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Harrington J, Sattar N, Felker GM, Januzzi JL, Lam CSP, Pagidipati NJ, Pandey A, Van Spall HGC, McGuire DK. Putting More Weight on Obesity Trials in Heart Failure. Curr Heart Fail Rep 2024; 21:194-202. [PMID: 38619690 DOI: 10.1007/s11897-024-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE OF REVIEW To review ongoing and planned clinical trials of weight loss among individuals with or at high risk of heart failure. RECENT FINDINGS Intentional weight loss via semaglutide among persons with heart failure and preserved ejection fraction and obesity significantly improves weight loss and health status as assessed by the KCCQ-CSS score and is associated with improvements in 6-min walk test. Ongoing and planned trials will explore the role of intentional weight loss with treatments such as semaglutide or tirzepatide for individuals with heart failure across the entire ejection fraction spectrum.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA.
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - G Michael Felker
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA
| | - James L Januzzi
- Baim Institute for Clinical Research, Boston, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- National Heart Centre Singapore and Duke-National University of Singapore, Bukit Merah, Singapore
| | - Neha J Pagidipati
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, 300 W. Morris St, Durham, NC, 27701, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Harriette G C Van Spall
- Baim Institute for Clinical Research, Boston, MA, USA
- Research Institute of St. Joe's, Hamilton, Canada
- McMaster University, Hamilton, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
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Cresci S, Bach RG, Saberi S, Owens AT, Spertus JA, Hegde SM, Lakdawala NK, Nilles EK, Wojdyla DM, Sehnert AJ, Wang A. Effect of Mavacamten in Women Compared With Men With Obstructive Hypertrophic Cardiomyopathy: Insights From EXPLORER-HCM. Circulation 2024; 149:498-509. [PMID: 37961906 PMCID: PMC11006596 DOI: 10.1161/circulationaha.123.065600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Compared with men, women with hypertrophic cardiomyopathy (HCM) have a higher incidence of heart failure and worse outcomes. We investigated baseline clinical and echocardiographic characteristics and response to mavacamten among women compared with men in the EXPLORER-HCM study (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy). METHODS A prespecified post hoc analysis of sex from the blinded, randomized EXPLORER-HCM trial of mavacamten versus placebo in symptomatic patients with obstructive HCM was performed. Baseline characteristics were compared with t tests for continuous variables (expressed as mean values) and χ2 tests for categorical variables. Prespecified primary, secondary, and exploratory end points and echocardiographic measurements from baseline to end of treatment (week 30) were analyzed with ANCOVA for continuous end points and a generalized linear model with binomial distribution for binary end points, with adjustment for each outcome's baseline value, New York Heart Association class, β-blocker use, and ergometer type. RESULTS At baseline, women (n=102) were older (62 years versus 56 years; P<0.0001), had lower peak oxygen consumption (16.7 mL·kg-1·min-1 versus 21.3 mL·kg-1·min-1; P<0.0001), were more likely to be assigned New York Heart Association class III (42% versus 17%; P<0.0001), had worse health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 64 versus 75; P<0.0001), and had higher baseline plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels (1704 ng/L versus 990 ng/L; P=0.004) than men (n=149). After 30 weeks of mavacamten treatment, similar improvements were observed in women and men in the primary composite end point (percentage difference on mavacamten versus placebo, 22% versus 19%, respectively; P=0.759) and in the secondary end points of change in postexercise left ventricular outflow tract gradient (-42.4 mm Hg versus -33.6 mm Hg; P=0.348), change in peak oxygen consumption (1.2 mL·kg-1·min-1 versus 1.6 mL·kg-1·min-1; P=0.633), and percentage achieving ≥1 New York Heart Association class improvement (41% versus 28%; P=0.254). However, women had greater improvement in health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 14.8 versus 6.1; P=0.026) and in the exploratory end point of NT-proBNP levels (-1322 ng/L versus -649 ng/L; P=0.0008). CONCLUSIONS Although at baseline women with symptomatic obstructive HCM enrolled in EXPLORER-HCM were older and had worse heart failure and health status than men, treatment with mavacamten resulted in similar improvements in the primary and most secondary EXPLORER-HCM end points and greater improvements in health status and NT-proBNP. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Sharon Cresci
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Genetics, Washington University School of Medicine, St. Louis, MO
| | - Richard G. Bach
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali T. Owens
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John A. Spertus
- University of Missouri-Kansas City’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, USA
| | - Sheila M. Hegde
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Neal K. Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Kondo T, Gasparyan SB, Jhund PS, Bengtsson O, Claggett BL, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Køber L, Lam CSP, Langkilde AM, Martinez FA, Petersson M, Ponikowski P, Sabatine MS, Shah SJ, Sjostrand M, Wilderang U, Vaduganathan M, Solomon SD, McMurray JJV. Use of Win Statistics to Analyze Outcomes in the DAPA-HF and DELIVER Trials. NEJM EVIDENCE 2023; 2:EVIDoa2300042. [PMID: 38320525 DOI: 10.1056/evidoa2300042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: The primary end point in most heart failure (HF) trials is a composite of time to a first worsening HF event or cardiovascular death. Prevention of recurrent events and improvements in symptoms/quality of life are also important for patients but are usually analyzed separately. Win statistics can integrate all these outcomes into a single composite end point, which is analyzed in hierarchical order, reflecting the clinical importance of each component. METHODS: The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF, n=4744) and Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure (DELIVER, n=6263) trials enrolled patients with New York Heart Association class II, III, or IV HF, elevated natriuretic peptides, and either an ejection fraction of 40% or less (DAPA-HF) or greater than 40% and left atrial enlargement/left ventricular hypertrophy (DELIVER). We examined the effects of dapagliflozin compared with placebo on a hierarchical composite outcome, including cardiovascular death, total (first and recurrent) HF hospitalizations, total urgent HF visits, and improvement/deterioration in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ-TSS; range from 0 to 100, with a higher score indicating fewer symptoms and physical limitations) at 8 months. RESULTS: For this composite outcome, the win ratio was 1.30 (95% confidence interval [CI], 1.23 to 1.36) in the pooled cohort, 1.33 (95% CI, 1.23 to 1.43) in the DAPA-HF trial, and 1.27 (95% CI, 1.18 to 1.36) in the DELIVER trial. Win odds and net benefit in overall patients were 1.19 (95% CI, 1.14 to 1.24) and 8.7% (95% CI, 6.6 to 10.9%), respectively. In the overall pooled cohort, the majority of wins and losses were accounted for by KCCQ-TSS; 52.4% were settled by the KCCQ-TSS tier in the pooled cohort. CONCLUSIONS: In both the DAPA-HF and DELIVER trials, dapagliflozin led to a significant improvement in composite outcomes that incorporated patient-reported outcomes along with total HF events, as well as cardiovascular deaths. These analyses provided a comprehensive presentation of win statistics and illustrated the utility and flexibility of win statistics in describing the effects of dapagliflozin in two recent clinical trials in patients with HF. (Funded by British Heart Foundation Centre of Research Excellence and others; clinical trial registration numbers, NCT03036124 and NCT03619213.)
