Global geographical variation in patient characteristics in percutaneous coronary intervention clinical trials: A systematic review and meta-analysis

Left atrial appendage occlusion: trends in demographics and in-hospital outcomes-a German nationwide analysis

BACKGROUND

LAAO is an interventional, prophylactic treatment to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation.

AIMS

The aim of this study was to assess gender differences and age-related in-hospital course of all patients undergoing left atrial appendage occlusion (LAAO) in Germany.

METHODS

The Research Data Center of the Federal Statistical Office accessed interrogation of its Diagnosis Related Groups (DRG) statistics database. In a retrospective observational manner, all German in-hospital cases from 2016 to 2022 with a coded LAAO procedure were analyzed.

RESULTS

LAAO was performed on a total of 40,435 patients, 39.2% of whom were female. The relative frequency of procedures in the German male population over the age of 60 was twice as high as in the German female population. The median age was 78 (IQR: 72-82) years. Compared to 28.3% in 2016, in 2022 40.1% of all patients were over 80 years of age (increased by 152%). Cases of patients over 85 years of age increased from 7.7 to 11.4% during the same time period. We found an in-hospital death rate for patients < 70, 70-75, 80-85 and > 85 years of age of 0.8, 1.0, 1.4 and 2.2% respectively. Further, we saw significantly higher MACE rates (< 75 years: 4%, 75-85 years: 5%, > 85 years: 7%) in patients with a higher age. Gender was not significantly associated with a higher rate of in-hospital mortality.

CONCLUSIONS

In Germany, LAAO is increasingly performed in older patients with a strong gender imbalance. Age was independently associated with higher in-hospital MACE and mortality rates. This data provides a further basis to balance risks and benefits of LAAO as a preventive procedure and highlights the need for further prospective studies.

Long-term clinical outcomes following percutaneous coronary intervention in patients aged 90 years and older

BACKGROUND

In an aging society, percutaneous coronary intervention (PCI) for super-elderly patients is commonly performed in clinical practice. However, data are scarce regarding the clinical features and outcomes of this population.

METHODS

This multicenter observational study enrolled patients aged over 90 years who underwent PCI across 10 hospitals between 2011 and 2020. The study included patients presenting with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). The occurrence of all-cause and cardiac deaths during hospitalization and after discharge was investigated.

RESULTS

In total, 402 patients (91.9 ± 2.0 years, 48.3 % male) participated in the study, of whom 77.9 % presented with ACS. The rate of in-hospital death was significantly higher in patients with ACS compared to patients with CCS (15.3 % vs. 2.2 %, p < 0.001). The estimated cumulative incidence rates of all-cause death were 24.3 %, 39.5 %, and 60.4 % at 1, 3, and 5 years, respectively. No significant difference was observed in the occurrence of all-cause death between patients with ACS and CCS. Regarding causes of death after discharge, non-cardiac deaths accounted for just over half of the cases.

CONCLUSION

This study highlights the clinical features and long-term clinical course of patients aged over 90 years who underwent PCI in a real-world setting. Patients presenting with ACS exhibited a higher rate of in-hospital mortality compared to those with CCS. Following discharge, both ACS and CCS patients experienced comparable and substantial increases in the incidence rates of both cardiac and non-cardiac mortality over time, and a more holistic management approach is warranted.

Outcomes of Complex Percutaneous Cardiac Interventions in Women

Complex percutaneous cardiac intervention (PCI) is a growing procedure in modern day cath labs. The treated population is often older, with multiple comorbidities, complex coronary anatomy, left ventricular dysfunction, and possibly concomitant valvular heart disease and/or cardiogenic shock. As such, PCI of bifurcations, chronic total occlusions, and atherectomy coronary interventions are becoming more common. The outcomes in terms of acute procedural success, procedure-related complications, and long-term mortality or heart failure hospitalizations are important to consider. Unfortunately, to date there is a paucity of data identifying sex and gender disparities following such interventions. With respect to bifurcation lesions, women usually have more comorbidities with less complex coronary anatomy. However, despite less complex anatomy, women have a significantly increased risk of MI. These differences are also noted with left main stem and multivessel disease, during which women appear to have a trend towards worse outcomes following PCI compared with coronary artery bypass grafting. Randomized trials have revealed that women present with increased cardiovascular risk factors, which may contribute to adverse longer-term outcomes. Revascularization of women with concomitant valvular heart disease is particularly challenging because the existing data are conflicted on not only the indication, but also the timing of revascularization. Similarly, women undergoing PCI of calcified lesions with drug-eluting stents have a worse clinical profile and remain at increased ischemic risk. The lower incidence of coronary calcification in women, combined with the under-representation of women in randomized trials, poses a real challenge when attempting to address safety and survival benefit in women undergoing complex interventions. This warrants dedicated trials exploring the safety and efficacy of complex interventions in women.

