1
|
Peikert A, Bart BA, Vaduganathan M, Claggett BL, Kulac IJ, Kosiborod MN, Desai AS, Jhund PS, Lam CSP, Inzucchi SE, Martinez FA, de Boer RA, Hernandez AF, Shah SJ, Petersson M, Langkilde AM, McMurray JJV, Solomon SD, Vardeny O. Contemporary Use and Implications of Beta-Blockers in Patients With HFmrEF or HFpEF: The DELIVER Trial. JACC. HEART FAILURE 2024; 12:631-644. [PMID: 37767674 DOI: 10.1016/j.jchf.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Although beta-blockers are not recommended for the treatment of heart failure with preserved ejection fraction (HFpEF) according to the latest European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines, these therapies remain commonly used for comorbidity management. There has been concern that beta-blockers may adversely influence clinical outcomes by limiting chronotropic response in HFpEF. OBJECTIVES This study sought to examine the contemporary use and implications of beta-blockers in patients with heart failure with mildly reduced ejection fraction (HFmrEF) or HFpEF. METHODS In the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial, a total of 6,263 patients with symptomatic heart failure (HF) with a left ventricular ejection fraction (LVEF) >40% were randomized to dapagliflozin or placebo across 20 countries. In this prespecified analysis, efficacy and safety outcomes were examined according to beta-blocker use at randomization. The primary outcome was cardiovascular death or worsening HF. RESULTS Overall, beta-blockers were used in 5,177 patients (83%), with wide variation by geographic region. Beta-blocker use was associated with a lower risk of the primary outcome in covariate-adjusted models (HR: 0.70; 95% CI: 0.60-0.83). Dapagliflozin consistently reduced the risk of the primary outcome in patients taking beta-blockers (HR: 0.82; 95% CI: 0.72-0.94) and in patients not taking beta-blockers (HR: 0.79; 95% CI: 0.61-1.03; Pinteraction = 0.85), with similar findings for key secondary endpoints. Adverse events were balanced between patients randomized to dapagliflozin and placebo, regardless of background beta-blocker use. CONCLUSIONS In patients with HFmrEF or HFpEF who were enrolled in DELIVER, 4 out of 5 participants were treated with a beta-blocker. Beta-blocker use was not associated with a higher risk of worsening HF or cardiovascular death. Dapagliflozin consistently and safely reduced clinical events, irrespective of background beta-blocker use. (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
Collapse
Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradley A Bart
- Minneapolis VA Center for Care Delivery and Outcomes Research, Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian J Kulac
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore; Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | | | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
2
|
Maeda M, Humber D, Hida E, Ohtani T, Wang G, Wu T, Takeda S, Situ JN, Hayashi J, Nonen S, Takeda T, Okamoto H, Hori M, Sakata Y, Fujio Y, Tsunoda SM. Lower doses of carvedilol in Japanese heart failure patients with reduced ejection fraction could show the potential to be non-inferior to higher doses in US patients: An international collaborative observational study. PLoS One 2024; 19:e0299510. [PMID: 38452137 PMCID: PMC10919845 DOI: 10.1371/journal.pone.0299510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
The Japanese national guidelines recommend significantly lower doses of carvedilol for heart failure with reduced ejection fraction (HFrEF) management than the US guidelines. Using real-world data, we determined whether initial and target doses of carvedilol in Japanese patients (JPNs) differ from those in US patients (USPs), especially in Asian Americans (ASA) and Caucasians (CA), and investigated differences in outcomes. We collected data from the electronic medical records, including demographics, carvedilol dosing, tolerability, cardiac functional indicators like EF, cardiovascular events including all-cause deaths, and laboratory values from the University of California, San Diego Health and Osaka University. JPNs had significantly lower doses (mg/day) of carvedilol initiation (66 USPs composed of 38 CAs and 28 ASAs, 17.1±16.2; 93 JPNs, 4.3±4.2, p<0.001) and one year after initiation (33.0±21.8; 11.2±6.5, p<0.001), and a significantly lower relative rate (RR) of dose discontinuation and reduction than USPs (RR: 0.406, 95% confidence interval (CI): 0.181-0.911, p<0.05). CAs showed the highest reduction rate (0.184), and ASAs had the highest discontinuation rate (0.107). A slight mean difference with narrow 95% CI ranges straddling zero was observed between the two regions in the change from the baseline of each cardiac functional indicator (LVEF, -0.68 [-5.49-4.12]; LVDd, -0.55 [-3.24-2.15]; LVDd index, -0.25 [-1.92-1.43]; LVDs, -0.03 [-3.84-3.90]; LVDs index, -0.04 [-2.38-2.30]; heart rate, 1.62 [-3.07-6.32]). The event-free survival showed no difference (p = 0.172) among the races. Conclusively, despite JPNs exhibiting markedly lower carvedilol doses, their dose effectiveness has the potential to be non-inferior to that in USPs. Dose de-escalation, not discontinuation, could be an option in some Asian and ASA HFrEF patients intolerable to high doses of carvedilol.
Collapse
Affiliation(s)
- Makiko Maeda
- Laboratory of Clinical Pharmacology, Department of Pharmaceutical Sciences, Osaka University, Osaka, Japan
- Medical Center for Translational Research, Osaka University Hospital, Osaka, Japan
- Department of Molecular Pharmaceutical Science, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Douglas Humber
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, United States of America
- San Diego Health, University of California San Diego, San Diego, CA, United States of America
| | - Eisuke Hida
- Department of Biostatistics and Data Science, Osaka University Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Guannan Wang
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, United States of America
| | - Tong Wu
- Medical Center for Translational Research, Osaka University Hospital, Osaka, Japan
| | - Shiori Takeda
- Laboratory of Clinical Pharmacology, Department of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | - Jacinta N. Situ
- Medical Center for Translational Research, Osaka University Hospital, Osaka, Japan
| | - Jun Hayashi
- Laboratory of Clinical Pharmacology, Department of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | - Shinpei Nonen
- School of Pharmacy, Hyogo Medical University, Hyogo, Japan
| | - Toshihiro Takeda
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Osaka University, Osaka, Japan
| | | | - Masatsugu Hori
- National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasushi Fujio
- Laboratory of Clinical Science and Biomedicine, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
- Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Osaka, Japan
| | - Shirley M. Tsunoda
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, United States of America
- San Diego Health, University of California San Diego, San Diego, CA, United States of America
| |
Collapse
|
3
|
Butt JH, Claggett BL, Miao ZM, Jering KS, Sim D, van der Meer P, Ntsekhe M, Amir O, Cho MC, Carrillo-Calvillo J, Núñez JE, Cadena A, Kerkar P, Maggioni AP, Steg PG, Granger CB, Mann DL, Merkely B, Lewis EF, Solomon SD, Zhou Y, Køber L, Braunwald E, McMurray JJV, Pfeffer MA. Geographic differences in patients with acute myocardial infarction in the PARADISE-MI trial. Eur J Heart Fail 2023; 25:1228-1242. [PMID: 37042062 DOI: 10.1002/ejhf.2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/29/2023] [Accepted: 04/08/2023] [Indexed: 04/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Zi M Miao
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Karola S Jering
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - David Sim
- National Heart Center Singapore, Singapore, Singapore
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mpiko Ntsekhe
- Division of Cardiology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Offer Amir
- Cardiovascular Institute, Hadassah Medical Center, Jerusalem, Israel
| | - Myeong-Chan Cho
- Department of Cardiology and Cardiocerebrovascular Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Jorge Carrillo-Calvillo
- Department of Cardiology, Hospital Central 'Dr. Ignacio Morones Prieto' San Luis Potosí, San Luis Potosí, Mexico
| | - Julio E Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | | | - Prafulla Kerkar
- Department of Cardiology, KEM Hospital, Mumbai, Maharashtra, India
| | | | - Philippe G Steg
- Université de Paris, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, Paris, France
| | | | - Douglas L Mann
- Department of Medicine, Washington University, St. Louis, MO, USA
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
4
|
Cotter G, Davison BA, Edwards C, Senger S, Teerlink JR, Zannad F, Nielsen OW, Metra M, Mebazaa A, Chioncel O, Greenberg BH, Maggioni AP, Ertl G, Sato N, Cohen-Solal A. Regional variation of effects of new antidiabetic medications in cardiovascular outcome trials. Am Heart J 2021; 240:73-80. [PMID: 34107289 DOI: 10.1016/j.ahj.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In international trials, glucagon-like protein-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2Is) were effective in improving cardiovascular (CV) outcomes. METHODS We assessed the effect of GLP-1RAs and SGLT2Is treatment effect on CV endpoints by geographical region in multiple international trials using random effects weighted least squares meta-regressions. RESULTS The estimated effects of both SGLT2Is and GLP-1RAs on major adverse CV events (MACE) in North America (SGLT2Is n = 12,399, HR 0.90, 95% CI 0.81-1.01; GLP-1RAs n = 12,515, HR 0.95, 95% CI 0.83- 1.09) and in Europe (SGLT2Is n = 19,435, HR 0.93, 95% CI 0.85-1.02; GLP-1RAs n = 22,812, HR 0.88, 95% CI 0.79-0.99) were numerically lower but not statistically different to the rest of the world (ROW) (SGLT2Is n = 15,127, HR 0.83, 95% CI 0.75-0.92, p-value for interaction 0.26; GLP-1RAs n = 17,494, HR 0.82, 95% CI 0.73-0.92, p-value for interaction 0.28). Effects of SGLT2Is on heart failure readmission or CV death varied significantly by region (P = 0.0094). The effect of SGLT2Is was significantly smaller in Europe (n = 18,653, HR 0.86, 95% CI 0.78-0.95) than in the ROW (n = 12,463, HR 0.68, 95% CI 0.61-0.76, P = 0.0024). The smaller effect in North America (n = 9776, HR 0.76, 95% CI 0.66-0.87) did not differ significantly from that in the ROW (P = 0.2370). CONCLUSION The effects of SGLT2Is on HF events are larger in the ROW. Further analyses and studies are needed to better elucidate the differential effects of SGLTIs and GLP-1RAs by geographical regions.
