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Marquis-Gravel G, Moliterno DJ, Francis DP, Jüni P, Rosenberg YD, Claessen BE, Mentz RJ, Mehran R, Cutlip DE, Chauhan C, Quella S, Zannad F, Goodman SG. Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:435-450. [PMID: 32703515 PMCID: PMC10018282 DOI: 10.1016/j.jacc.2020.05.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 01/09/2023]
Abstract
The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.
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Affiliation(s)
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Darrel P Francis
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | | | - Faiez Zannad
- Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto and Canadian Heart Research Centre, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
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Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
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Effect of prompt revascularization on outcomes in diabetic patients with stable ischemic heart disease and previous myocardial infarction in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Coron Artery Dis 2017; 28:301-306. [DOI: 10.1097/mca.0000000000000492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bittner V, Bertolet M, Barraza Felix R, Farkouh ME, Goldberg S, Ramanathan KB, Redmon JB, Sperling L, Rutter MK. Comprehensive Cardiovascular Risk Factor Control Improves Survival: The BARI 2D Trial. J Am Coll Cardiol 2015; 66:765-773. [PMID: 26271057 DOI: 10.1016/j.jacc.2015.06.019] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/20/2015] [Accepted: 06/09/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unclear whether achieving multiple risk factor (RF) goals through protocol-guided intensive medical therapy is feasible or improves outcomes in type 2 diabetes mellitus. OBJECTIVES This study sought to quantify the relationship between achieved RF goals in the BARI 2D (Bypass Angioplasty Investigation Revascularization 2 Diabetes) trial and cardiovascular events/survival. METHODS We performed a nonrandomized analysis of survival/cardiovascular events and control of 6 RFs (no smoking, non-high-density lipoprotein cholesterol <130 mg/dl, triglycerides <150 mg/dl, blood pressure [systolic <130 mm Hg; diastolic <80 mm Hg], glycosylated hemoglobin <7%) in BARI 2D. Cox models with time-varying number of RFs in control were adjusted for baseline number of RFs in control, clinical characteristics, and trial randomization assignments. RESULTS In 2,265 patients (mean age 62 years, 29% women) followed up for 5 years, the mean ± SD number of RFs in control improved from 3.5 ± 1.4 at baseline to 4.2 ± 1.3 at 5 years (p < 0.0001). The number of RFs in control during the trial was strongly related to death (global p = 0.0010) and the composite of death, myocardial infarction, and stroke (global p = 0.0035) in fully adjusted models. Participants with 0 to 2 RFs in control during follow-up had a 2-fold higher risk of death (hazard ratio: 2.0; 95% confidence interval: 1.3 to 3.3; p = 0.0031) and a 1.7-fold higher risk of the composite endpoint (hazard ratio: 1.7; 95% confidence interval: 1.2 to 2.5; p = 0.0043), compared with those with 6 RFs in control. CONCLUSIONS Simultaneous control of multiple RFs through protocol-guided intensive medical therapy is feasible and relates to cardiovascular morbidity and mortality in patients with coronary disease and type 2 diabetes mellitus. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).
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Affiliation(s)
- Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Marnie Bertolet
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Suzanne Goldberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - J Bruce Redmon
- Department of Medicine and Urologic Surgery, University of Minnesota, Minneapolis, Minnesota
| | | | - Martin K Rutter
- The Endocrinology and Diabetes Research Group, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom; Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Barth J, Jacob T, Daha I, Critchley JA. Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database Syst Rev 2015; 2015:CD006886. [PMID: 26148115 PMCID: PMC11064764 DOI: 10.1002/14651858.cd006886.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required. OBJECTIVES This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification. SEARCH METHODS The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI). MAIN RESULTS We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status). AUTHORS' CONCLUSIONS Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.