Geographic differences in patients with acute myocardial infarction in the PARADISE-MI trial

AIM

The globalization of clinical trials has highlighted geographic differences in patient characteristics, treatments, and outcomes. We examined these differences in PARADISE-MI.

METHODS AND RESULTS

Overall, 23.0% were randomized in Eastern Europe/Russia, 17.5% in Western Europe, 12.2% in Southern Europe, 10.1% in Northern Europe, 12.0% in Latin America (LA), 9.3% in North America (NA), 10.0% in East/South-East Asia and 5.8% in South Asia (SA). Those from Asia, particularly SA, were different from patients enrolled in the other regions, being younger and thinner. They also differed in terms of comorbidities (high prevalence of diabetes and low prevalence of atrial fibrillation), type of myocardial infarction (more often ST-elevation myocardial infarction), and treatment (low rate of primary percutaneous coronary intervention). By contrast, patients from LA did not differ meaningfully from those randomized in Europe or NA. Use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (34.8%) and beta-blockers (65.5%) was low in SA, whereas mineralocorticoid receptor antagonist use was lowest in NA (22%) and highest in Eastern Europe/Russia (53%). Rates of the primary composite outcome of cardiovascular death or incident heart failure varied two-fold among regions, with the lowest rate in SA (4.6/100 person-years) and the highest in LA (9.2/100 person-years). Rates of incident heart failure varied almost six-fold among regions, with the lowest rate in SA (1.0/100 person-years) and the highest in Northern Europe (5.9/100 person-years). The effect of sacubitril/valsartan was not modified by region.

CONCLUSION

In PARADISE-MI, there were substantial regional differences in patient characteristics, treatments and outcomes. Although the generalizability of these findings to a 'real-world' unselected population may be limited, these findings underscore the importance of considering both regional and within-region differences when designing global clinical trials.

Geographic Variations on the Safety and Efficacy of the Supreme Biodegradable Polymer DES: Results From PIONEER III

Background

The PIONEER III trial showed the 12-month safety and efficacy of the Supreme drug-eluting stent (DES) vs the durable polymer everolimus-eluting stent. We sought to assess whether the characteristics and clinical outcomes of the Supreme DES in PIONEER III were consistent among patients by enrollment location.

Methods

This subgroup analysis of the PIONEER III trial compared the characteristics and outcomes of patients recruited from North America, Europe, and Japan and the relative differences in patient outcomes according to the site recruitment volume.

Results

From October 2017 to July 2019, 1629 patients were recruited in North America (816, 50.1%), Europe (650, 39.9%), and Japan (163, 10%). Procedural success was achieved in 1556 of 1611 procedures (96.6%), with no difference by the geographic location. Target lesion failure at 12 months for combined groups was observed in 84 of 1629 patients (5.2%), with no significant geographic differences (4.7%, 6.5%, and 2.5%, respectively; P =.08), with similar results in the Supreme DES group alone (4.4%, 6.8%, and 3.7%, respectively, P =.20). Cardiac death at 12 months occurred in 0.4%, 0.2%, and 0.0% (P =.79), target vessel-related myocardial infarction occurred in 2.2%, 4.7%, and 3.7%, (P =.10), and clinically driven target lesion revascularization was required in 2.1%, 3.1%, and 0%, respectively (P =.15). Compared with those from high-recruiting sites, results from low-recruiting sites were similar for target lesion failure, major adverse cardiac events, stent thrombosis, and mortality, with a nonsignificant trend for higher rates of myocardial infarction.

Conclusions

Despite regional differences in patient characteristics, the clinical outcomes between Supreme DES and durable polymer everolimus-eluting stent in the PIONEER III trial were not different, supporting the generalizability and robustness of the findings from this multicenter controlled trial.

Participant Recruitment From Low- and Middle-Income Countries for Pivotal Trials of Drugs Approved by the U.S. Food and Drug Administration : A Cross-Sectional Analysis

BACKGROUND

Many participants in clinical trials supporting U.S. Food and Drug Administration (FDA) drug approvals are recruited from outside the United States, including from low- and middle-income countries (LMICs). Where participants are recruited for pivotal trials has implications for ethical research conduct and generalizability.

OBJECTIVE

To describe LMIC recruitment for pivotal trials of newly approved drugs for cancer, neurologic disease, and cardiovascular disease.