Collapse
Affiliation(s)
- Gad Cotter
- Momentum Research Inc, Durham, North Carolina; Inserm U942 MASCOT, Paris, France.
| | - Beth A Davison
- Momentum Research Inc, Durham, North Carolina; Inserm U942 MASCOT, Paris, France
| | | | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco,San Francisco, CA
| | - Faiez Zannad
- Inserm CIC-P 1433, Université de Lorraine, CHRU de Nancy, FCRIN INI-CRCT, Nancy, France
| | | | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, Saint Louis Lariboisière University Hospitals, Université de Paris, Paris, France
| | | | - Barry H Greenberg
- Division of Cardiology, University of California San Diego, California
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalien (ANMCO) Research Center, Florence, Italy
| | - Georg Ertl
- Julius-Maximilians-Universität Würzburg, Germany
| | - Naoki Sato
- Cardiology and Intensive Care Unit, Nippon Medical School, Musashi-Kosugi Hospital, Kawasaki, Japan
| | | |
Collapse
|
5
|
Asakura M, Ito S, Yamada T, Saito Y, Kimura K, Yamashina A, Hirayama A, Kobayashi Y, Hanatani A, Tsujimoto M, Yasuda S, Abe Y, Higashino Y, Tamaki Y, Sugino H, Niinuma H, Okuhara Y, Koitabashi T, Momomura SI, Asai K, Nomura A, Kawai H, Satoh Y, Yoshikawa T, Hirata KI, Yokoi Y, Tanaka J, Shibata Y, Maejima Y, Tamaki S, Kawata H, Iwahashi N, Kobayashi M, Higuchi Y, Kada A, Yamamoto H, Kitakaze M. Efficacy and safety of early initiation of eplerenone treatment in patients with acute heart failure (EARLIER trial): a multicenter, randomized, double-blind, placebo-controlled trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:108-117. [PMID: 33175088 DOI: 10.1093/ehjcvp/pvaa132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/16/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022]
Abstract
AIMS A mineralocorticoid receptor antagonist (MRA) is effective in patients with chronic heart failure; however, the effects of the early initiation of an MRA in patients with acute heart failure (AHF) have not been elucidated. METHODS AND RESULTS In this multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we focused on the safety and effectiveness of the treatment with eplerenone, a selective MRA in 300 patients with AHF, that is, 149 in the eplerenone group and 151 in the placebo group in 27 Japanese institutions. The key inclusion criteria were (1) patients aged 20 years or older and (2) those with left ventricular ejection fraction of ≤ 40%. The primary outcome was a composite of cardiac death or first re-hospitalization due to cardiovascular disease within 6 months. The mean age of the participants was 66.8 years, 27.3% were women, and the median levels of brain natriuretic peptide were 376.0 pg/mL. The incidences of the primary outcome were 19.5% in the eplerenone group and 17.2% in the placebo group (hazard ratio (HR): 1.09, 95% confidence interval (CI): 0.642-1.855). In prespecified secondary outcomes, HR for the composite endpoint, cardiovascular death, or first re-hospitalization due to heart failure (HF) within 6 months was 0.55 (95% CI: 0.213 to 1.434). The safety profile for eplerenone was as expected. CONCLUSION The early initiation of eplerenone in patients with AHF could safely be utilized. The reduction of the incidence of a composite of cardiovascular death or first re-hospitalization for cardiovascular diseases by eplerenone is inconclusive because of inadequate power.
Collapse
Affiliation(s)
- Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shin Ito
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Akira Yamashina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Youichi Kobayashi
- Division of Cardiology, Department of Medicine, Showa University Hospital, Tokyo, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mitsuru Tsujimoto
- Department of Cardiology, Cardiovascular Center, Veritas Hospital, Hyogo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yorihiko Higashino
- Department of Cardiology, Higashi Takarazuka Satoh Hospital, Hyogo, Japan
| | - Yodo Tamaki
- Department of Cardiology, Tenri Hospital, Nara, Tenri, Japan
| | - Hiroshi Sugino
- Department of Cardiac Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroyuki Niinuma
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshitaka Okuhara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Toshimi Koitabashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Tokyo, Japan
| | - Shin-Ichi Momomura
- Cardiovascular Division, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Hiroya Kawai
- Division of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center, Hyogo Brain and Heart Center, Hyogo, Japan
| | - Yasuhiro Satoh
- Department of Cardiology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | | | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Yokoi
- Department of Medicine, Cardiac Arrhythmia Center, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Jun Tanaka
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Medical Hospital, Tokyo, Japan
| | - Shunsuke Tamaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Kawata
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yoshiharu Higuchi
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Haruko Yamamoto
- Department of Advance Medical Technology Development, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi Suita 564-8565, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Hanwa Daini Senboku Hospital, 3176 Fukaikitamachi, Naka-ku Sakai City, Osaka 599-8271, Japan
| |
Collapse
|
6
|
Chandrasekhar J, Kalkman DN, Aquino MB, Sartori S, Hájek P, Atzev B, Hudec M, Ong TK, Mates M, Borisov B, Warda HM, den Heijer P, Wojcik J, Iñiguez A, Coufal Z, Khashaba A, Schee A, Munawar M, Gerber RT, Yan BP, Tejedor P, Kala P, Liew HB, Lee M, Baber U, Vogel B, Dangas GD, Colombo A, de Winter RJ, Mehran R. 1-year results after PCI with the COMBO stent in all-comers in Asia versus Europe: Geographical insights from the COMBO collaboration. Int J Cardiol 2020; 307:17-23. [PMID: 32111358 DOI: 10.1016/j.ijcard.2020.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/03/2020] [Accepted: 01/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The COMBO drug-eluting stent combines sirolimus-elution from a biodegradable polymer with an anti-CD34+ antibody coating for early endothelialization. OBJECTIVE We investigated for geographical differences in outcomes after percutaneous coronary intervention (PCI) with the COMBO stent among Asians and Europeans. METHODS The COMBO Collaboration is a pooled patient-level analysis of the MASCOT and REMEDEE registries of all-comers undergoing attempted COMBO stent PCI. The primary outcome was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction (TV-MI) and target lesion revascularization (TLR). RESULTS This study included 604 Asians (17.9%) and 2775 Europeans (82.1%). Asians were younger and included fewer females, with a higher prevalence of diabetes mellitus but lower prevalence of other comorbidities than Europeans. Asians had a higher prevalence of ACC/AHA C type lesions and received longer stent lengths. More Asians than Europeans were discharged on clopidogrel (86.5% vs 62.8%) rather than potent P2Y12 inhibitors. One-year TLF occurred in 4.0% Asians and 4.1% of Europeans, p = 0.93. The incidence of cardiac death was higher in Asians (2.8% vs. 1.3%, p = 0.007) with similar rates of TV-MI (1.5% vs. 1.2%, p = 0.54) and definite stent thrombosis (0.3% vs. 0.5%, p = 0.84) and lower incidence of TLR than Europeans (1.0% vs. 2.5%, p = 0.025). After adjustment, differences for cardiac death and TLR were no longer significant. CONCLUSIONS In the COMBO collaboration, although 1-year TLF was similar regardless of geography, Asians experienced higher rates of cardiac death and lower TLR than Europeans, while incidence of TV-MI and ST was similar in both regions. Adjusted differences did not reach statistical significance. CLINICALTRIAL. GOV IDENTIFIER-NUMBERS NCT01874002 (REMEDEE Registry), NCT02183454 (MASCOT registry).
Collapse
Affiliation(s)
- Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America; Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Deborah N Kalkman
- Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Melissa B Aquino
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America
| | - Petr Hájek
- Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Martin Mates
- Nemocnice na Homolce - Kardiologie, Prague, Czech Republic
| | | | - Hazem M Warda
- Alhyatt Cardiovascular Center and Tanta University Hospital, Alexandria, Egypt
| | | | - Jaroslaw Wojcik
- Hospital of Invasive Cardiology IKARDIA, Lublin, Nałęczów, Poland
| | | | - Zdeněk Coufal
- T. Bata Regional Hospital Zlin, Zlin, Czech Republic
| | | | - Alexandr Schee
- Karlovarská krajská nemocnice a.s., Karlovy Vary, Czech Republic
| | | | | | - Bryan P Yan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | | | - Petr Kala
- University Hospital Brno, Brno, Czech Republic
| | | | - Michael Lee
- Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America
| | | | - Robbert J de Winter
- Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai Hospital, New York, United States of America.
| |
Collapse
|
7
|
Geographical differences in heart failure characteristics and treatment across Europe: results from the BIOSTAT-CHF study. Clin Res Cardiol 2020; 109:967-977. [DOI: 10.1007/s00392-019-01588-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/02/2019] [Indexed: 12/19/2022]
|
8
|
Newman JD, Alexander KP, Gu X, O'Brien SM, Boden WE, Govindan SC, Senior R, Moorthy N, Rezende PC, Demkow M, Lopez-Sendon JL, Bockeria O, Pandit N, Gosselin G, Stone PH, Spertus JA, Stone GW, Fleg JL, Hochman JS, Maron DJ. Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial. Circ Cardiovasc Qual Outcomes 2019; 12:e006002. [PMID: 31718297 DOI: 10.1161/circoutcomes.119.006002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described. METHODS AND RESULTS The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]). CONCLUSIONS In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.