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Olof Bengtsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | | | | | | | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago
| | - Mikaela Sjostrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrica Wilderang
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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Angélico-Gonçalves A, Leite AR, Neves JS, Saraiva F, Brochado L, Oliveira AC, Butler J, Packer M, Zannad F, Vasques-Nóvoa F, Leite-Moreira A, Ferreira JP. Changes in health-related quality of life and treatment effects in chronic heart failure: A meta-analysis. Int J Cardiol 2023:S0167-5273(23)00726-X. [PMID: 37211049 DOI: 10.1016/j.ijcard.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Heart failure (HF) is associated with poor health status, and high morbi-mortality. However, it is not well established how health status changes correlate with treatment effects on clinical outcomes. Our aim was to study the association between treatment-induced changes in health-status, assessed by Kansas City Cardiomyopathy Questionnaire 23 (KCCQ-23) and clinical outcomes in chronic HF. METHODS Systematic search of phase III-IV pharmacological RCTs in chronic HF that assessed KCCQ-23 changes and clinical outcomes throughout follow-up. We studied the association between treatment induced changes in KCCQ-23 and treatment effects on clinical outcomes (HF hospitalization or cardiovascular death, HF hospitalization, cardiovascular death, and all-cause death) using weighted random-effects meta-regression. RESULTS Sixteen trials were included, enrolling a total of 65,664 participants. Treatment induced KCCQ-23 changes were moderately correlated with treatment effects on the combined outcome of HF hospitalization or cardiovascular mortality (regression coefficient (RC) = -0.047, 95%CI: -0.085 to -0.009; R2 = 49%), a correlation that was mainly driven by HF hospitalization (RC = -0.076, 95%CI: -0.124 to -0.029; R2 = 56%). Correlations of treatment induced KCCQ-23 changes with cardiovascular death (RC = -0.029, 95%CI: -0.073 to 0.015; R2 = 10%) and all-cause death (RC = -0.019, 95%CI: -0.057 to 0.019; R2 = 0%) were weak and non-significant. CONCLUSIONS Treatment-induced changes in KCCQ-23 were moderately correlated with treatment-effects on HF hospitalizations but were not correlated with the effects on cardiovascular and all-cause mortality. Treatment-induced changes in patient-centered outcomes (i.e., KCCQ-23) may reflect non-fatal symptomatic changes in the clinical course of HF leading to hospitalization.
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Affiliation(s)
- António Angélico-Gonçalves
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Internal Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana Rita Leite
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Endocrinology and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - João Sérgio Neves
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Endocrinology and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Francisca Saraiva
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liliana Brochado
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Cristina Oliveira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, United States of America; Department of Medicine, University of Mississippi, Jackson, MS, United States of America
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, United States of America; Imperial College, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques, - Plurithématique 14-33 and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Francisco Vasques-Nóvoa
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - João Pedro Ferreira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Demystifying the Value of Minimal Clinically Important Difference in the Cardiothoracic Surgery Context. Life (Basel) 2023; 13:life13030716. [PMID: 36983869 PMCID: PMC10056462 DOI: 10.3390/life13030716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/08/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
The aim of this review is to describe the different statistical methods used in estimating the minimal clinically important difference (MCID) for the assessment of quality of life (QOL)-related and clinical improvement interventions, along with their implementation in cardiothoracic surgery. A thorough literature search was performed in three databases (PubMed/Medline, Scopus, Google Scholar) for relevant articles from 1980 to 2022. We included articles that implemented and assessed statistical methods used to estimate the concept of MCID in cardiothoracic surgery. MCID has been successfully implemented in several medical specialties. Anchor-based and distribution-based methods are the most common approaches when evaluating the MCID. Nonetheless, we found only five studies investigating the MCID in the context of cardiothoracic surgery. Four of them used anchor-based approaches, and one used both anchor-based and distribution-based methods. MCID values were very variable depending on the methods applied, as was the clinical context of the study. The variables of interest were certain QOL measuring questionnaires, used as anchors. Multiple anchors and methods were applied, leading to different estimations of MCID. Since cardiothoracic surgery is related to important perioperative morbidity, MCID might represent an important and efficient adjunct tool to interpret clinical outcomes. The need for MCID methodology implementation is even higher in patients with heart failure undergoing cardiac surgery. More studies are needed to validate different MCID methods in this context.