DESIGN

Cross-sectional analysis.

SETTING

Pivotal trials of new cancer, cardiovascular, and neurologic drugs approved from 2012 to 2019 matched to ClinicalTrials.gov, FDA records, and publications.

MEASUREMENTS

Host countries and available per country enrollments were extracted. The primary end point was the proportion of pivotal trials enrolling participants in LMICs. The secondary end point was the proportion of pivotal trial participants contributed by LMICs for each indication area.

RESULTS

Data were obtained from 66 new drugs and 144 pivotal clinical trials. All cardiovascular approvals (12 drugs, 29 trials) and neurologic approvals (26 drugs, 54 trials) were analyzed, as well as a random sample of cancer approvals (28 of 85 drugs [33%]) matched to their pivotal trials (61 of 210 trials [29%]). Among the trials, 56% in cancer, 79% in cardiovascular disease, and 56% in neurology recruited from an LMIC. For multicountry trials, country-level enrollment figures were not available for 71 trials (55%). For those reporting per country enrollment, the percentage of participants recruited from LMICs was 8% for cancer trials, 36% for cardiovascular trials, and 17% for neurology trials.

LIMITATIONS

The study was limited to FDA-approved drugs in 3 areas, including a sample of cancer drugs. Pivotal trials of nonapproved drugs or drugs for other indications were not captured.

CONCLUSION

Most pivotal trials for FDA-approved drugs recruit from LMICs. Publications and FDA documents generally do not provide country-level data on recruitment.

PRIMARY FUNDING SOURCE

None.

Geographical variations in left main coronary artery revascularisation: a prespecified analysis of the EXCEL trial

BACKGROUND

The EXCEL trial reported similar five-year rates of the primary composite outcome of death, myocardial infarction (MI), or stroke after percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) for treatment of obstructive left main coronary artery disease (LMCAD).

AIMS

We sought to determine whether these outcomes remained consistent regardless of geography of enrolment.

METHODS

We performed a prespecified subgroup analysis based on regional enrolment.

RESULTS

Among 1,905 patients randomised to PCI (n=948) or CABG (n=957), 1,075 (56.4%) were recruited at 52 European Union (EU) centres, and 752 (39.5%) were recruited at 67 North American (NA) centres. EU versus NA patients varied according to numerous baseline demographics, anatomy, pharmacotherapy and procedural characteristics. Nonetheless, the relative rates of the primary endpoint after PCI versus CABG were consistent across EU versus NA centres at 30 days and 5 years. However, NA participants had substantially higher late rates of ischaemia-driven revascularisation (IDR) after PCI, driven predominantly by the need for greater target vessel and lesion revascularisation. This culminated in a significant difference in the relative risk of the secondary composite outcome of death, MI, stroke, or IDR at 5 years (p_interaction=0.02).

CONCLUSIONS

In the EXCEL trial, the relative risks for the 30-day and five-year primary composite outcome of death, MI or stroke after PCI versus CABG were consistent irrespective of geography. However, five-year rates of IDR after PCI were significantly higher in NA centres, a finding the Heart Team and patients should consider when making treatment decisions. ClinicalTrials.gov identifier: NCT01205776.

Percutaneous coronary intervention procedures performed at a hospital in Southern Brazil

BACKGROUND

Despite the advantages of percutaneous coronary intervention (PCI) compared to fibrinolytic therapy, it holds some potential risks such as contrast related reactions and technical problems. In addition, recent studies have shown disparities in which access is more exposed to radiation.

OBJECTIVES

To analyze the clinical profile, differences between radial and femoral approach and complications presented in patients who underwent PCI performed in a hospital in the south of Brazil.

METHODS

A total of 733 patients who underwent PCI in 2016 were included and retrospectively analyzed through their clinical records. The primary outcomes analyzed were procedure approach and the presence of complications.

RESULTS

The median age was 62.5 years; 54.8% were male; 50.8% had hypertension and 18.6% were diabetic; and mortality was seen in 2.3% of the population. Femoral approach was the most exposed to radiation, as well as the most used in ST-elevation myocardial infarction (STEMI). Complications were seen in 16.1% of the population and cardiovascular complication was the most frequent. Different accesses or degree of urgency showed no association with complication development. On the other hand, STEMI was related to a bigger complication burden.

CONCLUSION

The femoral approach demonstrated more expressive radiation exposure, which can be explained by anatomic reasons. Femoral access represented a safe approach for interventionists in more urgent cases, such as STEMI. Different accesses or degree of urgency did not show an association with complications, as opposed to STEMI, revealing that this condition deserves more attention regarding its procedures and post-PCI care.

