1
|
Park DY, Jamil Y, Moumneh MB, Batchelor B W, Nanna MG, Damluji AA. Quality of Life in Older Adults With Stable Ischemic Heart Disease and Diabetes Mellitus: A Post Hoc Analysis of the BARI 2D Trial. Am J Cardiol 2024; 223:58-69. [PMID: 38797195 PMCID: PMC11214881 DOI: 10.1016/j.amjcard.2024.05.016] [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: 02/11/2024] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
Studies on the long-term differences in quality-of-life (QoL) metrics after treatment for stable ischemic heart disease (SIHD) in older adults with diabetes mellitus are lacking. Older patients (age ≥65 years) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial were stratified into those who received intensive medical therapy (IMT) only versus revascularization (percutaneous coronary intervention [PCI] vs coronary artery bypass graft surgery [CABG]) with Optimal Medical Therapy (OMT). Self-health score, Duke activity status index (DASI), energy rating, and health distress rating at 5 years were compared using multivariable linear regression. A total of 929 older adults were included, of whom 469 (50.5%) underwent medical therapy alone, 302 (32.5%) underwent PCI, and 158 (17.0%) had CABG. Patients who underwent CABG were more likely to have proximal left anterior descending coronary artery disease, chronic total occlusion, and higher myocardial jeopardy index. At 5 years of follow-up, no differences in self-health score, DASI, energy rating, and health distress rating were observed between PCI and IMT. There are also no differences in the 4 QoL measures between CABG and IMT alone. However, the DASI was marginally higher with CABG but not statistically significant (mean difference 3.88, 95% confidence interval -0.10 to -7.86, p = 0.057). At 5 years of follow-up, no differences in QoL measures were observed between PCI and CABG with OMT versus OMT alone in older adult patients with diabetes mellitus and SIHD. Future blinded randomized trials are necessary to investigate the impact of SIHD treatment in the older adult population, considering the risks associated with multimorbidity, polypharmacy, frailty, and cognitive impairment.
Collapse
Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Yasser Jamil
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Falls Church, Virginia; Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
2
|
Jamil Y, Park DY, Verde LM, Sherwood MW, Tehrani BN, Batchelor WB, Frampton J, Damluji AA, Nanna MG. Do Clinical Outcomes and Quality of Life Differ by the Number of Antianginals for Stable Ischemic Heart Disease? Insights from the BARI 2D Trial. Am J Cardiol 2024; 214:66-76. [PMID: 38160927 PMCID: PMC10923116 DOI: 10.1016/j.amjcard.2023.12.045] [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: 09/30/2023] [Revised: 11/21/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was β blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.
Collapse
Affiliation(s)
- Yasser Jamil
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
| | - Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Luis More Verde
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Falls Church, Virginia; Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
3
|
Mustafaoglu R, Demir R, Aslan GK, Sinan UY, Zeren M, Yildiz A, Kucukoglu MS. Translation, cross-cultural adaptation, reliability, and validity of the Turkish version of the Duke Activity Status Index in patients with pulmonary hypertension. Pulmonology 2023; 29 Suppl 4:S18-S24. [PMID: 34281801 DOI: 10.1016/j.pulmoe.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with pulmonary hypertension (PH), shortness of breath, fatigue, chest pain, and syncope limit exercise capacity. Exercise tests are often time-consuming, expensive, and some patients may not be able to perform such procedures and they are also difficult to apply in the studies including large samples. The aim of this study was to translate and culturally adapt the DASI into Turkish and to investigate its reliability and validity in patients with PH. METHODS The final Turkish version of the DASI questionnaire was applied to 109 clinically stable patients with a diagnosis of PH. Exercise capacity of the patients was determined by maximal VO 2 achieved in the 6-minute walk test (6MWT) and quality of life by the EmPHasis-10 questionnaire. Cronbach alpha (internal consistency) was used to assess the questionnaire's reliability. The validity assessment was performed by using Spearman correlation. RESULTS Internal consistency of the DASI was high (Cronbach's alpha = 0.99) and the test-retest reliability was excellent (ICC = 0.98). Validity was supported by significant correlations of DASI-VO 2 scores with estimated VO 2 (6MWT) scores (r = 0.58, p < 0.0001) and EmPHasis-10 (= -0.62, p < 0.0001). No floor or ceiling effect was present for the questionnaire. CONCLUSIONS The Turkish version of the culturally adapted DASI questionnaire was found to be a valid and reliable assessment tool. It is a rapidly administered, simple-toscore questionnaire for assessing the functional ability of individuals with PH. The use of the DASI to assess exercise capacity in patients with PH may assist researchers and clinicians detecting functional impairment in these patients.
