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Gabriel EE, Sachs MC, Waernbaum I, Goetghebeur E, Blanche PF, Vansteelandt S, Sjölander A, Scheike T. Propensity weighting plus adjustment in proportional hazards model is not doubly robust. Biometrics 2024; 80:ujae069. [PMID: 39036984 DOI: 10.1093/biomtc/ujae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/26/2024] [Accepted: 07/05/2024] [Indexed: 07/23/2024]
Abstract
Recently, it has become common for applied works to combine commonly used survival analysis modeling methods, such as the multivariable Cox model and propensity score weighting, with the intention of forming a doubly robust estimator of an exposure effect hazard ratio that is unbiased in large samples when either the Cox model or the propensity score model is correctly specified. This combination does not, in general, produce a doubly robust estimator, even after regression standardization, when there is truly a causal effect. We demonstrate via simulation this lack of double robustness for the semiparametric Cox model, the Weibull proportional hazards model, and a simple proportional hazards flexible parametric model, with both the latter models fit via maximum likelihood. We provide a novel proof that the combination of propensity score weighting and a proportional hazards survival model, fit either via full or partial likelihood, is consistent under the null of no causal effect of the exposure on the outcome under particular censoring mechanisms if either the propensity score or the outcome model is correctly specified and contains all confounders. Given our results suggesting that double robustness only exists under the null, we outline 2 simple alternative estimators that are doubly robust for the survival difference at a given time point (in the above sense), provided the censoring mechanism can be correctly modeled, and one doubly robust method of estimation for the full survival curve. We provide R code to use these estimators for estimation and inference in the supporting information.
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Affiliation(s)
- Erin E Gabriel
- Section of Biostatistics, Department of Public Health, University of Copenhagen, København 1353, Denmark
| | - Michael C Sachs
- Section of Biostatistics, Department of Public Health, University of Copenhagen, København 1353, Denmark
| | | | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Gent 9000, Belgium
| | - Paul F Blanche
- Section of Biostatistics, Department of Public Health, University of Copenhagen, København 1353, Denmark
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Gent 9000, Belgium
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm 17177, Sweden
| | - Thomas Scheike
- Section of Biostatistics, Department of Public Health, University of Copenhagen, København 1353, Denmark
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Holt A, Nouhravesh N, Strange JE, Kinnberg Nielsen S, Schjerning AM, Vibe Rasmussen P, Torp-Pedersen C, Gislason GH, Schou M, McGettigan P, Lamberts M. Cannabis for chronic pain: cardiovascular safety in a nationwide Danish study. Eur Heart J 2024; 45:475-484. [PMID: 38200679 DOI: 10.1093/eurheartj/ehad834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND AND AIMS A rising number of countries allow physicians to treat chronic pain with medical cannabis. However, recreational cannabis use has been linked with cardiovascular side effects, necessitating investigations concerning the safety of prescribed medical cannabis. METHODS Using nationwide Danish registers, patients with chronic pain initiating first-time treatment with medical cannabis during 2018-21 were identified and matched 1:5 to corresponding control patients on age, sex, chronic pain diagnosis, and concomitant use of other pain medication. The absolute risks of first-time arrhythmia (atrial fibrillation/flutter, conduction disorders, paroxysmal tachycardias, and ventricular arrhythmias) and acute coronary syndrome were reported comparing medical cannabis use with no use. RESULTS Among 1.88 million patients with chronic pain (46% musculoskeletal, 11% cancer, 13% neurological, and 30% unspecified pain), 5391 patients claimed a prescription of medical cannabis [63.2% women, median age: 59 (inter-quartile range 48-70) years] and were compared with 26 941 control patients of equal sex- and age composition. Arrhythmia was observed in 42 and 107 individuals, respectively, within 180 days. Medical cannabis use was associated with an elevated risk of new-onset arrhythmia {180-day absolute risk: 0.8% [95% confidence interval (CI) 0.6%-1.1%]} compared with no use [180-day absolute risk: 0.4% (95% CI 0.3%-0.5%)]: a risk ratio of 2.07 (95% CI 1.34-2.80) and a 1-year risk ratio of 1.36 (95% CI 1.00-1.73). No significant association was found for acute coronary syndrome [180-day risk ratio: 1.20 (95% CI 0.35-2.04)]. CONCLUSIONS In patients with chronic pain, the use of prescribed medical cannabis was associated with an elevated risk of new-onset arrhythmia compared with no use-most pronounced in the 180 days following the initiation of treatment.