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Valsaraj A, Kalmady SV, Sharma V, Frost M, Sun W, Sepehrvand N, Ong M, Equibec C, Dyck JRB, Anderson T, Becher H, Weeks S, Tromp J, Hung CL, Ezekowitz JA, Kaul P. Development and validation of echocardiography-based machine-learning models to predict mortality. EBioMedicine 2023; 90:104479. [PMID: 36857967 PMCID: PMC10006431 DOI: 10.1016/j.ebiom.2023.104479] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Echocardiography (echo) based machine learning (ML) models may be useful in identifying patients at high-risk of all-cause mortality. METHODS We developed ML models (ResNet deep learning using echo videos and CatBoost gradient boosting using echo measurements) to predict 1-year, 3-year, and 5-year mortality. Models were trained on the Mackay dataset, Taiwan (6083 echos, 3626 patients) and validated in the Alberta HEART dataset, Canada (997 echos, 595 patients). We examined the performance of the models overall, and in subgroups (healthy controls, at risk of heart failure (HF), HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)). We compared the models' performance to the MAGGIC risk score, and examined the correlation between the models' predicted probability of death and baseline quality of life as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ). FINDINGS Mortality rates at 1-, 3- and 5-years were 14.9%, 28.6%, and 42.5% in the Mackay cohort, and 3.0%, 10.3%, and 18.7%, in the Alberta HEART cohort. The ResNet and CatBoost models achieved area under the receiver-operating curve (AUROC) between 85% and 92% in internal validation. In external validation, the AUROCs for the ResNet (82%, 82%, and 78%) were significantly better than CatBoost (78%, 73%, and 75%), for 1-, 3- and 5-year mortality prediction respectively, with better or comparable performance to the MAGGIC score. ResNet models predicted higher probability of death in the HFpEF and HFrEF (30%-50%) subgroups than in controls and at risk patients (5%-20%). The predicted probabilities of death correlated with KCCQ scores (all p < 0.05). INTERPRETATION Echo-based ML models to predict mortality had good internal and external validity, were generalizable, correlated with patients' quality of life, and are comparable to an established HF risk score. These models can be leveraged for automated risk stratification at point-of-care. FUNDING Funding for Alberta HEART was provided by an Alberta Innovates - Health Solutions Interdisciplinary Team Grant no. AHFMRITG 200801018. P.K. holds a Canadian Institutes of Health Research (CIHR) Sex and Gender Science Chair and a Heart & Stroke Foundation Chair in Cardiovascular Research. A.V. and V.S. received funding from the Mitacs Globalink Research Internship.
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Affiliation(s)
| | - Sunil Vasu Kalmady
- Canadian VIGOUR Centre, University of Alberta, Alberta, Canada; Department of Computing Science, University of Alberta, Edmonton, Alberta, Canada; Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | | | | | - Weijie Sun
- Canadian VIGOUR Centre, University of Alberta, Alberta, Canada; Department of Computing Science, University of Alberta, Edmonton, Alberta, Canada
| | - Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Alberta, Canada; Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | | | | | - Jason R B Dyck
- Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | - Todd Anderson
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Harald Becher
- Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | - Sarah Weeks
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore & National University Health System, Singapore; Duke-NUS Medical School, Singapore
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Alberta, Canada; Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Alberta, Canada; Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada.
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7
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Kalwani NM, Calma J, Varghese GM, Gupta A, Zheng J, Brown-Johnson C, Amano A, Vilendrer S, Winget M, Asch SM, Heidenreich P, Sandhu A. The patient-reported outcome measurement in heart failure clinic trial: Rationale and methods of the PRO-HF trial. Am Heart J 2023; 255:137-146. [PMID: 36309127 PMCID: PMC10069382 DOI: 10.1016/j.ahj.2022.10.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention. STUDY DESIGN The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and health care utilization, including clinic visits, testing, hospitalizations, and emergency department visits. As a sub-study, PRO-HF will also evaluate the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice. CONCLUSIONS PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.
