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Kim H, Shahbal H, Parpia S, Averbuch T, Van Spall HGC, Thabane L, Ma J. Trials using composite outcomes neglect the presence of competing risks: a methodological survey of cardiovascular studies. J Clin Epidemiol 2023; 160:1-13. [PMID: 37245700 DOI: 10.1016/j.jclinepi.2023.05.015] [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: 02/28/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To determine how frequently competing risks were accounted for in recently published cardiovascular disease (CVD) trials with composite end points. STUDY DESIGN AND SETTING We conducted a methodological survey of CVD trials that used composite end points and published from January 1 to September 27, 2021. The following databases were searched: PubMed, Medline, Embase, CINAHL, and Web of Science. Eligible studies were categorized according to whether they mentioned a competing risk analysis plan. If yes, whether a competing risk analysis was proposed as the primary or sensitivity analysis. RESULTS Among the 136 included studies, only 14 (10.3%) conducted a competing risk analysis and reported the corresponding results. Seven (50%) of them conducted a competing risk analysis as their primary analysis, whereas the other seven (50%) as a sensitivity analysis to assess the robustness of their findings. The most commonly used competing risk analysis methods were the subdistribution hazard model (nine studies), followed by the cause-specific hazard model (four studies) and restricted mean time lost method (one study). None of the studies accounted for competing risks in their sample size calculations. CONCLUSION Our findings underscore the pressing need for and importance of applying appropriate competing risk analysis in this field to disseminate clinically meaningful and unbiased results.
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Affiliation(s)
- Hyunwoo Kim
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Canada
| | - Hamad Shahbal
- Department of Biology, McMaster University, Hamilton, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada
| | - Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary, Canada
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada; The Research Institute at St Joe's Hamilton, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Canada; The Research Institute at St Joe's Hamilton, St Joseph's Healthcare Hamilton, Hamilton, Canada; Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa.
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Canada.
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Kawashima H, Ono M, Hara H, de Winter RJ, Holmes DR, Thuijs DJFM, Milojevic M, Garg S, Serruys PW, Onuma Y. Ten-year all-cause mortality following staged percutaneous revascularization in patients with complex coronary artery disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 38:124-126. [PMID: 34503909 DOI: 10.1016/j.carrev.2021.08.027] [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: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Medical and/or economic reasons sometimes necessitate the staging of percutaneous coronary intervention (SPCI) procedures in patients with complex coronary artery disease; however, the impact of this on very long-term outcomes is unknown. The aim of the present study is to assess 10-year all-cause mortality in patients with the three-vessel disease (3VD) and/or left main disease (LM) undergoing SPCI. METHODS This is a sub-analysis of patients undergoing SPCI in the SYNTAXES study, which investigated 10-year all-cause mortality in patients with 3VD and/or LM in the randomized SYNTAX trial, beyond its original 5-year follow-up. An SPCI was allowed within 72 h or, if renal insufficiency or contrast-induced nephropathy occurred, within 14 days of the index procedure. Mortality was compared between patients having SPCI versus those not having SPCI or undergoing CABG. PCI patients were further stratified according to 3VD or LM. RESULTS In the SYNTAX PCI population (overall: n = 903, 3VD: n = 546, LM: n = 357), 125 (13.8%) patients underwent SPCI. Patients with SPCI had a higher 10-year mortality compared to those who didn't (40.0% vs 26.6%; hazard ratio [HR] 1.69; 95% confidence interval [CI] 1.23-2.32; p < 0.01) and those having CABG(40.0% vs 24.5%; HR 1.85; 95%CI 1.35-2.53; p < 0.01). Patients having SPCI with 3VD (n = 103) or LM (n = 22) had higher mortality than respective patients not having SPCI (3VD: 37.4% vs 27.1%; HR 1.52; 95%CI 1.05-2.21; p = 0.03 and LM: 51.8% vs 25.9%; HR 2.39; 95%CI 1.27-4.47; p = 0.01). CONCLUSIONS At 10-year follow-up, SPCI was associated with higher mortality than single-session PCI, so that CABG may be preferable if a staged procedure is anticipated.
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Affiliation(s)
- Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG) and CORRIB Corelab and Center for Research and Imaging, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG) and CORRIB Corelab and Center for Research and Imaging, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG) and CORRIB Corelab and Center for Research and Imaging, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - David R Holmes
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG) and CORRIB Corelab and Center for Research and Imaging, Galway, Ireland; CÚRAM, the SFI Research Centre for Medical Devices, Galway, Ireland; NHLI, Imperial College London, London, United Kingdom.
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG) and CORRIB Corelab and Center for Research and Imaging, Galway, Ireland; CÚRAM, the SFI Research Centre for Medical Devices, Galway, Ireland
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Wang R, Wu S, Gamal A, Gao C, Hara H, Kawashima H, Ono M, van Geuns RJ, Vranckx P, Windecker S, Onuma Y, Serruys PW, Garg S. Aspirin-free antiplatelet regimens after PCI: insights from the GLOBAL LEADERS trial and beyond. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:547-556. [PMID: 33930107 PMCID: PMC8566303 DOI: 10.1093/ehjcvp/pvab035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 01/16/2023]
Abstract
Historically, aspirin has been the primary treatment for the prevention of ischaemic events in patients with coronary artery disease. For patients undergoing percutaneous coronary intervention (PCI) standard treatment has been 12 months of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, followed by aspirin monotherapy; however, DAPT is undeniably associated with an increased risk of bleeding. For over a decade novel P2Y12 inhibitors, which have increased specificity, potency, and efficacy have been available, prompting studies which have tested whether these newer agents can be used in aspirin-free antiplatelet regimens to augment clinical benefits in patients post-PCI. Among these studies, the GLOBAL LEADERS trial is the largest by cohort size, and so far has provided a wealth of evidence in a variety of clinical settings and patient groups. This article summarizes the state-of-the-art evidence obtained from the GLOBAL LEADERS and other trials of aspirin-free strategies.
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Affiliation(s)
- Rutao Wang
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sijing Wu
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of cardiology, Beijing Anzhen hospital, Beijing, China.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Amr Gamal
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, North Cumbria University Hospitals NHS Trust, England, United Kingdom.,Department of Cardiology, Zagazig University, Egypt
| | - Chao Gao
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert-Jan van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium.,Faculty of medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Imperial College London, London, United Kingdom
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, United Kingdom
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