Collapse
Affiliation(s)
| | | | - Xiangqiong Gu
- Duke Clinical Research Institute, Durham, NC (K.P.A., X.G., S.M.O.)
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, NC (K.P.A., X.G., S.M.O.)
| | | | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom (R.S.)
| | - Nagaraja Moorthy
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India (N.M.)
| | - Paulo C Rezende
- Heart Instituto do Coracao, University of Sao Paulo, Brazil (P.C.R.)
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland (M.D.)
| | | | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia (O.B.)
| | | | | | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, MO (J.A.S.)
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, NY (J.W.S.)
| | | | | | | |
Collapse
|
9
|
Tromp J, Ferreira JP, Janwanishstaporn S, Shah M, Greenberg B, Zannad F, Lam CS. Heart failure around the world. Eur J Heart Fail 2019; 21:1187-1196. [DOI: 10.1002/ejhf.1585] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/23/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jasper Tromp
- National Heart Centre Singapore Singapore
- Duke‐NUS Medical School Singapore
- Department of Cardiology University Medical Centre Groningen, University of Groningen Groningen The Netherlands
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques‐ Plurithématique 14‐33, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) Nancy France
| | - Satit Janwanishstaporn
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | | | - Barry Greenberg
- Division of Cardiovascular Medicine UC San Diego Health System La Jolla NC USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques‐ Plurithématique 14‐33, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) Nancy France
| | - Carolyn S.P. Lam
- National Heart Centre Singapore Singapore
- Duke‐NUS Medical School Singapore
- Department of Cardiology University Medical Centre Groningen, University of Groningen Groningen The Netherlands
- The George Institute for Global Health Sydney Australia
| |
Collapse
|
10
|
Mortensen AL, Rosenfeldt F, Filipiak KJ. Effect of coenzyme Q10 in Europeans with chronic heart failure: A sub-group analysis of the Q-SYMBIO randomized double-blind trial. Cardiol J 2019; 26:147-156. [PMID: 30835327 DOI: 10.5603/cj.a2019.0022] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/05/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Geographical differences in patient characteristics, management and outcomes in heart failure (HF) trials are well recognized. The aim of this study was to assess the consistency of the treat- ment effect of coenzyme Q10 (CoQ10) in the European sub-population of Q-SYMBIO, a randomized double-blind multinational trial of treatment with CoQ10, in addition to standard therapy in chronic HF. METHODS Patients with moderate to severe HF were randomized to CoQ10 300 mg daily or placebo in addition to standard therapy. At 3 months the primary short-term endpoints were changes in New York Heart Association (NYHA) functional classification, 6-min walk test, and levels of N-terminal pro-B type natriuretic peptide. At 2 years the primary long-term endpoint was major adverse cardiovascular events (MACE). RESULTS There were no significant changes in short-term endpoints. The primary long-term endpoint of MACE was reached by significantly fewer patients in the CoQ10 group (n = 10, 9%) compared to the placebo group (n = 33, 27%, p = 0.001). The following secondary endpoints were significantly improved in the CoQ10 group compared with the placebo group: all-cause and cardiovascular mortality, NYHA classification and left ventricular ejection fraction (LVEF). In the European sub-population, when compared to the whole group, there was greater adherence to guideline directed therapy and similar results for short- and long-term endpoints. A new finding revealed a significant improvement in LVEF. CONCLUSIONS The therapeutic efficacy of CoQ10 demonstrated in the Q-SYMBIO study was confirmed in the European sub-population in terms of safely reducing MACE, all-cause mortality, cardiovascular mortality, hospitalization and improvement of symptoms.
Collapse
Affiliation(s)
| | - Franklin Rosenfeldt
- Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia.,Baker Heart and Diabetes Institute, Melbourne, Australia
| | | |
Collapse
|
11
|
Commentary: On the levels of patient selection in registry-based randomized controlled trials. Trials 2019; 20:100. [PMID: 30717778 PMCID: PMC6360703 DOI: 10.1186/s13063-019-3214-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 01/18/2019] [Indexed: 11/30/2022] Open
Abstract
Registry-based randomized controlled trials (RCTs) are presumed to include a less-selected patient population and thus to have enhanced generalizability compared to conventional RCTs. However, this view disregards the levels of patient selection in registry-based RCTs: the registry selection level and the trial selection level. At both levels, systematic selection can occur and generalizability can be diminished. Nevertheless, using a registry as a basis for recruitment, randomization, and data collection results in an advantage: the trial selection takes place within the registry framework, where baseline characteristics of non-enrolled patients are automatically documented as well. By comparing the baseline variables of the enrolled and non-enrolled patients, the trial selection can always be investigated, which gives a sound basis for discussing the generalizability to the registry population.
Collapse
|
12
|
Kim SH, Yun SC, Park JJ, Lee SE, Jeon ES, Kim JJ, Cho MC, Chae SC, Kang SM, Choi DJ, Yoo BS, Kim KH, Oh BH, Baek SH. Beta-Blockers in Patients with Heart Failure with Preserved Ejection Fraction: Results from The Korea Acute Heart Failure (KorAHF) Registry. Korean Circ J 2018; 49:238-248. [PMID: 30468042 PMCID: PMC6393317 DOI: 10.4070/kcj.2018.0259] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Beta-blockers are indicated in patients with heart failure (HF) with reduced ejection fraction. However, their efficacy in patients with HF with preserved ejection fraction (HFpEF) is uncertain. We investigated the hypothesis that beta-blockers are associated with reduced adverse events in patients with HFpEF. Methods The Korea Acute Heart Failure (KorAHF) is a prospective observational multicentre cohort study. The 5,625 patients hospitalized for acute HF syndrome in 10 tertiary university hospitals across the country have been consecutively enrolled between March 2011 and February 2014. Of these patients, 2,152 patients with HFpEF (ejection fraction ≥40%) were investigated. The primary outcome was all-cause mortality according to beta-blocker use. Results During a median follow-up duration of 807 days, 702 patients died. In Cox proportional hazards model beta-blocker use was associated with a 14% reduced all-cause death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.75–0.98), but not with reduce rehospitalization (HR, 1.03; 95% CI, 0.85–1.27). In the propensity-score matched population, beta-blockers were also associated with reduced all-cause death (HR, 0.80; 95% CI, 0.69–0.94) but not with reduced rehospitalization (HR, 1.08; 95% CI, 0.87–1.33). Conclusions In Korean patients with HFpEF, use of beta-blockers is associated with reduced all-cause death but not with reduced rehospitalization.
Collapse
Affiliation(s)
- Sung Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Cheol Yun
- Department of Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Joo Park
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Eun Lee
- Division of Cardiology, Heart institute, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Eun Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jae Joong Kim
- Division of Cardiology, Heart institute, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Seok Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kye Hun Kim
- Department of Internal Medicine, Heart Research Center of Chonnam National University, Gwangju, Korea
| | - Byung Hee Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Hong Baek
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | | |
Collapse
|
13
|
Abstract
More than 50% of patients with clinical heart failure have a preserved ejection fraction. Despite mortality that is similar to or slightly lower than heart failure with reduced ejection fraction, trials to date have not shown a therapy that imparts a mortality benefit in heart failure with preserved ejection fraction (HFpEF). HFpEF represents a heterogeneous disorder with a complex pathophysiologic basis, and this may contribute to the negative results in clinical trials. Geographic variations in both patient selection and adherence to study medications confound the interpretation of the trial results. Mineralocorticoid receptor antagonists may be useful in selected patients.
Collapse
Affiliation(s)
- Ajith Nair
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, 6620 Main Street, 12th Floor, Suite 1225, Houston, TX 77030, USA
| | - Anita Deswal
- Department of Medicine, Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA.
| |
Collapse
|
14
|
Ofstad AP, Atar D, Gullestad L, Langslet G, Johansen OE. The heart failure burden of type 2 diabetes mellitus-a review of pathophysiology and interventions. Heart Fail Rev 2018; 23:303-323. [PMID: 29516230 PMCID: PMC5937871 DOI: 10.1007/s10741-018-9685-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes and heart failure (HF) are both global epidemics with tremendous costs on society with increased rates of HF hospitalizations and worsened prognosis when co-existing, making it a significant "deadly duo." The evidence for pharmacological treatment of HF in patients with type 2 diabetes mellitus (T2DM) stems typically from either subgroup analyses of patients that were recruited to randomized controlled trials of HF interventions, usually in patients with reduced ejection fraction (EF), or from subgroup analyses of HF patients recruited to cardiovascular (CV) outcome trials (CVOT) of glucose lowering agents involving patients with T2DM. Studies in patients with HF with preserved EF are sparse. This review summarizes the literature on pathophysiology and interventions aiming to reduce the HF burden in T2DM and includes HF trials of ACEi, digoxin, β-blocker, ARB, If-blocker, MRA, and ARNI involving 38,600 patients, with or without prevalent diabetes, and CV outcome trials in T2DM involving 74,351 patients, with or without prevalent HF. In all HF trials, HF outcomes by prevalent diabetes were reported with an incremental risk of HF and death confessed by prevalent diabetes and a treatment effect similar to those without diabetes. All T2DM CVOTs reported on HF outcomes with heterogeneity between trials with two reporting benefits (empagliflozin and canagliflozin) and two reporting increased risk (saxagliptin, pioglitazone). In vulnerable T2DM patients with concomitant HF, guideline-recommended HF drugs are effective. When choosing glucose-lowering therapy, outcomes from available CVOTs should be considered.
