Limitations of Long-Term Mortality as a Clinical Trial Endpoint

Search Engines to Capture Missing Deaths From Institutional Data Warehouse

INTRODUCTION

Clinical publications use mortality as a hard end point. It is unknown how many patient deaths are under-reported in institutional databases. The objective of this study was to query mortality in our patient cohort from our data warehouse and compare these deaths to those identified in different databases.

METHODS

We passed the first/last name and date of birth of 134 patients through online mortality search engines (Find a Grave Index, US Cemetery and Funeral Home Collection, etc.) to assess their ability to capture patient deaths and compared that to deaths recorded from our institutional data warehouse.

RESULTS

Our institutional data warehouse found approximately one-third of the total patient mortalities. After the Social Security Death Index, we found that the Find a Grave Index captured the most mortalities missed by the institutional data warehouse. These results highlight the advantages of incorporating readily available search engines into institutional data warehouses for the accurate collection of patient mortalities, particularly those that occur outside of index operative admission.

CONCLUSIONS

The incorporation of the mortality search engines significantly augmented the capture of patient deaths. Our approach may be useful for tailored patient outreach and reporting mortalities with institutional data.

Long-term follow-up after invasive or conservative management of stable coronary disease: the ISCHEMIA-EXTEND study

The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.

Cardiac mortality in patients randomised to elective coronary revascularisation plus medical therapy or medical therapy alone: a systematic review and meta-analysis

Aims

The value of elective coronary revascularisation plus medical therapy over medical therapy alone in managing stable patients with coronary artery disease is debated. We reviewed all trials comparing the two strategies in this population.

Methods and results

From inception through November 2020, MEDLINE, EMBASE, Google Scholar, and other databases were searched for randomised trials comparing revascularisation against medical therapy alone in clinically stable coronary artery disease patients. Treatment effects were measured by rate ratios (RRs) with 95% confidence intervals, using random-effects models. Cardiac mortality was the pre-specified primary endpoint. Spontaneous myocardial infarction (MI) and its association with cardiac mortality were secondary endpoints. Further endpoints included all-cause mortality, any MI, and stroke. Longest follow-up data were abstracted. The study is registered with PROSPERO (CRD42021225598). Twenty-five trials involving 19 806 patients (10 023 randomised to revascularisation plus medical therapy and 9783 to medical therapy alone) were included. Compared with medical therapy alone, revascularisation yielded a lower risk of cardiac death [RR 0.79 (0.67–0.93), P < 0.01] and spontaneous MI [RR 0.74 (0.64–0.86), P < 0.01]. By meta-regression, the cardiac death risk reduction after revascularisation, compared with medical therapy alone, was linearly associated with follow-up duration [RR per 4-year follow-up: 0.81 (0.69–0.96), P = 0.008], spontaneous MI absolute difference (P = 0.01) and percentage of multivessel disease at baseline (P = 0.004). Trial sequential and sensitivity analyses confirmed the reliability of the cardiac mortality findings. All-cause mortality [0.94 (0.87–1.01), P = 0.11], any MI (P = 0.14), and stroke risk (P = 0.30) did not differ significantly between strategies.

Conclusion

In stable coronary artery disease patients, randomisation to elective coronary revascularisation plus medical therapy led to reduced cardiac mortality compared with medical therapy alone. The cardiac survival benefit after revascularisation improved with longer follow-up times and was associated with fewer spontaneous MIs.