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Affiliation(s)
- Jürgen Barth
- University of BernInstitute of Social and Preventive MedicineNiesenweg 6BernSwitzerlandCH‐3012
| | - Tiffany Jacob
- University of BernInstitute of Social and Preventive MedicineNiesenweg 6BernSwitzerlandCH‐3012
| | - Ioana Daha
- Carol Davila University of Medicine and Pharmacy, Colentina Clinical HospitalDepartment of Cardiology19‐21, Stefan cel MareBucharestRomania020142
| | - Julia A Critchley
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
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Krone RJ, Althouse AD, Tamis-Holland J, Venkitachalam L, Campos A, Forker A, Jacobs AK, Ocampo S, Steiner G, Fuentes F, Pena Sing IR, Brooks MM. Appropriate revascularization in stable angina: lessons from the BARI 2D trial. Can J Cardiol 2014; 30:1595-601. [PMID: 25475464 DOI: 10.1016/j.cjca.2014.07.748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/25/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The 2012 Guidelines for Diagnosis and Management of Patients with Stable Ischemic Heart Disease recommend intensive antianginal and risk factor treatment (optimal medical management [OMT]) before considering revascularization to relieve symptoms. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomized patients with ischemic heart disease and anatomy suitable to revascularization to (1) initial OMT with revascularization if needed or (2) initial revascularization plus OMT and found no difference in major cardiovascular events. Ultimately, however, 37.9% of the OMT group was revascularized during the 5-year follow-up period. METHODS Data from the 1192 patients randomized to OMT were analyzed to identify subgroups in which the incidence of revascularization was so high that direct revascularization without a trial period could be justified. Multivariate logistic analysis, Cox regression models of baseline data, and a landmark analysis of participants who did not undergo revascularization at 6 months were constructed. RESULTS The models that used only data available at the time of study entry had limited predictive value for revascularization by 6 months or by 5 years; however, the model incorporating severity of angina during the first 6 months could better predict revascularization (C statistic = 0.789). CONCLUSIONS With the possible exception of patients with severe angina and proximal left anterior descending artery disease, this analysis supports the recommendation of the 2012 guidelines for a trial of OMT before revascularization. Patients could not be identified at the time of catheterization, but a short period of close follow-up during OMT identified the nearly 40% of patients who underwent revascularization.
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Affiliation(s)
- Ronald J Krone
- Division of Cardiology, Washington University, St. Louis, Missouri, USA.
| | - Andrew D Althouse
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Lakshmi Venkitachalam
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Arturo Campos
- Department of Cardiology, Hospital de Especialidades, Centro Medico La Raza, IMSS, Mexico City, Mexico
| | - Alan Forker
- Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Alice K Jacobs
- Boston University and Boston Medical Center, Boston, Massachusetts, USA
| | - Salvador Ocampo
- Department of Cardiology, Hospital de Especialidades, Centro Medico La Raza, IMSS, Mexico City, Mexico
| | | | - Francisco Fuentes
- Division of Cardiology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ivan R Pena Sing
- Heart and Vascular Catheterization Laboratories, Nanticoke Memorial Hospital, Seaford, Delaware, USA; New York University, New York, New York, USA
| | - Maria Mori Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Beohar N, Sansing VV, Davis AM, Srinivas VS, Helmy T, Althouse AD, Thomas SB, Brooks MM. Race/ethnic disparities in risk factor control and survival in the bypass angioplasty revascularization investigation 2 diabetes (BARI 2D) trial. Am J Cardiol 2013; 112:1298-305. [PMID: 23910429 DOI: 10.1016/j.amjcard.2013.05.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 02/07/2023]
Abstract
This study sought to evaluate the impact of race/ethnicity on cardiovascular risk factor control and on clinical outcomes in a setting of comparable access to medical care. The BARI 2D trial enrolled 1,750 participants from the United States and Canada that self-reported either White non-Hispanic (n = 1,189), Black non-Hispanic (n = 349), or Hispanic (n = 212) race/ethnicity. Participants had type 2 diabetes and coronary artery disease and were randomized to cardiac and glycemic treatment strategies. All patients received intensive target-based medical treatment for cardiac risk factors. Average follow-up was 5.3 years. Kaplan-Meier survival curves and Cox proportional hazards regression models were constructed to assess potential differences in mortality and cardiovascular outcomes across racial/ethnic groups. Long-term risk of death and death/myocardial infarction/stroke did not vary significantly by race/ethnicity (5-year death: 11.0% Whites, 13.7% Blacks, 8.7% Hispanics, p = 0.19; adjusted hazard ratio 1.18 Black versus White, 95% confidence interval 0.84 to 1.67, p = 0.33 and 0.82 Hispanic versus White, 95% confidence interval 0.51 to 1.34, p = 0.43). Among the 1,168 patients with suboptimal risk factor control at baseline, the ability to attain better risk factor control during the trial was associated with higher 5-year survival (71%, 86% and 95% for patients with 0 or 1, 2, and 3 factors in control, respectively, p <0.001); this pattern was observed within each race/ethnic group. In conclusion, significant race/ethnic differences in cardiac risk profiles that persisted during follow-up did not translate into significant differences in 5-year death or death/MI/stroke.