Collapse
Affiliation(s)
- Anne Pernille Ofstad
- Bærum Hospital, Vestre Viken HF, Rud, Norway.
- Medical Department, Boehringer Ingelheim, Asker, Norway.
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Gisle Langslet
- Rikshospitalet, Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Bærum Hospital, Vestre Viken HF, Rud, Norway
- Medical Department, Boehringer Ingelheim, Asker, Norway
| |
Collapse
|
15
|
Sarwar CMS, Vaduganathan M, Butler J. Impact of Site Selection and Study Conduct on Outcomes in Global Clinical Trials. Curr Heart Fail Rep 2017. [PMID: 28647916 DOI: 10.1007/s11897-017-0335-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW There are over 25 million patients living with heart failure globally. Overall, and especially post-discharge, clinical outcomes have remained poor in heart failure despite multiple trials, with both successes and failures over the last two decades. Matching therapies to the right patient population, identifying high-quality sites, and ensuring optimal trial design and execution represent important considerations in the development of novel therapeutics in this space. RECENT FINDINGS While clinical trials have undergone rapid globalization, this has come with regional variation in comorbidities, clinical parameters, and even clinical outcomes and treatment effects across international sites. These issues have now highlighted knowledge gaps about the conduct of trials, selection of study sites, and an unmet need to develop and identify "ideal" sites. There is a need for all stakeholders, including academia, investigators, healthcare organizations, patient advocacy groups, industry sponsors, research organizations, and regulatory authorities, to work as a multidisciplinary group to address these problems and develop practical solutions to improve trial conduct, efficiency, and execution. We review these trial-level issues using examples from contemporary studies to inform and optimize the design of future global clinical trials in heart failure.
Collapse
Affiliation(s)
- Chaudhry M S Sarwar
- Cardiology Division, Health Sciences Center, Stony Brook University, T-16, Room 080 SUNY, Stony Brook, NY, 11794, USA
| | | | - Javed Butler
- Cardiology Division, Health Sciences Center, Stony Brook University, T-16, Room 080 SUNY, Stony Brook, NY, 11794, USA.
| |
Collapse
|
16
|
Mentz RJ, Roessig L, Greenberg BH, Sato N, Shinagawa K, Yeo D, Kwok BWK, Reyes EB, Krum H, Pieske B, Greene SJ, Ambrosy AP, Kelly JP, Zannad F, Pitt B, Lam CSP. Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps. JACC-HEART FAILURE 2017; 4:419-27. [PMID: 27256745 DOI: 10.1016/j.jchf.2016.01.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 12/22/2015] [Accepted: 01/08/2016] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is a major and increasing global public health problem. In Asia, aging populations and recent increases in cardiovascular risk factors have contributed to a particularly high burden of HF, with outcomes that are poorer than those in the rest of the world. Representation of Asians in landmark HF trials has been variable. In addition, HF patients from Asia demonstrate clinical differences from patients in other geographic regions. Thus, the generalizability of some clinical trial results to the Asian population remains uncertain. In this article, we review differences in HF phenotype, HF management, and outcomes in patients from East and Southeast Asia. We describe lessons learned in Asia from recent HF registries and clinical trial databases and outline strategies to improve the potential for success in future trials. This review is based on discussions among scientists, clinical trialists, industry representatives, and regulatory representatives at the CardioVascular Clinical Trialist Asia Forum in Singapore on July 4, 2014.
Collapse
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
| | | | - Barry H Greenberg
- Division of Cardiology, University of California San Diego, San Diego, California
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Kaori Shinagawa
- Office of New Drug II, Pharmaceuticals and Medical Devices Agency, Chiyoda-ku, Tokyo, Japan
| | | | | | | | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Burkert Pieske
- Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum, and German Heart Center Berlin, Berlin, Germany
| | - Stephen J Greene
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew P Ambrosy
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Jacob P Kelly
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, Vandoeuvre-lès-Nancy, France; INSERM U1116, Nancy, France; Université de Lorraine, Nancy, France; CHU Nancy, Pôle de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre-lès-Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| |
Collapse
|
17
|
Pharmacological reasons that may explain why randomized clinical trials have failed in acute heart failure syndromes. Int J Cardiol 2016; 233:1-11. [PMID: 28161130 DOI: 10.1016/j.ijcard.2016.11.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022]
Abstract
Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.
Collapse
|
18
|
Kristensen SL, Martinez F, Jhund PS, Arango JL, Bĕlohlávek J, Boytsov S, Cabrera W, Gomez E, Hagège AA, Huang J, Kiatchoosakun S, Kim KS, Mendoza I, Senni M, Squire IB, Vinereanu D, Wong RCC, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR, Packer M, McMurray JJV. Geographic variations in the PARADIGM-HF heart failure trial. Eur Heart J 2016; 37:3167-3174. [PMID: 27354044 PMCID: PMC5106574 DOI: 10.1093/eurheartj/ehw226] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/07/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022] Open
Abstract
Aims The globalization of clinical trials has highlighted geographic variations in patient characteristics, event rates, and treatment effects. We investigated these further in PARADIGM-HF, the largest and most globally representative trial in heart failure (HF) to date. Methods and results We looked at five regions: North America (NA) 602 (8%), Western Europe (WE) 1680 (20%), Central/Eastern Europe/Russia (CEER) 2762 (33%), Latin America (LA) 1433 (17%), and Asia-Pacific (AP) 1487 (18%). Notable differences included: WE patients (mean age 68 years) and NA (65 years) were older than AP (58 years) and LA (63 years) and had more coronary disease; NA and CEER patients had the worst signs, symptoms, and functional status. North American patients were the most likely to have a defibrillating-device (54 vs. 2% AP) and least likely prescribed a mineralocorticoid receptor antagonist (36 vs. 65% LA). Other evidence-based therapies were used most frequently in NA and WE. Rates of the primary composite outcome of cardiovascular (CV) death or HF hospitalization (per 100 patient-years) varied among regions: NA 13.6 (95% CI 11.7–15.7) WE 9.6 (8.6–10.6), CEER 12.3 (11.4–13.2), LA 11.2 (10.0–12.5), and AP 12.5 (11.3–13.8). After adjustment for prognostic variables, relative to NA, the risk of CV death was higher in LA and AP and the risk of HF hospitalization lower in WE. The benefit of sacubitril/valsartan was consistent across regions. Conclusion There were many regional differences in PARADIGM-HF, including in age, symptoms, comorbidity, background therapy, and event-rates, although these did not modify the benefit of sacubitril/valsartan. Clinical trial registration URL http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
Collapse
Affiliation(s)
- Søren Lund Kristensen
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK .,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Felipe Martinez
- Emeritus Professor of Medicine, Universidad Nacional of Cordoba, Cordoba, Argentina
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Jan Bĕlohlávek
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Sergey Boytsov
- National Research Center for Preventive Medicine, Moscow, Russia
| | | | | | - Albert A Hagège
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Cardiologie ; Paris Descartes University, Sorbonne Paris Cité ; INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Jun Huang
- First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | | | - Kee-Sik Kim
- Daegu Catholic University Hospital, Daegu, Korea
| | - Iván Mendoza
- Venezuela Instituto Tropical Medicine Universidad Central Venezuela, Caracas, Venezuela
| | - Michele Senni
- Azienda Ospedaliera Papa Giovanni XXIII, Cardiologia 1 - Scompenso e Trapianti di Cuore, Bergamo, Italy
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila - University and Emergency Hospital, Bucharest, Romania
| | | | - Jianjian Gong
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor C Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | - Karl Swedberg
- University of Gothenburg, Gothenburg, Sweden .,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| |
Collapse
|
19
|
|
20
|
Metra M, Mentz RJ, Hernandez AF, Heizer GM, Armstrong PW, Clausell N, Corbalan R, Costanzo MR, Dickstein K, Dunlap ME, Ezekowitz JA, Howlett JG, Komajda M, Krum H, Lombardi C, Fonarow GC, McMurray JJ, Nieminen MS, Swedberg K, Voors AA, Starling RC, Teerlink JR, O'Connor CM. Geographic Differences in Patients in a Global Acute Heart Failure Clinical Trial (from the ASCEND-HF Trial). Am J Cardiol 2016; 117:1771-8. [PMID: 27108685 DOI: 10.1016/j.amjcard.2016.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 01/31/2023]
Abstract
A growing number of countries and geographical regions are involved in major clinical trials. Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure is the largest trial in acutely decompensated heart failure (HF) with patients from 5 geographical regions: North America (NA), Latin America (LA), Western Europe (WE), Central Europe (CE), and Asia-Pacific (AP). Data from the 5 geographical areas were compared including baseline characteristics, medications, 30-day outcomes (mortality and mortality or HF hospitalization), and 180-day mortality. Of the 7,141 study patients, 3,243 (45.4%) were from NA (average of 15.2 patients/site), 1,762 (24.7%) from AP (28.4 patients/site), 967 (13.5%) from CE (20.2 patients/site), 665 (9.3%) from LA (17.1 patients/site), and 504 (7.1%) from WE (14.4 patients/site). There were marked differences in co-morbidities, clinical profile, medication use, length of stay, 30-day event rates, and 180-day mortality by region. Compared with NA, the adjusted risk for death or HF hospitalization at 30 days was significantly lower in CE (odds ratio [OR] 0.46, 95% CI 0.33 to 0.64), WE (OR 0.52 95% CI 0.35 to 0.75), and AP (OR 0.62 95% CI 0.48 to 0.79) and numerically lower in LA (OR 0.77, 95% CI 0.57 to 1.04) with similar results for 180-day mortality. In conclusion, in patients with acutely decompensated HF, major differences in baseline characteristics, treatments, length of the hospital stay, and 30-day HF rehospitalization rates, and 180-day mortality were found in patients enrolled from different geographical areas.
