1
|
Assessment of Comorbidity Burden and Treatment Response: Reanalysis of the SCD-HEFT Trial. Drugs Aging 2022; 39:165-173. [PMID: 35102532 DOI: 10.1007/s40266-021-00915-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Comorbidity burden may be associated with treatment-effect heterogeneity (HTE) in clinical trials, which could alter the interpretation or clinical translation of results for many patients in the real world. OBJECTIVE In this analysis, we sought to determine the distribution of multimorbidity scores in patients enrolled in SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) and tested the association between comorbidity burden and treatment efficacy for the outcome of all-cause death. METHODS Each patient was assigned a modified Charlson Comorbidity Index (mCCI) score from 1 to 14 based on available enrollment data. We investigated the relationship between mCCI score and time to all-cause death using Cox proportional hazards models. Models were fit for quartiles of the comorbidity index, reference coding was used, with quartile 1 (Q1; mCCI score of 1-2) selected as the reference. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were reported from these models. Following the same analysis framework as the original manuscript, patients assigned to amiodarone or implantable cardioverter-defibrillator (ICD) were compared with those assigned to placebo in separate Cox models. Each model included the mCCI score in quartiles, group assignment, and an interaction term for the quartile and group assignment. HRs and corresponding 97.5% CIs were reported from these models. RESULTS The majority of patients had an mCCI score ≤5 (75.4%), and mortality risk was associated with increasing score. The HRs for Q2 (score 3), Q3 (scores 4-5), and Q4 (scores ≥6) were 1.46 (97.5% CI 1.06-1.99), 3.03 (97.5% CI 2.35-3.90), and 4.51 (97.5% CI 3.46-5.88), respectively. For the subgroup analysis, amiodarone was not associated with a significant difference compared with placebo for individuals in Q1-Q3; however, it was associated with an increase in death for those in Q4 (HR 1.50; 97.5% CI 1.03-2.18). ICD was associated with a significant reduction in death compared with placebo for individuals in Q1 and Q3 (HR 0.42; 97.5% CI 0.20-0.84 and HR 0.70; 97.5% CI 0.50-0.97, respectively) but not for those in Q2 or Q4. Interaction testing across subgroups suggested HTE for amiodarone (p = 0.07) and ICD (p = 0.08) versus placebo across mCCI quartiles. CONCLUSIONS Increasing comorbidity burden was associated with HTE when evaluating amiodarone and ICD compared with placebo in the SCD-HeFT trial. Our results highlight the importance of enrolling diverse patient populations in clinical trials and considering the possibility of HTE when translating results to clinical practice.
Collapse
|
2
|
Romero J, Velasco A, Pisani CF, Alviz I, Briceno D, Díaz JC, Della Rocca DG, Natale A, de Lourdes Higuchi M, Scanavacca M, Di Biase L. Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:1225-1242. [PMID: 33663741 DOI: 10.1016/j.jacc.2020.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 11/24/2022]
Abstract
Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.
Collapse
Affiliation(s)
- Jorge Romero
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Cristiano F Pisani
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Isabella Alviz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - David Briceno
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Juan Carlos Díaz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Andrea Natale
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA
| | - Maria de Lourdes Higuchi
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA.
| |
Collapse
|
3
|
Yu Y, Luo D, Li Z, Zhang J, Li F, Qiao J, Yu F, Li M. Inhibitory Effects of Dronedarone on Small Conductance Calcium Activated Potassium Channels in Patients with Chronic Atrial Fibrillation: Comparison to Amiodarone. Med Sci Monit 2020; 26:e924215. [PMID: 32470968 PMCID: PMC7282350 DOI: 10.12659/msm.924215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/04/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Dysfunction of small conductance calcium activated potassium (SK) channels plays a vital role in atrial arrhythmogenesis. Amiodarone and dronedarone are the most effective class III antiarrhythmic drugs. It is unclear whether the antiarrhythmic effect of amiodarone and dronedarone is related to SK channel inhibition. MATERIAL AND METHODS Tissue samples were obtained from the right atria of 46 patients with normal sinus rhythm and 39 patients with chronic atrial fibrillation. Isolated atrial myocytes were obtained by enzymatic dissociation. KCNN2 (SK2) channels were transiently expressed in human embryonic kidney (HEK)-293 cells. SK currents were recorded using whole-cell conventional patch clamp techniques. RESULTS Amiodarone and dronedarone showed a concentration-dependent inhibitory effect on SK currents (IKAS) in atrial myocytes from normal sinus rhythm patients and chronic atrial fibrillation patients. The suppressed efficacy of dronedarone and amiodarone on IKAS was greater in atrial myocytes from chronic atrial fibrillation patients than that from normal sinus rhythm patients. Furthermore, in patients with chronic atrial fibrillation, the IC₅₀ value was 2.42 µM with dronedarone and 8.03 µM with amiodarone. In HEK-293 cells with transiently transfected SK2 channels, both dronedarone and amiodarone had a dose-dependent inhibitory effect on IKAS. The IC₅₀ value was 1.7 µM with dronedarone and 7.2 µM with amiodarone in cells from patients with chronic atrial fibrillation. Compared to amiodarone, dronedarone is more efficacy to inhibit IKAS and could be a potential intervention for patients with chronic atrial fibrillation. CONCLUSIONS Dronedarone provides a great degree of IKAS inhibition in atrial myocytes from chronic atrial fibrillation than amiodarone. IKAS might be a potential target of amiodarone and dronedarone for the management of chronic atrial fibrillation.
Collapse
Affiliation(s)
- Yiyan Yu
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
- Department of Electrocardiography, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Dan Luo
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Zhiyi Li
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Juan Zhang
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Fang Li
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Jie Qiao
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Fengxu Yu
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Miaoling Li
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Medical Electrophysiology Key Lab of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, Sichuan, P.R. China
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| |
Collapse
|