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Affiliation(s)
- Nirat Beohar
- Division of Cardiology, Columbia University, Mount Sinai Medical Center, Miami Beach, Florida
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Brooks MM, Chaitman BR, Nesto RW, Hardison RM, Feit F, Gersh BJ, Krone RJ, Sako EY, Rogers WJ, Garber AJ, King SB, Davidson CJ, Ikeno F, Frye RL. Clinical and angiographic risk stratification and differential impact on treatment outcomes in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Circulation 2012; 126:2115-24. [PMID: 23008442 PMCID: PMC4104411 DOI: 10.1161/circulationaha.112.092973] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial assigned patients with type 2 diabetes mellitus to prompt coronary revascularization plus intensive medical therapy versus intensive medical therapy alone and reported no significant difference in mortality. Among patients selected for coronary artery bypass graft surgery, prompt coronary revascularization was associated with a significant reduction in death/myocardial infarction/stroke compared with intensive medical therapy. We hypothesized that clinical and angiographic risk stratification would affect the effectiveness of the treatments overall and within revascularization strata. METHODS AND RESULTS An angiographic risk score was developed from variables assessed at randomization; independent prognostic factors were myocardial jeopardy index, total number of coronary lesions, prior coronary revascularization, and left ventricular ejection fraction. The Framingham Risk Score for patients with coronary disease was used to summarize clinical risk. Cardiovascular event rates were compared by assigned treatment within high-risk and low-risk subgroups. Overall, no outcome differences between the intensive medical therapy and prompt coronary revascularization groups were seen in any risk stratum. The 5-year risk of death/myocardial infarction/stroke was 36.8% for intensive medical therapy compared with 24.8% for prompt coronary revascularization among the 381 coronary artery bypass graft surgery-selected patients in the highest angiographic risk tertile (P=0.005); this treatment effect was amplified in patients with both high angiographic and high Framingham risk (47.3% intensive medical therapy versus 27.1% prompt coronary revascularization; P=0.010; hazard ratio=2.10; P=0.009). Treatment group differences were not significant in other clinical-angiographic risk groups within the coronary artery bypass graft surgery stratum, or in any subgroups within the percutaneous coronary intervention stratum. CONCLUSION Among patients with diabetes mellitus and stable ischemic heart disease, a strategy of prompt coronary artery bypass graft surgery significantly reduces the rate of death/myocardial infarction MI/stroke in those with extensive coronary artery disease or impaired left ventricular function. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00006305.
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Affiliation(s)
- Maria Mori Brooks
- Department of Epidemiology, University of Pittsburgh, GSPH, A530 Crabtree Hall/130 DeSoto St, Pittsburgh, PA 15261, USA.
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Brooks MM, Chung SC, Helmy T, Hillegass WB, Escobedo J, Melsop KA, Massaro EM, McBane RD, Hyde P, Hlatky MA. Health status after treatment for coronary artery disease and type 2 diabetes mellitus in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. Circulation 2010; 122:1690-9. [PMID: 20937978 DOI: 10.1161/circulationaha.109.912642] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health status is a key outcome for comparing treatments, particularly when mortality does not differ significantly. METHODS AND RESULTS Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) randomized 2368 patients with type 2 diabetes mellitus and stable ischemic heart disease to (1) prompt revascularization versus medical therapy and (2) insulin sensitization versus insulin provision. Randomization was stratified by the intended method of revascularization, coronary artery bypass graft surgery or percutaneous coronary intervention. The Duke Activity Status Index and RAND Energy, Health Distress, and Self-Rated Health scales were assessed at study entry and annually thereafter; linear mixed models were used to evaluate the effect of randomized treatment on these measures. Health status improved significantly from baseline to 1 year (P<0.001) in each randomized treatment group. Compared with medical therapy, prompt revascularization was associated with significantly greater improvements in Duke Activity Status Index (1.32 points; P<0.001), Energy (1.36 points; P=0.02), and Self-rated Health (1.77 points; P=0.007) but not Health Distress (-0.47; P=0.46). These treatment effects were largely maintained over 4 years of follow-up. The effect of revascularization on the Duke Activity Status Index was significantly larger in the subgroup of patients intended for coronary artery bypass graft surgery compared with the subgroup intended for percutaneous coronary intervention. Health status did not differ significantly on any of the 4 measures between the insulin provision and insulin sensitization strategies. CONCLUSIONS Prompt coronary revascularization was associated with small yet statistically significant improvements in health status compared with initial medical therapy among patients with diabetes mellitus and stable ischemic heart disease. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT00006305.
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Affiliation(s)
- Maria Mori Brooks
- Department of Epidemiology, University of Pittsburgh, GSPH, 130 DeSoto St, Pittsburgh, PA 15261, USA.