Collapse
|
21
|
Bristow MR, Silva Enciso J, Gersh BJ, Grady C, Rice MM, Singh S, Sopko G, Boineau R, Rosenberg Y, Greenberg BH. Detection and Management of Geographic Disparities in the TOPCAT Trial: Lessons Learned and Derivative Recommendations. JACC Basic Transl Sci 2016; 1:180-189. [PMID: 27747305 PMCID: PMC5065247 DOI: 10.1016/j.jacbts.2016.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 11/28/2022]
Abstract
TOPCAT was a multinational clinical trial of 3,445 heart failure with preserved ejection fraction (HFpEF) patients that enrolled in 233 sites in six countries in North America, Eastern Europe and South America. Patients with a heart failure hospitalization in the last 12 months or an elevated B-type natriuretic peptide (BNP) were randomized to the mineralocorticoid receptor antagonist spironolactone vs. placebo. Sites in Russia and the Republic of Georgia provided the majority of early enrollment, primarily based on the hospitalization criterion since BNP levels were initially unavailable there. With the emergence of country-specific aggregate event rate data indicating lower rates in Eastern Europe and differences in patient characteristics there, the DSMB recommended relatively increasing enrollment in North America plus other corrective measures. Although final enrollment reflected the increased contribution from North America, a plurality of the final cohort came from Russia and Georgia (49% vs. 43% in North America). BNP measurements from Russia and Georgia available later in the trial suggested no or a mild level of heart failure consistent with low event rates. The primary results showed no significant spironolactone treatment effect overall (primary endpoint hazard ratio 0.89 (0.77, 1.04)), with a significant hazard ratio in North and South America (0.82 (0.69, 0.98), p =0.026) but not in Russia and Georgia (1.10 (0.79, 1.51), interaction p = 0.12). This report describes the DSMB's detection and management recommendations for regional differences in patient characteristics in TOPCAT, and suggests methods of surveillance and corrective actions that may be useful for future trials.
Collapse
Affiliation(s)
- Michael R. Bristow
- Cardiovascular Institute, University of Colorado, Boulder and Aurora, Colorado
| | - Jorge Silva Enciso
- Department of Medicine, Division of Cardiology University of California, San Diego Medical Center, La Jolla, California
| | - Bernard J. Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Christine Grady
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Steven Singh
- Department of Medicine, Division of Cardiology Washington Veterans Affairs Medical Center, Washington, DC
| | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Robin Boineau
- Office of Clinical and Regulatory Affairs, National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Yves Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Barry H. Greenberg
- Department of Medicine, Division of Cardiology University of California, San Diego Medical Center, La Jolla, California
| |
Collapse
|
22
|
Mecklai A, Subačius H, Konstam MA, Gheorghiade M, Butler J, Ambrosy AP, Katz SD. In-Hospital Diuretic Agent Use and Post-Discharge Clinical Outcomes in Patients Hospitalized for Worsening Heart Failure: Insights From the EVEREST Trial. JACC-HEART FAILURE 2016; 4:580-588. [PMID: 27039131 DOI: 10.1016/j.jchf.2016.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/17/2016] [Accepted: 02/19/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The aim of this study was to characterize the association between decongestion therapy and 30-day outcomes in patients hospitalized for heart failure (HF). BACKGROUND Loop diuretic agents are commonly prescribed for the treatment of symptomatic congestion in patients hospitalized for HF, but the association between loop diuretic agent dose response and post-discharge outcomes has not been well characterized. METHODS Cox proportional hazards models were used to estimate the association among average loop diuretic agent dose, congestion status at discharge, and 30-day post-discharge all-cause mortality and HF rehospitalization in 3,037 subjects hospitalized with worsening HF enrolled in the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) study. RESULTS In univariate analysis, subjects exposed to high-dose diuretic agents (≥160 mg/day) had greater risk for the combined outcome than subjects exposed to low-dose diuretic agents (18.9% vs. 10.0%; hazard ratio: 2.00; 95% confidence interval: 1.64 to 2.46; p < 0.0001). After adjustment for pre-specified covariates of disease severity, the association between diuretic agent dose and outcomes was not significant (hazard ratio: 1.11; 95% confidence interval: 0.89 to 1.38; p = 0.35). Of the 3,011 subjects with clinical assessments of volume status, 2,063 (69%) had little or no congestion at hospital discharge. Congestion status at hospital discharge did not modify the association between diuretic agent exposure and the combined endpoint (p for interaction = 0.84). CONCLUSIONS Short-term diuretic agent exposure during hospital treatment for worsening HF was not an independent predictor of 30-day all-cause mortality and HF rehospitalization in multivariate analysis. Congestion status at discharge did not modify the association between diuretic agent dose and clinical outcomes.
Collapse
Affiliation(s)
- Alicia Mecklai
- Weill Cornell Medical College, New York, New York; New York University School of Medicine, New York, New York
| | - Haris Subačius
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center and Tufts Medical Center, Boston, Massachusetts
| | - Mihai Gheorghiade
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Javed Butler
- Stony Brook School of Medicine, Stony Brook, New York
| | | | - Stuart D Katz
- New York University School of Medicine, New York, New York.
| |
Collapse
|
23
|
Abstract
Randomized controlled trials (RCTs) are essential to develop advances in heart failure (HF). The need for increasing numbers of patients (without substantial cost increase) and generalization of results led to the disappearance of international boundaries in large RCTs. The significant geographic differences in patients' characteristics, outcomes, and, most importantly, treatment effect observed in HF trials have recently been highlighted. Whether the observed regional discrepancies in HF trials are due to trial-specific issues, patient heterogeneity, structural differences in countries, or a complex interaction between factors are the questions we propose to debate in this review. To do so, we will analyse and review data from HF trials conducted in different world regions, from heart failure with preserved ejection fraction (HF-PEF), heart failure with reduced ejection fraction (HF-REF), and acute heart failure (AHF). Finally, we will suggest objective and actionable measures in order to mitigate regional discrepancies in future trials, particularly in HF-PEF where prognostic modifying treatments are urgently needed and in which trials are more prone to selection bias, due to a larger patient heterogeneity.
Collapse
Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| |
Collapse
|
24
|
Kelly JP, Mentz RJ, Mebazaa A, Voors AA, Butler J, Roessig L, Fiuzat M, Zannad F, Pitt B, O'Connor CM, Lam CSP. Patient selection in heart failure with preserved ejection fraction clinical trials. J Am Coll Cardiol 2015; 65:1668-1682. [PMID: 25908073 DOI: 10.1016/j.jacc.2015.03.043] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/08/2015] [Indexed: 12/11/2022]
Abstract
Recent clinical trials in patients with heart failure with preserved ejection fraction (HFpEF) have provided important insights into participant selection strategies. Historically, HFpEF trials have included patients with relatively preserved left ventricular ejection fraction ranging from 40% to 55% and a clinical history of heart failure. Contemporary HFpEF trials have also incorporated inclusion criteria such as hospitalization for HFpEF, altered functional capacity, cardiac structural and functional abnormalities, and abnormalities in neurohormonal status (e.g., elevated natriuretic peptide levels). Careful analyses of the effect of these patient selection criteria on outcomes in prior trials provide valuable lessons for future trial design. We review recent and ongoing HFpEF clinical trials from a patient selection perspective and appraise trial patient selection methodologies in relation to outcomes. This review reflects discussions between clinicians, scientists, trialists, regulators, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum in Paris, France, on December 6, 2013.