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Affiliation(s)
- Anders Holt
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
- Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, 85 Park Road, Grafton, Auckland 1142, New Zealand
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Sebastian Kinnberg Nielsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
| | - Anne-Marie Schjerning
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, DK-4000 Roskilde, Denmark
- The Danish Heart Foundation, Department of Research, Vognmagergade 7, DK-1120 Copenhagen, Denmark
| | - Peter Vibe Rasmussen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, DK-1353 Copenhagen, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
- The Danish Heart Foundation, Department of Research, Vognmagergade 7, DK-1120 Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, DK-1353 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455 Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
| | - Patricia McGettigan
- William Harvey Research Institute, Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 6, PO Box 635, DK-2900 Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
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Wagner AK, D'Souza M, Bang CN, Holmstrup P, Blanche P, Fiehn NE, Gislason G, Pedersen CT, Damgaard C, Nielsen CH, Hansen PR. Treated periodontitis and recurrent events after first-time myocardial infarction: A Danish nationwide cohort study. J Clin Periodontol 2023; 50:1305-1314. [PMID: 37464548 DOI: 10.1111/jcpe.13853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 06/23/2023] [Accepted: 06/30/2023] [Indexed: 07/20/2023]
Abstract
AIM To investigate the association between previous periodontal treatment and recurrent events after first-time myocardial infarction (MI). MATERIALS AND METHODS From the Danish nationwide registries, patients with first-time MI between 2000 and 2015 were divided into three groups according to oral health care within 1 year prior to first-time MI. A multiple logistic regression model provided adjusted odds ratios (ORs) with 95% confidence intervals (CIs) to assess the 3-year risk of major adverse cardiovascular events (MACE). RESULTS A total of 103,949 patients were included. Patients with treated periodontitis (PD) prior to first-time MI had an adjusted 3-year risk of MACE similar to patients presumed periodontally healthy (OR 0.97 [95% CI 0.92-1.03]). Patients with no prior dental visits were significantly older, had more comorbidities and showed significantly increased adjusted 3-year risks of MACE (OR 1.47 [95% CI 1.42-1.52]), cardiovascular death (OR 1.71 [95% CI 1.64-1.78]) and heart failure (OR 1.13 [95% CI 1.07-1.20]) compared with patients presumed periodontally healthy. CONCLUSIONS Patients with treated PD 1 year prior to first-time MI had a similar risk of recurrent cardiovascular events as patients presumed periodontally healthy. No dental visit prior to first-time MI was an independent risk factor for recurrent events.
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Affiliation(s)
- Andrea Kjellström Wagner
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Maria D'Souza
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Casper N Bang
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Palle Holmstrup
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paul Blanche
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Nils-Erik Fiehn
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Christian Damgaard
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Henrik Nielsen
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute for Inflammation Research, Center for Rheumatology and Spine Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Riis Hansen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Halili A, Holt A, Eroglu TE, Haxha S, Zareini B, Torp-Pedersen C, Bang CN. The effect of discontinuing beta-blockers after different treatment durations following acute myocardial infarction in optimally treated, stable patients without heart failure: a Danish, nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:553-561. [PMID: 37391361 DOI: 10.1093/ehjcvp/pvad046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/17/2023] [Accepted: 06/29/2023] [Indexed: 07/02/2023]
Abstract
AIMS We studied the effect of discontinuing beta-blockers following myocardial infarction in comparison to continuous beta-blocker use in optimally treated, stable patients without heart failure. METHODS AND RESULTS Using nationwide registers, we identified first-time myocardial infarction patients treated with beta-blockers following percutaneous coronary intervention or coronary angiography. The analysis was based on landmarks selected as 1, 2, 3, 4, and 5 years after the first redeemed beta-blocker prescription date. The outcomes included all-cause death, cardiovascular death, recurrent myocardial infarction, and a composite outcome of cardiovascular events and procedures. We used logistic regression and reported standardized absolute 5-year risks and risk differences at each landmark year. Among 21 220 first-time myocardial infarction patients, beta-blocker discontinuation was not associated with an increased risk of all-cause death, cardiovascular death, or recurrent myocardial infarction compared with patients continuing beta-blockers (landmark year 5; absolute risk difference [95% confidence interval]), correspondingly; -4.19% [-8.95%; 0.57%], -1.18% [-4.11%; 1.75%], and -0.37% [-4.56%; 3.82%]). Further, beta-blocker discontinuation within 2 years after myocardial infarction was associated with an increased risk of the composite outcome (landmark year 2; absolute risk [95% confidence interval] 19.87% [17.29%; 22.46%]) compared with continued beta-blocker use (landmark year 2; absolute risk [95% confidence interval] 17.10% [16.34%; 17.87%]), which yielded an absolute risk difference [95% confidence interval] at -2.8% [-5.4%; -0.1%], however, there was no risk difference associated with discontinuation hereafter. CONCLUSION Discontinuation of beta-blockers 1 year or later after a myocardial infarction without heart failure was not associated with increased serious adverse events.
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Affiliation(s)
- Andrim Halili
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Anders Holt
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, 22-30 Park Avenue, Auckland 1023, New Zealand
| | - Talip E Eroglu
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Saranda Haxha
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Bochra Zareini
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark
| | - Casper N Bang
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark
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