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BARI 2D - where has it taken us to and what the future has in store for us. COR ET VASA 2010. [DOI: 10.33678/cor.2010.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Relationships of obesity and fat distribution with atherothrombotic risk factors: baseline results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Obesity (Silver Spring) 2009; 18:1046-54. [PMID: 19875998 DOI: 10.1038/oby.2009.339] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The impact of obesity on cardiovascular disease (CVD) outcomes in patients with type 2 diabetes mellitus (T2DM) and established coronary artery disease (CAD) is controversial; whether BMI and/or waist circumference correlate with atherothrombotic risk factors in such patients is uncertain. We sought to evaluate whether higher BMI or waist circumference are associated with specific risk factors among 2,273 Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) study participants with T2DM and documented CAD (baseline data, mean age 62 years, 66% non-Hispanic white, 71% men). Multiple linear regression models were constructed after adjusting for sex, age, race/ethnicity, US vs. non-US site, diabetes duration, exercise, smoking, alcohol, and relevant medication use. First-order partial correlations of BMI with risk factors after controlling for waist circumference and of waist circumference with risk factors after controlling for BMI were also evaluated. Ninety percent of the patients were overweight (BMI > or =25 kg/m(2)); 68% of men and 89% of women had high-risk waist circumference measures (> or =102 and > or =88 cm, respectively). BMI and waist circumference, in separate models, explained significant variation in metabolic (insulin, lipids, blood pressure (BP)) and inflammatory/procoagulation (C-reactive protein, PAI-1 activity and antigen, and fibrinogen) risk factors. In partial correlation analyses BMI was independently associated with BP and inflammatory/procoagulation factors, waist circumference with lipids, and both BMI and waist circumference with insulin. We conclude that, in cross-sectional analyses, both BMI and waist circumference, independently, are associated with increased atherothrombotic risk in centrally obese cohorts such as the BARI 2D patients with T2DM and CAD.
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Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TLZ, Molitch ME, Nesto RW, Sako EY, Sobel BE. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 2009; 360:2503-15. [PMID: 19502645 PMCID: PMC2863990 DOI: 10.1056/nejmoa0805796] [Citation(s) in RCA: 1344] [Impact Index Per Article: 89.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Optimal treatment for patients with both type 2 diabetes mellitus and stable ischemic heart disease has not been established. METHODS We randomly assigned 2368 patients with both type 2 diabetes and heart disease to undergo either prompt revascularization with intensive medical therapy or intensive medical therapy alone and to undergo either insulin-sensitization or insulin-provision therapy. Primary end points were the rate of death and a composite of death, myocardial infarction, or stroke (major cardiovascular events). Randomization was stratified according to the choice of percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG) as the more appropriate intervention. RESULTS At 5 years, rates of survival did not differ significantly between the revascularization group (88.3%) and the medical-therapy group (87.8%, P=0.97) or between the insulin-sensitization group (88.2%) and the insulin-provision group (87.9%, P=0.89). The rates of freedom from major cardiovascular events also did not differ significantly among the groups: 77.2% in the revascularization group and 75.9% in the medical-treatment group (P=0.70) and 77.7% in the insulin-sensitization group and 75.4% in the insulin-provision group (P=0.13). In the PCI stratum, there was no significant difference in primary end points between the revascularization group and the medical-therapy group. In the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization group (22.4%) than in the medical-therapy group (30.5%, P=0.01; P=0.002 for interaction between stratum and study group). Adverse events and serious adverse events were generally similar among the groups, although severe hypoglycemia was more frequent in the insulin-provision group (9.2%) than in the insulin-sensitization group (5.9%, P=0.003). CONCLUSIONS Overall, there was no significant difference in the rates of death and major cardiovascular events between patients undergoing prompt revascularization and those undergoing medical therapy or between strategies of insulin sensitization and insulin provision. (ClinicalTrials.gov number, NCT00006305.)