Collapse
Affiliation(s)
- Jacob P Kelly
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques, Université de Lorraine and CHU de Nancy, Nancy, France
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Christopher M O'Connor
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore
| |
Collapse
|
25
|
Murthy S, Mandl KD, Bourgeois FT. Industry-sponsored clinical research outside high-income countries: an empirical analysis of registered clinical trials from 2006 to 2013. Health Res Policy Syst 2015; 13:28. [PMID: 26041551 PMCID: PMC4465475 DOI: 10.1186/s12961-015-0019-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/26/2015] [Indexed: 12/31/2022] Open
Abstract
Background Industry-sponsored clinical trials, in the past performed almost exclusively in more developed countries, now often recruit participants globally. However, recruitment from outside high-income countries may not represent the ultimate target population for the intervention. Clinical trial registries provide an opportunity to quantify and examine the type of clinical research performed in various geographic regions. We sought to characterize industry-sponsored randomized controlled trials conducted in high-income countries and to compare these trials to those performed outside high-income countries. Methods Clinical trial data on all industry-funded randomized controlled trials conducted between 2006 and 2014 were obtained from the registry ClinicalTrials.gov. Trials were classified according to their study sites as conducted in high or non-high income countries, and data on trial characteristics were collected. Results Of 22,511 relevant trials, a total of 6,085 (27.0 %) trials included study sites outside a high-income country, and 2,045 (9.1 %) were conducted exclusively outside high-income countries. Of country groups, Central Europe had the greatest number of trials (3,127), followed by Eastern Europe (2,075). The percentage of trials with study sites outside high-income countries remained relatively constant over the study period. Studies with sites outside high-income countries tended to recruit more participants (median enrolled participants 265 vs. 71, P <0.001), to be longer (median study duration 20 vs. 13 months, P <0.05), and to study more advanced phase interventions (Phase 3 or 4 trial 58 % vs. 33 %, P <0.001). Conclusions More than a quarter of industry-sponsored trials include participants from outside high-income countries and this rate remained stable over the 7-year study period. Trials conducted outside high-income countries tend to be larger, have a longer duration, and study later phase interventions compared to studies performed exclusively in high-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0019-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Srinivas Murthy
- Department of Pediatrics, University of British Columbia, 4500 Oak Street, V6H 3V4, Vancouver, BC, Canada. .,Division of Critical Care, BC Children's Hospital, Vancouver, BC, Canada.
| | - Kenneth D Mandl
- Center for Biomedical Informatics, Harvard Medical School, Boston, MA, USA. .,Children's Hospital Informatics Program, Boston Children's Hospital, 320 Longwood Avenue, 02115-5737, Boston, MA, USA. .,Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Florence T Bourgeois
- Children's Hospital Informatics Program, Boston Children's Hospital, 320 Longwood Avenue, 02115-5737, Boston, MA, USA. .,Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
26
|
Butler J, Fonarow GC, O'Connor C, Adams K, Bonow RO, Cody RJ, Collins SP, Dunnmon P, Dinh W, Fiuzat M, Georgiopoulou VV, Grant S, Kim SY, Kupfer S, Lefkowitz M, Mentz RJ, Misselwitz F, Pitt B, Roessig L, Schelbert E, Shah M, Solomon S, Stockbridge N, Yancy C, Gheorghiade M. Improving cardiovascular clinical trials conduct in the United States: recommendation from clinicians, researchers, sponsors, and regulators. Am Heart J 2015; 169:305-14. [PMID: 25728719 DOI: 10.1016/j.ahj.2014.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022]
Abstract
Advances in medical therapies leading to improved patient outcomes are in large part related to successful conduct of clinical trials that offer critical information regarding the efficacy and safety of novel interventions. The conduct of clinical trials in the United States, however, continues to face increasing challenges with recruitment and retention. These trends are paralleled by an increasing shift toward more multinational trials where most participants are enrolled in countries outside the United States, bringing into question the generalizability of the results to the American population. This manuscript presents the perspectives and recommendations from clinicians, researchers, sponsors, and regulators who attended a meeting facilitated by the Food and Drug Administration to improve upon the current clinical trial trends in the United States.
Collapse
Affiliation(s)
- Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY.
| | | | | | | | - Robert O Bonow
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert J Cody
- Cardiovascular & Metabolism, Janssen Pharmaceuticals, Raritan, NJ
| | | | - Preston Dunnmon
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Wilfried Dinh
- Department of Cardiology, Witten University, Witten, Germany; Global Drug Discovery, Clinical Sciences, Bayer Pharma AG, Berlin, Germany
| | - Mona Fiuzat
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Stephen Grant
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - So-Young Kim
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | | | | | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Frank Misselwitz
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Bertram Pitt
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Lothar Roessig
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Erik Schelbert
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA
| | - Monica Shah
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Clyde Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
27
|
|
28
|
Asakura M, Yamamoto H, Asai K, Hanatani A, Hirata KI, Hirayakma A, Kimura K, Kobayashi Y, Momomura SI, Nakagawa Y, Nishi Y, Saito Y, Satoh Y, Yamada T, Yamashina A, Yasuda S, Yoshikawa T, Kada A, Uesaka H, Kitakaze M. Rationale and Design of the Double-Blind, Randomized, Placebo-Controlled Multicenter Trial on Efficacy of Early Initiation of Eplerenone Treatment in Patients with Acute Heart Failure (EARLIER). Cardiovasc Drugs Ther 2015; 29:179-85. [DOI: 10.1007/s10557-014-6565-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
29
|
Kristensen SL, Køber L, Jhund PS, Solomon SD, Kjekshus J, McKelvie RS, Zile MR, Granger CB, Wikstrand J, Komajda M, Carson PE, Pfeffer MA, Swedberg K, Wedel H, Yusuf S, McMurray JJV. International geographic variation in event rates in trials of heart failure with preserved and reduced ejection fraction. Circulation 2014; 131:43-53. [PMID: 25406306 DOI: 10.1161/circulationaha.114.012284] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND International geographic differences in outcomes may exist for clinical trials of heart failure and reduced ejection fraction (HF-REF), but there are few data for those with preserved ejection fraction (HF-PEF). METHODS AND RESULTS We analyzed outcomes by international geographic region in the Irbesartan in Heart Failure with Preserved systolic function trial (I-Preserve), the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM)-Preserved trial, the CHARM-Alternative and CHARM-Added HF-REF trials, and the Controlled Rosuvastatin Multinational Trial in HF-REF (CORONA). Crude rates of heart failure hospitalization varied by geographic region, and more so for HF-PEF than for HF-REF. Rates in patients with HF-PEF were highest in the United States/Canada (HF hospitalization rate 7.6 per 100 patient-years in I-Preserve; 8.8 in CHARM-Preserved), intermediate in Western Europe (4.8/100 and 4.7/100), and lowest in Eastern Europe/Russia (3.3/100 and 2.8/100). The difference between the United States/Canada versus Eastern Europe/Russia persisted after adjustment for key prognostic variables: adjusted hazard ratios 1.34 (95% confidence interval, 1.01-1.74; P=0.04) in I-Preserve and 1.85 (95% confidence interval, 1.17-2.91; P=0.01) in CHARM-Preserved. In HF-REF, rates of HF hospitalization were slightly lower in Western Europe compared with other regions. For both HF-REF and HF-PEF, there were few regional differences in rates of all-cause or cardiovascular mortality. CONCLUSIONS The differences in event rates observed suggest there is international geographic variation in 1 or more of the definition and diagnosis of HF-PEF, the risk profile of patients enrolled, and the threshold for hospitalization, which has implications for the conduct of future global trials.
Collapse
Affiliation(s)
- Søren L Kristensen
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Lars Køber
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Pardeep S Jhund
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Scott D Solomon
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John Kjekshus
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Robert S McKelvie
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Michael R Zile
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Christopher B Granger
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John Wikstrand
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Michel Komajda
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Peter E Carson
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Marc A Pfeffer
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Karl Swedberg
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Hans Wedel
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Salim Yusuf
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John J V McMurray
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.).
| |
Collapse
|
30
|
Ambrosy AP, Gheorghiade M, Chioncel O, Mentz RJ, Butler J. Global Perspectives in Hospitalized Heart Failure: Regional and Ethnic Variation in Patient Characteristics, Management, and Outcomes. Curr Heart Fail Rep 2014; 11:416-27. [DOI: 10.1007/s11897-014-0221-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
31
|
Labos C, Nguyen V, Giannetti N, Huynh T. Beta-blockers Associated with a Mortality Benefit in Patients with Systolic Dysfunction and Elevated Serum Bilirubin. Open Cardiovasc Med J 2014; 8:76-82. [PMID: 25246987 PMCID: PMC4168649 DOI: 10.2174/1874192401408010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 06/24/2014] [Accepted: 06/28/2014] [Indexed: 11/24/2022] Open
Abstract
Background:
Hyperbilirubinemia is associated with increased mortality in heart failure (HF) patients. We evaluated the impact of evidence-based medical therapy, in particular beta-blocker on the survival of patients with HF and hyperbilirubinemia. Methods and Results:
We reviewed the charts of all patients followed at our tertiary care heart failure clinic. Hyperbilirubinemia was defined as total bilirubin >30 µmol/L (1.5 times the upper limit of our laboratory value). The primary endpoint was all-cause mortality. The secondary endpoint was a composite of death, cardiac transplant or ventricular assistance device implantation (VAD). Of 1035 HF patients, 121 patients (11.7%) had hyperbilirubinemia. Median follow-up was 556 days. Hyperbilirubinemia was associated with an eight-fold increase in all-cause mortality, hazard ratio (HR): 8.78[95% Confidence Intervals (CI): 5.89-13.06]. Beta-blocker use was associated with approximately 60% reduction in all-cause mortality (HR: 0.38, 95% CI:0.15-0.94) and 70% reduction in the composite secondary endpoint (HR:0.31, 95% CI:0.13-0.71) in patients with hyperbilirubinemia. Conclusion:
HF patients with hyperbilirubinemia have increased early mortality, need for cardiac transplantation or VAD. Beta-blocker use was associated with early survival benefit in these patients. Bilirubin levels should be monitored in patients with HF and early initiation of beta-blockers in patients with hyperbilirubinemia should be considered.
