the size of the accumulator becomes large, the installation of the heater may not be easy. Therefore, when the test is conducted, the system was preheated by the latent heat generated from the phase change. Insufficient thermal insulation may cause temperature differences and it can cause mechanical problems in the accumulator structure. If insulation is sufficient, the temperature difference is indicated by the height. As the cooled condensate moves downwards, the condensate is discharged by the drain valve control and the temperature difference of the structure can be disappeared. The results of this paper can be applied to the conceptualization of equipment that uses latent heat and for the design of high-precision steam experimental devices or the design of high-capacity steam utilization systems.

The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

OBJECTIVE

To examine the association between pre-eclampsia definition and pregnancy outcome.

DESIGN

Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data.

SETTING

International multicentre randomised controlled trial (RCT).

POPULATION

In all, 987 women with non-severe non-proteinuric pregnancy hypertension.

METHODS

We evaluated the association between pre-eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control.

MAIN OUTCOME MEASURES

Main CHIPS trial outcomes: primary (perinatal loss or high-level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth.

RESULTS

Of 979/987 women with informative data, 280 (28.6%) progressed to pre-eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre-eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62-79% versus 36-50%), lower specificities (range 53-65% versus 72-82%), and similar or higher diagnostic odds ratios and 'true-positive' to 'false-positive' ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre-eclampsia definition improved sensitivity (74-87%).

CONCLUSIONS

A broad (versus restrictive) pre-eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre-eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values.

TWEETABLE ABSTRACT

A broad (versus restrictive) pre-eclampsia definition better identifies the risk of adverse pregnancy outcomes.

Effectiveness and Safety of Apixaban vs. Warfarin in Venous Thromboembolism Patients with Obesity and Morbid Obesity

This study integrated 5 United States healthcare claims databases to evaluate the risk of recurrent venous thromboembolism (VTE) and major bleeding (MB) among VTE patients who initiated apixaban vs. warfarin, stratified by obesity. Obese and morbidly obese patients were identified based on diagnosis codes. Stabilized inverse probability treatment weighting (IPTW) was conducted to balance observed patient characteristics between treatment cohorts. An interaction analysis was conducted to evaluate treatment effects of apixaban vs. warfarin according to obesity status. Cox proportional hazard models were used to evaluate the risk of recurrent VTE and MB among IPTW weighted obese and morbidly obese patients. A total of 112,024 non-obese patients and 43,095 obese patients were identified, of whom 19,751 were morbidly obese. When stratified by obesity status post-IPTW, no significant interactions were observed for effects of apixaban vs. warfarin on recurrent VTE or MB (interaction p > 0.10). Among IPTW obese and morbidly obese patients, apixaban was associated with a significantly lower risk of recurrent VTE (obese: 0.73 [0.64–0.84]; morbidly obese: 0.65 [0.53–0.80]) and MB (obese: 0.73 [0.62–0.85]; morbidly obese: 0.68 [0.54–0.86]) as compared with warfarin. In this large sample of obese and morbidly obese VTE patients, apixaban had a significantly lower risk of recurrent VTE and MB vs. warfarin.

Effectiveness and Safety of Apixaban, Low-Molecular-Weight Heparin, and Warfarin among Venous Thromboembolism Patients with Active Cancer: A U.S. Claims Data Analysis

Background  This study primarily evaluates the risk of recurrent venous thromboembolism (VTE) and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban, low-molecular-weight heparin (LMWH), or warfarin, with claims data.

Methods  Four U.S. commercial insurance claims databases were used to identify patients with VTE and active cancer who initiated apixaban, LMWH, or warfarin within 30 days following the first VTE event. Stabilized inverse-probability treatment weighting (IPTW) was used to balance treatment cohorts. Cox proportional hazard models were used to evaluate risk of recurrent VTE and MB.

Results  All eligibility criteria were fulfilled by 3,393 apixaban, 6,108 LMWH, and 4,585 warfarin patients. After IPTW, all patient characteristics were balanced. When the follow-up was censored at 6 months, apixaban patients had a lower risk of recurrent VTE (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47–0.81) and MB (HR: 0.63; 95% CI: 0.47–0.86) versus LMWH. Apixaban patients had a lower risk of recurrent VTE (HR: 0.68; 95% CI: 0.52–0.90) and similar risk of MB (HR: 0.73; 95% CI: 0.53–1.00) versus warfarin. Warfarin patients had a similar risk of recurrent VTE (HR: 0.91; 95% CI: 0.72–1.15) and MB (HR: 0.87; 95% CI: 0.68–1.12) versus LMWH. The trends were similar for the entire follow-up; however, apixaban patients had a lower risk of MB versus warfarin patients.