Collapse
Affiliation(s)
- R Mustafaoglu
- Istanbul University-Cerrahpasa, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - R Demir
- Istanbul University-Cerrahpasa, Institute of Cardiology, Department of Cardiology, Istanbul, Turkey
| | - G K Aslan
- Istanbul University-Cerrahpasa, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - U Y Sinan
- Istanbul University-Cerrahpasa, Institute of Cardiology, Department of Cardiology, Istanbul, Turkey
| | - M Zeren
- Izmir Bakircay University, Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation, Izmir, Turkey
| | - A Yildiz
- Istanbul University-Cerrahpasa, Institute of Graduate Studies, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - M S Kucukoglu
- Istanbul University-Cerrahpasa, Institute of Cardiology, Department of Cardiology, Istanbul, Turkey.
| |
Collapse
|
4
|
Tower-Rader A, Szpakowski N, Popovic ZB, Bittel B, Fava A, Ospina S, Xu B, Thamilarasan M, Mentias A, Smedira NG, Desai MY. Patient reported outcomes in obstructive hypertrophic cardiomyopathy undergoing myectomy: Results from SPIRIT-HCM study. Prog Cardiovasc Dis 2023; 80:66-73. [PMID: 37302651 DOI: 10.1016/j.pcad.2023.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Patient reported outcomes (PRO) can assess quality of life (QOL) in obstructive hypertrophic cardiomyopathy (oHCM). In symptomatic oHCM patients, we sought to study the correlation between various PROs, their association with physician reported New York Heart Association (NYHA) class and changes after surgical myectomy. METHODS We prospectively studied 173 symptomatic oHCM patients undergoing myectomy (age 51 years, 62% men) between 3/17-6/20. PROs, including a) Kansas City Cardiomyopathy Questionnaire (KCCQ) summary score b) Patient-Reported Outcomes Measurement Information System [PROMIS] c) Duke Activity Status Index [DASI] & d) European QOL score [EQ-5D], along with NYHA class, 6-min walk test (6MWT) distance and peak left ventricular outflow tract gradient (PLVOTG) were recorded at baseline and 12 month follow-up. RESULTS The median baseline PRO scores (KCCQ summary, PROMIS physical, PROMIS mental, DASI, EQ-5D) were 50, 67, 63, 25, 50, 37, 44, 25 and 0.61, respectively; 6MWT distance was 366 m. There were significant correlations between various PROs (r-values between 0.66 and 0.92, p < 0.001), but only modest correlations with 6MWT and provokable LVOTG (r-values between 0.2 and 0.5, p < 0.01). At baseline, 35-49% patients in NYHA class II had PROs worse than median, while 30-39% patients in NYHA Class III/IV had PROs better than median. At follow-up, a 20 point improvement in KCCQ summary score was observed in 80%, 4 point improvement in DASI score in 83%, 4 point improvement in PROMIS physical score 86% and a 0.04 point improvement in EQ-5D in 85%); along with improvements in NYHA class (67% in Class I) and peak LVOTG (median 13 mmHg) and 6MWT (median distance 438 m). CONCLUSIONS In a prospective study of symptomatic oHCM patients, surgical myectomy significantly improved PROs, LVOT obstruction, and functional capacity, with a high correlation between various PROs. However, there was high rate of discordance between PROs and NYHA class. STUDY REGISTRATION ClinicalTrials.gov: NCT03092843.