Collapse
|
32
|
Chatterjee S, Udell JA, Sardar P, Lichstein E, Ryan JJ. Comparable Benefit of β-Blocker Therapy in Heart Failure Across Regions of the World: Meta-analysis of Randomized Clinical Trials. Can J Cardiol 2014; 30:898-903. [DOI: 10.1016/j.cjca.2014.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022] Open
|
33
|
Regional Variability in β-Blocker Efficacy and Safety: A Question of “Location, Location, Location”? Can J Cardiol 2014; 30:858-60. [DOI: 10.1016/j.cjca.2014.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 05/08/2014] [Accepted: 05/08/2014] [Indexed: 11/21/2022] Open
|
34
|
Abstract
The pathophysiology of heart failure (HF) is characterized by hemodynamic abnormalities that result in neurohormonal activation and autonomic imbalance with increase in sympathetic activity and withdrawal of vagal activity. Alterations in receptor activation from this autonomic imbalance may have profound effects on cardiac function and structure. Inhibition of the sympathetic drive to the heart through β-receptor blockade has become a standard component of therapy for HF with a dilated left ventricle because of its effectiveness in inhibiting the ventricular structural remodeling process and in prolonging life. Several devices for selective modulation of sympathetic and vagal activity have recently been developed in an attempt to alter the natural history of HF. The optimal counteraction of the excessive sympathetic activity is still unclear. A profound decrease in adrenergic support with excessive blockade of the sympathetic nervous system may result in adverse outcomes in clinical HF. In this review, we analyze the data supporting a contributory role of the autonomic functional alterations on the course of HF, the techniques used to assess autonomic nervous system activity, the evidence for clinical effectiveness of pharmacological and device interventions, and the potential future role of autonomic nervous system modifiers in the management of this syndrome.
Collapse
Affiliation(s)
- Viorel G Florea
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School
| | - Jay N Cohn
- From the Minneapolis VA Health Care System, Section of Cardiology (V.G.F.) and Rasmussen Center for Cardiovascular Disease Prevention, Department of Medicine (J.N.C.), University of Minnesota Medical School.
| |
Collapse
|
35
|
Chakraborty A, Chatterjee S. Convergence in findings from randomized trials and elaborately analysed observational data on mortality reduction with carvedilol in heart failure in comparison with metoprolol. Eur J Heart Fail 2014; 16:595-7. [PMID: 24863629 DOI: 10.1002/ejhf.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/16/2014] [Indexed: 11/06/2022] Open
Affiliation(s)
- Anasua Chakraborty
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | |
Collapse
|
36
|
Mentz RJ, Cotter G, Cleland JGF, Stevens SR, Chiswell K, Davison BA, Teerlink JR, Metra M, Voors AA, Grinfeld L, Ruda M, Mareev V, Lotan C, Bloomfield DM, Fiuzat M, Givertz MM, Ponikowski P, Massie BM, O'Connor CM. International differences in clinical characteristics, management, and outcomes in acute heart failure patients: better short-term outcomes in patients enrolled in Eastern Europe and Russia in the PROTECT trial. Eur J Heart Fail 2014; 16:614-24. [PMID: 24771609 DOI: 10.1002/ejhf.92] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/05/2014] [Accepted: 03/07/2014] [Indexed: 01/04/2023] Open
Abstract
AIMS The implications of geographical variation are unknown following adjustment for hospital length of stay (LOS) in heart failure (HF) trials that included patients whether or not they had systolic dysfunction. We investigated regional differences in an international acute HF trial. METHODS AND RESULTS The PROTECT trial investigated 2033 patients with acute HF and renal dysfunction hospitalized at 173 sites in 17 countries with randomization to rolofylline or placebo. We grouped enrolling countries into six regions. Baseline characteristics, in-hospital management, and outcomes were explored by region. The primary study outcome was 60-day mortality or cardiovascular/renal hospitalization. Secondary outcomes included 180-day mortality. Of 2033 patients, 33% were from Eastern Europe, 19% from Western Europe, 16% from Israel, 15% from North America, 14% from Russia, and 3% from Argentina. Marked differences in baseline characteristics, HF phenotype, in-hospital diuretic and vasodilator strategies, and LOS were observed by region. LOS was shortest in North America and Israel (median 5 days) and longest in Russia (median 15 days). Regional event rates varied significantly. Following multivariable adjustment, region was an independent predictor of the risk of mortality/hospitalization at 60 days, with the lowest risk in Russia (hazard ratio 0.39, 95% confidence interval 0.23-0.64 vs. Western Europe) due to lower rehospitalization; mortality differences were attenuated by 180 days. CONCLUSIONS In an international HF trial, there were differences in baseline characteristics, treatments, LOS, and rehospitalization amongst regions, but little difference in longer term mortality. Rehospitalization differences exist independent of LOS. This analysis may help inform future trial design and should be externally validated.
Collapse
|
37
|
Affiliation(s)
- John J V McMurray
- From the British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); and Duke University Medical Center, Durham, NC (C.O.)
| | | |
Collapse
|
38
|
Pitt B, Pfeffer MA, Assmann SF, Boineau R, Anand IS, Claggett B, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Harty B, Heitner JF, Kenwood CT, Lewis EF, O'Meara E, Probstfield JL, Shaburishvili T, Shah SJ, Solomon SD, Sweitzer NK, Yang S, McKinlay SM. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med 2014; 370:1383-92. [PMID: 24716680 DOI: 10.1056/nejmoa1313731] [Citation(s) in RCA: 1739] [Impact Index Per Article: 173.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mineralocorticoid-receptor antagonists improve the prognosis for patients with heart failure and a reduced left ventricular ejection fraction. We evaluated the effects of spironolactone in patients with heart failure and a preserved left ventricular ejection fraction. METHODS In this randomized, double-blind trial, we assigned 3445 patients with symptomatic heart failure and a left ventricular ejection fraction of 45% or more to receive either spironolactone (15 to 45 mg daily) or placebo. The primary outcome was a composite of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. RESULTS With a mean follow-up of 3.3 years, the primary outcome occurred in 320 of 1722 patients in the spironolactone group (18.6%) and 351 of 1723 patients in the placebo group (20.4%) (hazard ratio, 0.89; 95% confidence interval [CI], 0.77 to 1.04; P=0.14). Of the components of the primary outcome, only hospitalization for heart failure had a significantly lower incidence in the spironolactone group than in the placebo group (206 patients [12.0%] vs. 245 patients [14.2%]; hazard ratio, 0.83; 95% CI, 0.69 to 0.99, P=0.04). Neither total deaths nor hospitalizations for any reason were significantly reduced by spironolactone. Treatment with spironolactone was associated with increased serum creatinine levels and a doubling of the rate of hyperkalemia (18.7%, vs. 9.1% in the placebo group) but reduced hypokalemia. With frequent monitoring, there were no significant differences in the incidence of serious adverse events, a serum creatinine level of 3.0 mg per deciliter (265 μmol per liter) or higher, or dialysis. CONCLUSIONS In patients with heart failure and a preserved ejection fraction, treatment with spironolactone did not significantly reduce the incidence of the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. (Funded by the National Heart, Lung, and Blood Institute; TOPCAT ClinicalTrials.gov number, NCT00094302.).
Collapse
Affiliation(s)
- Bertram Pitt
- From the University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiovascular Division, Brigham and Women's Hospital, Boston (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Watertown, MA (S.F.A., B.H., C.T.K., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F., S.Y.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow (I.G.); New York Methodist Hospital, Brooklyn (J.F.H.); Montreal Heart Institute, Montreal (E.O.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago (S.J.S.); and the University of Wisconsin, Madison (N.K.S.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Parry HM, Doney AS, Palmer CN, Lang CC. State of Play of Pharmacogenetics and Personalized Medicine in Heart Failure. Cardiovasc Ther 2013; 31:315-22. [DOI: 10.1111/1755-5922.12030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Helen M. Parry
- Division of Cardiovascular and Diabetes Medicine; Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Alex S.F. Doney
- Division of Cardiovascular and Diabetes Medicine; Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Colin N.A. Palmer
- Department of Pharmacogenetics and Pharmacogenomics; Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Chim C. Lang
- Division of Cardiovascular and Diabetes Medicine; Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| |
Collapse
|
40
|
Bosch M, Tavender E, Bragge P, Gruen R, Green S. How to define 'best practice' for use in Knowledge Translation research: a practical, stepped and interactive process. J Eval Clin Pract 2013; 19:763-8. [PMID: 22487019 DOI: 10.1111/j.1365-2753.2012.01835.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Defining 'best practice' is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between 'desired' and 'actual' care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research-based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes. METHODS Our process encompasses the following steps: (1) identify current, high-quality clinical practice guidelines (CPGs) and extract recommendations; (2) select strong recommendations in key clinical management areas; (3) update evidence and create evidence overviews; (4) discuss evidence and produce agreed 'evidence statements'; (5) discuss the relevance of the evidence with local stakeholders; and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators. CONCLUSIONS Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high-quality CPGs that are in line with current research evidence.