Conclusion  Patients with VTE and active cancer who initiated apixaban had a lower risk of recurrent VTE and MB compared with LMWH patients. Apixaban patients also had a lower risk of recurrent VTE compared with warfarin patients.

Comparison of neointimal coverage between biodegradable-polymer everolimus-eluting stent and durable-polymer everolimus-eluting stent using angioscopy for the patients with acute coronary syndrome

Background

New-generation biodegradable-polymer platinum chromium everolimus-eluting stent (BP-PtCr-EES) is available, which has different polymer and alloy compare to more established stent design, a durable-polymer cobalt-chromium everolimus-eluting stent (DP-CoCr-EES).

Purpose

To compare neointimal coverage (NIC) between BP-PtCr-EES and DP-CoCr-EES by using coronary angioscopy (CAS).

Methods

A total of 36 patients (44 stents) with BP-PtCr-EES or DP-CoCr-EES who underwent CAS at 1 year after stenting were investigated. We compared angioscopic findings assessed by angioscopy between BP-PtCr-EES (n=18) and DP-CoCr-EES (n=26). NIC grade and yellow plaque grade (YPG) was adopted from earlier reports from grade 0 to 3. We determined maximum (max-) and minimum (min-) NIC grade and heterogeneity score (HGS = max NIC grade minus min NIC grade). We also assessed YPG and the presence of thrombus (TH).

Results

Six lesions (33.3%) in BP-PtCr-EES group and 7 (26.9%) lesions in DP-CoCr-EES group were culprit lesions of acute coronary syndrome, which did not statistically differ between the two groups (p=0.74). And there were no significant differences in stent diameter (BP-PtCr-EES: 2.97±0.39 mm vs DP-CoCr-EES: 3.14±0.45 mm, p=0.22) and length (BP-PtCr-EES: 26.9±7.9 mm vs DP-CoCr-EES: 28.4±8.0 mm, p=0.54). In terms of CAS findings, BP-PtCr-EES group has better neointimal coverage than DP-CoCr-EES group (max NIC grade: 2.6±0.7 vs 2.0±0.9, p=0.01. min NIC grade: 1.1±0.8 vs 0.5±0.5, p&lt;0.01), but HGS was almost same (1.6±0.7 vs 1.5±0.9, p=0.70). YPG of BP-PtCr-EES group showed significantly lower than DP-CoCr-EES group (1.0±1.0 vs 1.7±1.0, p=0.02). The rate of TH was significantly lower in BP-PtCr-EES group than DP-CoCr-EES group (25%, n=6, vs 75%, n=18, p=0.03). There were no clinical events such as stent thrombosis or restenosis during the observation period in both stent groups.

Conclusion

Superior neointimal coverage and less YPG or TH were observed by CAS in the BP-PtCr-EES group at 1 year after stenting. Clinical significance was still unknown because of no clinical events in both groups. Prospective and large populations studies may be required.

Funding Acknowledgement

Type of funding source: None

Building global development strategies for cf therapeutics during a transitional cftr modulator era

As CFTR modulator therapy transforms the landscape of cystic fibrosis (CF) care, its lack of uniform access across the globe combined with the shift towards a new standard of care creates unique challenges for the development of future CF therapies. The advancement of a full and promising CF therapeutics pipeline remains a necessary priority to ensure maximal clinical benefits for all people with CF. It is through collaboration across the global CF community that we can optimize the evaluation and approval process of new therapies. To this end, we must identify areas for which harmonization is lacking and for which efficiencies can be gained to promote ethical, feasible, and credible study designs amidst the changing CF care landscape. This article summarizes the counsel from core advisors across multiple international regions and clinical trial networks, developed during a one-day workshop in October 2019. The goal of the workshop was to identify, in consideration of the highly transitional era of CFTR modulator availability, the drug development areas for which global alignment is currently uncertain, and paths forward that will enable advancement of CF therapeutic development.