Antithrombotic management and long-term outcomes following percutaneous coronary intervention for acute coronary syndrome in Asia

BACKGROUND

Cardiovascular diseases account for approximately half of all deaths in Asia. The present analysis aimed to evaluate characteristics, antithrombotic management patterns (AMPs), and outcomes in patients with acute coronary syndrome (ACS) who underwent in-hospital percutaneous coronary intervention (PCI) and survived to hospital discharge, using data from the EPICOR Asia registry (NCT01361386).

METHODS

Two-year post-discharge follow-up data were analyzed from 8757 ACS PCI patients from EPICOR Asia (218 centers, eight countries). Major adverse cardiovascular events (MACE; death, non-fatal myocardial infarction [MI], non-fatal ischemic stroke), PCI characteristics, and AMPs were recorded. For MACE, time - to - event was analyzed using Cox regression.

RESULTS

Primary PCI was performed in 62.0% of ST-segment elevation MI (STEMI), 38.7% of non-STEMI (NSTEMI), and 24.2% of unstable angina (UA) patients. At 12 months, 88.1% of patients were on dual antiplatelet therapy (DAPT), with no differences by index event. Most (61.5%) still received DAPT at 2 years. Two-year incidences of mortality, composite MACE, and bleeding were 3.6%, 6.2%, and 6.6%, respectively. Risk of death and MACE was increased with STEMI and NSTEMI vs. UA. Patients from East Asia showed lower mortality and more bleeding vs. Southeast Asia/India.

CONCLUSIONS

Many patients in EPICOR Asia underwent PCI and received DAPT up to 2 years post-discharge. These real-world findings improve our understanding of AMP impact on outcomes in Asian patients with ACS undergoing PCI.

Reframing implementation science to address inequities in healthcare delivery

BACKGROUND

Research has generated valuable knowledge in identifying, understanding, and intervening to address inequities in the delivery of healthcare, yet these inequities persist. The best available interventions, programs and policies designed to address inequities in healthcare are not being adopted in routine practice settings. Implementation science can help address this gap by studying the factors, processes, and strategies at multiple levels of a system of care that influence the uptake, use, and the sustainability of these programs for vulnerable populations. We propose that an equity lens can help integrate the fields of implementation science and research that focuses on inequities in healthcare delivery.

MAIN TEXT

Using Proctor et al.' (12) framework as a case study, we reframed five elements of implementation science to study inequities in healthcare. These elements include: 1) focus on reach from the very beginning; 2) design and select interventions for vulnerable populations and low-resource communities with implementation in mind; 3) implement what works and develop implementation strategies that can help reduce inequities in care; 4) develop the science of adaptations; and 5) use an equity lens for implementation outcomes.

CONCLUSIONS

The goal of this paper is to continue the dialogue on how to critically infuse an equity approach in implementation studies to proactively address healthcare inequities in historically underserved populations. Our examples provide ways to operationalize how we can blend implementation science and healthcare inequities research.

Do Asian and North American patients with bipolar disorder have similar efficacy, tolerability, and safety profile during clinical trials with atypical antipsychotics?

BACKGROUND

The approvals of psychotropics for bipolar disorder (BD) are mainly based on randomized, double-blind, placebo-controlled trials (RCTs) from North America. It remains unknown whether approved psychotropics have similar efficacy, tolerability, and safety for Asians with BD. The aim of this systematic review was to compare those differences of psychotropics between Asians and North Americans with BD.

METHODS

MEDLINE, EMBASE, and PsycINFO were searched for RCTs studied in two regions. The effect size, remission/response rate, and risk for discontinuation due to adverse events (AEs), weight gain (WG), nervous systems and gastrointestinal AEs were assessed and compared between two regions with Cohen's d or number needed to treat/harm.

RESULTS

Eleven studies of aripiprazole, olanzapine, risperidone, and quetiapine in BD were included. Similar efficacy and relatively benign tolerability of atypical antipsychotics (AAPs) between Asians and Americans with BD were observed in most studies. The risk for AAP-related WG was similar between two regions. Asians with mania or bipolar depression were more vulnerable to akathisia/tremor or constipation. Japanese and Chinese with bipolar depression were more sensitive to somnolence and dizziness, respectively. Americans were more likely to have dry mouth, nausea, and vomiting.

LIMITATIONS

The number of included psychotropics and papers was small.

CONCLUSIONS

Differences in AAP-related efficacy and tolerability were minimal between the two regions, but some AEs appeared to be different. Clinicians should pay attention to these differences to optimize treatment strategies in different races/ethnicities with BD.