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Abete I, Parra D, Crujeiras AB, Goyenechea E, Martinez JA. Specific insulin sensitivity and leptin responses to a nutritional treatment of obesity via a combination of energy restriction and fatty fish intake. J Hum Nutr Diet 2008; 21:591-600. [DOI: 10.1111/j.1365-277x.2008.00902.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Baseline characteristics of patients with diabetes and coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Am Heart J 2008; 156:528-536, 536.e1-5. [PMID: 18760137 PMCID: PMC2701266 DOI: 10.1016/j.ahj.2008.05.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 05/16/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was undertaken to determine whether early revascularization intervention is superior to deferred intervention in the presence of aggressive medical therapy and whether antidiabetes regimens targeting insulin sensitivity are more or less effective than regimens targeting insulin provision in reducing cardiovascular events among patients with type 2 diabetes mellitus and stable coronary artery disease (CAD). METHODS The BARI 2D trial is a National Institutes of Health-sponsored randomized clinical trial with a 2 x 2 factorial design. Between 2001 and 2005, 49 clinical sites in North America, South America, and Europe randomized 2,368 patients. At baseline, the trial collected data on clinical history, symptoms, and medications along with centralized evaluations of angiograms, electrocardiograms, and blood and urine specimens. RESULTS Most of the BARI 2D patients were referred from the cardiac catheterization laboratory (54%) or cardiology clinic (27%). Of the randomized participants, 30% were women, 34% were minorities, 61% had angina, and 67% had multiregion CAD. Moreover, 29% had been treated with insulin, 58% had hemoglobin A(1c) >7.0%, 41% had low-density lipoprotein cholesterol >or=100 mg/dL, 52% had blood pressure >130/80 mm Hg, and 56% had body mass index >or=30 kg/m(2). CONCLUSIONS Baseline characteristics in BARI 2D are well balanced between the randomized treatment groups, and the clinical profile of the study cohort is representative of the target population. As a result, the BARI 2D clinical trial is in an excellent position to evaluate alternative treatment approaches for diabetes and CAD.
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Parente LB, Aguila MB, Mandarim-de-Lacerda CA. Deleterious effects of high-fat diet on perinatal and postweaning periods in adult rat offspring. Clin Nutr 2008; 27:623-34. [PMID: 18614261 DOI: 10.1016/j.clnu.2008.05.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Revised: 05/26/2008] [Accepted: 05/27/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND & AIMS Pre- and postnatal environmental changes can reset the developmental path during intrauterine development leading to obesity and cardiovascular and metabolic disorders later in life. The effects of high-fat diets on body mass, fat mass, the plasma level of glucose, insulin and leptin, as well as the insulin/glucose ratio and cardiovascular parameters in adult rat offspring were studied. METHODS Pregnant Wistar rats in a standard chow group (SC) or high-fat chow group (HFC), at weaning their SC and HFC offspring were randomly divided into two postnatal groups: fed on SC or HFC. With euthanasia at 6-month-old, three-way ANOVA there were three-factor interactions among gender, perinatal diet and postweaning diet to body mass (BM), BP, left ventricle (LV) thickness, carbohydrate metabolism, plasma corticosterone concentrations and leptin/fat mass/adipocyte size pattern. RESULTS HFC/SC and SC/HFC offspring of both genders had high BM and BP, which were increased in HFC/HFC offspring. There was hyperinsulinism, hyperleptinemia, as well as high insulin/glucose ratio and high plasma corticosterone concentrations mainly in HFC/HFC offspring with adipocytes and LV hypertrophy. CONCLUSIONS Postweaning HFC was deleterious to the health of adult offspring from dams fed HFC during pregnancy and then during the first half of lactation period. HFC administrated in both periods shows supplementary effects, elevating BP with consequent LV hypertrophy, altering carbohydrate metabolism, plasma corticosterone concentrations and disturbing leptin/fat mass/adipocyte size pattern.
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Affiliation(s)
- Lyana Barbosa Parente
- Laboratory of Morphometry and Cardiovascular Morphology, Biomedical Center, Institute of Biology, State University of Rio de Janeiro, Brazil
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Barsness GW, Gersh BJ, Brooks MM, Frye RL. Rationale for the revascularization arm of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial. Am J Cardiol 2006; 97:31G-40G. [PMID: 16813736 DOI: 10.1016/j.amjcard.2006.03.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Modern coronary revascularization therapies, coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI), continue to evolve and are widely applied. However, for patients with mild stable angina, or those who are asymptomatic with angiographically documented coronary artery disease (CAD), no survival benefit or reduction in the incidence of myocardial infarction has been demonstrated with CABG or PCI, except in the case of subgroups with angiographically determined high risk due to extensive multivessel disease with depressed LV function or left main CAD. At the same time, medical therapy continues to advance, with demonstrable benefit in both primary and secondary prevention of atherosclerotic coronary disease events. Patients with type 2 diabetes mellitus, at increased risk for adverse cardiac events, have been shown to benefit from these approaches as well. However, in asymptomatic or mildly symptomatic patients with documented ischemia and angiographically significant CAD, the incremental benefit-or hazard-associated with early revascularization superimposed on aggressive medical and risk factor modification therapies is unknown. We discuss the background and rationale for investigating the impact of early revascularization in patients with diabetes and CAD.
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Affiliation(s)
- Gregory W Barsness
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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