Collapse
Affiliation(s)
- Marije Bosch
- Research Fellow Senior Research Fellow Professor of Surgery & Public Health, Director, National Trauma Research Institute/Central Clinical School, Monash University, Melbourne, Australia Professorial fellow, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | | |
Collapse
|
41
|
Relaxin for Treatment of Acute Heart Failure: Making the Case for Treating Targeted Patient Profiles. Curr Heart Fail Rep 2013; 10:198-203. [DOI: 10.1007/s11897-013-0148-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
42
|
Eapen ZJ, Reed SD, Li Y, Kociol RD, Armstrong PW, Starling RC, McMurray JJ, Massie BM, Swedberg K, Ezekowitz JA, Fonarow GC, Teerlink JR, Metra M, Whellan DJ, O'Connor CM, Califf RM, Hernandez AF. Do countries or hospitals with longer hospital stays for acute heart failure have lower readmission rates?: Findings from ASCEND-HF. Circ Heart Fail 2013; 6:727-32. [PMID: 23770519 DOI: 10.1161/circheartfailure.112.000265] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital readmission is an important clinical outcome of patients with heart failure. Its relation to length of stay for the initial hospitalization is not clear. METHODS AND RESULTS We used hierarchical modeling of data from a clinical trial to examine variations in length of stay across countries and across hospitals in the United States and its association with readmission within 30 days of randomization. Main outcomes included associations between country-level length of stay and readmission rates, after adjustment for patient-level case mix; and associations between length of stay and readmission rates across sites in the United States. Across 27 countries with 389 sites and 6848 patients, mean length of stay ranged from 4.9 to 14.6 days (6.1 days in the United States). Rates of all-cause readmission ranged from 2.5% to 25.0% (17.8% in the United States). There was an inverse correlation between country-level mean length of stay and readmission (r=-0.52; P<0.01). After multivariable adjustment, each additional inpatient day across countries was associated with significantly lower risk of all-cause readmission (odds ratio, 0.86; 95% confidence interval, 0.75-0.98; P=0.02) and heart failure readmission (odds ratio, 0.79; 95% confidence interval, 0.69-0.99; P=0.03). Similar trends were observed across US study sites concerning readmission for any cause (odds ratio, 0.92; 95% confidence interval, 0.85-1.00; P=0.06) and readmission for heart failure (odds ratio, 0.90; 95% confidence interval, 0.80-1.01; P=0.07). Across countries and across US sites, longer median length of stay was independently associated with lower risk of readmission. CONCLUSIONS Countries with longer length of stay for heart failure hospitalizations had significantly lower rates of readmission within 30 days of randomization. These findings may have implications for developing strategies to prevent readmission, defining quality measures, and designing clinical trials in acute heart failure. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.
Collapse
Affiliation(s)
- Zubin J Eapen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC 27715, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Rescuing clinical trials in the United States and beyond: a call for action. Am Heart J 2013; 165:837-47. [PMID: 23708153 DOI: 10.1016/j.ahj.2013.02.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 02/06/2013] [Indexed: 11/22/2022]
Abstract
Numerous challenges-financial, regulatory, and cultural-are hindering US participation and performance in multinational clinical trials. Consequently, it is increasingly unclear how the results of these trials should be applied to American patients, practice patterns, and systems of care. Both incremental and transformative changes are needed to revitalize US participation as well as the broader clinical trial enterprise. To promote consensus around the solutions needed to address the adverse trends in clinical research, the Duke Clinical Research Institute convenedstakeholders from academia, industry, and government. article summarizes the proceedings of this meeting and addresses: (1) adverse trends in the United States and multinational clinical trials, (2) the key issues that underlie these adverse trends, and (3) potential solutions to these problems.
Collapse
|
44
|
Pocock S, Calvo G, Marrugat J, Prasad K, Tavazzi L, Wallentin L, Zannad F, Alonso Garcia A. International differences in treatment effect: do they really exist and why?†. Eur Heart J 2013; 34:1846-52. [DOI: 10.1093/eurheartj/eht071] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
45
|
Relationship Between Clinical Trial Site Enrollment With Participant Characteristics, Protocol Completion, and Outcomes. J Am Coll Cardiol 2013; 61:571-9. [DOI: 10.1016/j.jacc.2012.10.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/21/2012] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
|
46
|
|
47
|
Chatterjee S, Biondi-Zoccai G, Abbate A, D'Ascenzo F, Castagno D, Van Tassell B, Mukherjee D, Lichstein E. Benefits of β blockers in patients with heart failure and reduced ejection fraction: network meta-analysis. BMJ 2013; 346:f55. [PMID: 23325883 PMCID: PMC3546627 DOI: 10.1136/bmj.f55] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To clarify whether any particular β blocker is superior in patients with heart failure and reduced ejection fraction or whether the benefits of these agents are mainly due to a class effect. DESIGN Systematic review and network meta-analysis of efficacy of different β blockers in heart failure. DATA SOURCES CINAHL(1982-2011), Cochrane Collaboration Central Register of Controlled Trials (-2011), Embase (1980-2011), Medline/PubMed (1966-2011), and Web of Science (1965-2011). STUDY SELECTION Randomized trials comparing β blockers with other β blockers or other treatments. DATA EXTRACTION The primary endpoint was all cause death at the longest available follow-up, assessed with odds ratios and Bayesian random effect 95% credible intervals, with independent extraction by observers. RESULTS 21 trials were included, focusing on atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol. As expected, in the overall analysis, β blockers provided credible mortality benefits in comparison with placebo or standard treatment after a median of 12 months (odds ratio 0.69, 0.56 to 0.80). However, no obvious differences were found when comparing the different β blockers head to head for the risk of death, sudden cardiac death, death due to pump failure, or drug discontinuation. Accordingly, improvements in left ventricular ejection fraction were also similar irrespective of the individual study drug. CONCLUSION The benefits of β blockers in patients with heart failure with reduced ejection fraction seem to be mainly due to a class effect, as no statistical evidence from current trials supports the superiority of any single agent over the others.
Collapse
Affiliation(s)
- Saurav Chatterjee
- Division of Internal Medicine, Maimonides Medical Center, New York, NY, USA.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Troponin leak in heart failure: Moving forward to arrest cardiomyocyte attrition and promote myocardial regeneration. Int J Cardiol 2013; 162:137-9. [DOI: 10.1016/j.ijcard.2012.01.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 01/28/2012] [Indexed: 11/18/2022]
|
49
|
Combinatorial pharmacogenetic interactions of bucindolol and β1, α2C adrenergic receptor polymorphisms. PLoS One 2012; 7:e44324. [PMID: 23071495 PMCID: PMC3468617 DOI: 10.1371/journal.pone.0044324] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 08/01/2012] [Indexed: 11/20/2022] Open
Abstract
Background Pharmacogenetics involves complex interactions of gene products affecting pharmacodynamics and pharmacokinetics, but there is little information on the interaction of multiple genetic modifiers of drug response. Bucindolol is a β-blocker/sympatholytic agent whose efficacy is modulated by polymorphisms in the primary target (β1 adrenergic receptor [AR] Arg389 Gly on cardiac myocytes) and a secondary target modifier (α2C AR Ins [wild-type (Wt)] 322–325 deletion [Del] on cardiac adrenergic neurons). The major allele homozygotes and minor allele carriers of each polymorphism are respectively associated with efficacy enhancement and loss, creating the possibility for genotype combination interactions that can be measured by clinical trial methodology. Methodology In a 1,040 patient substudy of a bucindolol vs. placebo heart failure clinical trial, we tested the hypothesis that combinations of β1389 and α2C322–325 polymorphisms are additive for both efficacy enhancement and loss. Additionally, norepinephrine (NE) affinity for β1389 AR variants was measured in human explanted left ventricles. Principal Findings The combination of β1389 Arg+α2C322–325 Wt major allele homozygotes (47% of the trial population) was non-additive for efficacy enhancement across six clinical endpoints, with an average efficacy increase of 1.70-fold vs. 2.32-fold in β1389 Arg homozygotes+α2C322–325 Del minor allele carriers. In contrast, the minor allele carrier combination (13% subset) exhibited additive efficacy loss. These disparate effects are likely due to the higher proportion (42% vs. 8.7%, P = 0.009) of high-affinity NE binding sites in β1389 Arg vs. Gly ARs, which converts α2CDel minor allele-associated NE lowering from a therapeutic liability to a benefit. Conclusions On combination, the two sets of AR polymorphisms 1) influenced bucindolol efficacy seemingly unpredictably but consistent with their pharmacologic interactions, and 2) identified subpopulations with enhanced (β1389 Arg homozygotes), intermediate (β1389 Gly carriers+α2C322–325 Wt homozygotes), and no (β1389 Gly carriers+α2C322–325 Del carriers) efficacy.
Collapse
|
50
|
Mentz RJ, Kaski JC, Dan GA, Goldstein S, Stockbridge N, Alonso-Garcia A, Ruilope LM, Martinez FA, Zannad F, Pitt B, Fiuzat M, O'Connor CM. Implications of geographical variation on clinical outcomes of cardiovascular trials. Am Heart J 2012; 164:303-12. [PMID: 22980295 DOI: 10.1016/j.ahj.2012.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
Abstract
Cardiovascular clinical trials are increasingly conducted globally as a means to reduce costs, expedite timelines, provide broad applicability, and satisfy regulatory authorities. Potential problems with trial globalization include regional differences in patient characteristics, medical practice patterns, and health policies which may influence outcomes and limit generalizability. Moreover, concerns have been raised about ethical misconduct and unsatisfactory quality oversight in regions with less trial experience and infrastructure. This article reviews geographical differences in cardiovascular trials in heart failure, acute coronary syndromes, hypertension and atrial fibrillation. It also explores potential explanations for these differences and methods to standardize the presentation of trial results. This review is based on discussions between basic scientists and clinical trialists at the 8th Global Cardio Vascular Clinical Trialists Forum 2011 in Paris, France, from December 2 to 3.
Collapse
|