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Affiliation(s)
- Neil M Kalwani
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Jamie Calma
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - George M Varghese
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Anshal Gupta
- Stanford University School of Medicine, Stanford, CA
| | - Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alexis Amano
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Stacie Vilendrer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Marcy Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Steven M Asch
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Paul Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Alexander Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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van der Vaart LR, Vollebregt A, Milani AL, Lagro-Janssen AL, Duijnhoven RG, Roovers JPWR, van der Vaart CH. Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial. JAMA 2022; 328:2312-2323. [PMID: 36538310 PMCID: PMC9857016 DOI: 10.1001/jama.2022.22385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase. OBJECTIVE To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse. DESIGN, SETTING, AND PARTICIPANTS The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022. INTERVENTIONS Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery. MAIN OUTCOMES AND MEASURES The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured. RESULTS Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery. CONCLUSIONS AND RELEVANCE Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery. TRIAL REGISTRATION Netherlands Trial Register Identifier: NTR4883.
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Affiliation(s)
- Lisa R. van der Vaart
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Astrid Vollebregt
- Department of Obstetrics and Gynecology, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Alfredo L. Milani
- Department of Obstetrics and Gynecology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Antoine L. Lagro-Janssen
- Department of General Practice/Women’s Studies Medicine, University Medical Centre Radboud, Nijmegen, the Netherlands
| | - Ruben G. Duijnhoven
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan-Paul W. R. Roovers
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gynecology, Women’s Health, Bergman Clinics, Amsterdam, the Netherlands
| | - Carl H. van der Vaart
- Department of Gynecology, Women’s Health, Bergman Clinics, Hilversum, the Netherlands
- Department of Obstetrics and Gynecology, UMCU, University of Utrecht, Utrecht, the Netherlands
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Dubinsky MC, Shan M, Delbecque L, Lissoos T, Hunter T, Harding G, Stassek L, Andrae D, Lewis JD. Psychometric evaluation of the Urgency NRS as a new patient-reported outcome measure for patients with ulcerative colitis. J Patient Rep Outcomes 2022; 6:114. [PMID: 36334163 PMCID: PMC9637076 DOI: 10.1186/s41687-022-00522-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background The Urgency Numeric Rating Scale (NRS) was developed as a content-valid single-item patient-reported outcome measure to assess severity of bowel urgency. Here, we evaluated the psychometric properties of the Urgency NRS. Methods Data were from a multicenter, randomized, placebo-controlled phase 3 trial in adults with moderately to severely active ulcerative colitis (NCT03518086). Patients completed the Urgency NRS using a daily electronic diary, from which weekly average Urgency NRS scores were calculated. Test–retest reliability, known-groups validity, construct validity, responsiveness, and score interpretation were assessed using the modified Mayo score, Inflammatory Bowel Disease Questionnaire (IBDQ), Patient Global Rating of Severity (PGRS), Patient Global Rating of Change (PGRC), and Geboes score. Results The study sample comprised 1,162 participants (40.2% female). Mean Urgency NRS score was higher (worse) at baseline than at week 12 (6.2 vs. 3.7). Test–retest reliability was strong, with intra-class correlation coefficients of 0.76–0.89. Baseline least-square mean Urgency NRS score was higher for participants with a PGRS score greater than the median (worse symptoms) than for those with a PGRS score less than or equal to the median (7.5 vs. 5.4; p < 0.0001), indicating good known-groups validity. Urgency NRS score was moderately correlated with IBDQ total and domain scores, PGRS, PGRC, and modified Mayo stool frequency, establishing its convergent validity. Correlations were weak for Geboes score and weak to moderate for modified Mayo endoscopic subscore and modified Mayo rectal bleeding, indicating that the Urgency NRS also had discriminant validity. Patients achieving clinical remission, clinical response, IBDQ remission, and PGRS score improvement showed significantly greater improvement on the Urgency NRS (p < 0.0001 for all), demonstrating responsiveness to change. A ≥ 3-point improvement in Urgency NRS score represented a meaningful improvement in bowel urgency and an Urgency NRS score of ≤ 1 point represented a bowel urgency remission threshold that was closely associated with clinical, endoscopic, and histologic remission. Conclusions The Urgency NRS is a valid and reliable patient-reported outcome measure that is suitable for evaluating treatment benefits in clinical trials in patients with moderately to severely active ulcerative colitis. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00522-2.
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