Collapse
Affiliation(s)
- Albree Tower-Rader
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Cardiovascular Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Natalie Szpakowski
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Zoran B Popovic
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Barabara Bittel
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Agostina Fava
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Susan Ospina
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Bo Xu
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Maran Thamilarasan
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Amgad Mentias
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Milind Y Desai
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America.
| |
Collapse
|
5
|
Mark DB, Spertus JA, Bigelow R, Anderson S, Daniels MR, Anstrom KJ, Baloch KN, Cohen DJ, Held C, Goodman SG, Bangalore S, Cyr D, Reynolds HR, Alexander KP, Rosenberg Y, Stone GW, Maron DJ, Hochman JS. Comprehensive Quality-of-Life Outcomes With Invasive Versus Conservative Management of Chronic Coronary Disease in ISCHEMIA. Circulation 2022; 145:1294-1307. [PMID: 35259918 PMCID: PMC9044280 DOI: 10.1161/circulationaha.121.057363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) compared an initial invasive treatment strategy (INV) with an initial conservative strategy in 5179 participants with chronic coronary disease and moderate or severe ischemia. The ISCHEMIA research program included a comprehensive quality-of-life (QOL) substudy. METHODS In 1819 participants (907 INV, 912 conservative strategy), we collected a battery of disease-specific and generic QOL instruments by structured interviews at baseline; at 3, 12, 24, and 36 months postrandomization; and at study closeout. Assessments included angina-related QOL (19-item Seattle Angina Questionnaire), generic health status (EQ-5D), depressive symptoms (Patient Health Questionnaire-8), and, for North American patients, cardiac functional status (Duke Activity Status Index). RESULTS Median age was 67 years, 19.2% were female, and 15.9% were non-White. The estimated mean difference for the 19-item Seattle Angina Questionnaire Summary score favored INV (1.4 points [95% CI, 0.2-2.5] over all follow-up). No differences were observed in patients with rare/absent baseline angina (SAQ Angina Frequency score >80). Among patients with more frequent angina at baseline (SAQ Angina Frequency score <80, 744 patients, 41%), those randomly assigned to INV had a mean 3.7-point higher 19-item Seattle Angina Questionnaire Summary score than conservative strategy (95% CI, 1.6-5.8) with consistent effects across SAQ subscales: Physical Limitations 3.2 points (95% CI, 0.2-6.1), Angina Frequency 3.2 points (95% CI, 1.2-5.1), Quality of Life/Health Perceptions 5.3 points (95% CI, 2.8-7.8). For the Duke Activity Status Index, no difference was estimated overall by treatment, but in patients with baseline SAQ Angina Frequency scores <80, Duke Activity Status Index scores were higher for INV (3.2 points [95% CI, 0.6-5.7]), whereas patients with rare/absent baseline angina showed no treatment-related differences. Moderate to severe depression was infrequent at randomization (11.5%-12.8%) and was unaffected by treatment assignment. CONCLUSIONS In the ISCHEMIA comprehensive QOL substudy, patients with more frequent baseline angina reported greater improvements in the symptom, physical functioning, and psychological well-being dimensions of QOL when treated with an invasive strategy, whereas patients who had rare/absent angina at baseline reported no consistent treatment-related QOL differences. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01471522.
Collapse
Affiliation(s)
- Daniel B. Mark
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/ University of Missouri - Kansas City, MO
| | - Robert Bigelow
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Sophia Anderson
- Duke Clinical Research Institute, Duke University, Durham, NC
| | | | | | | | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY, and St. Francis Hospital and Heart Center, Roslyn, NY
| | - Claes Held
- Dept of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, and Canadian Heart Research Centre, Toronto, Ontario, and Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Derek Cyr
- Duke Clinical Research Institute, Duke University, Durham, NC
| | | | | | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J. Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
6
|
Mustafaoglu R, Demir R, Aslan GK, Sinan UY, Zeren M, Kucukoglu MS. Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension? Respir Med 2021; 181:106375. [PMID: 33799051 DOI: 10.1016/j.rmed.2021.106375] [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: 12/26/2020] [Revised: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT. METHODS Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis. RESULTS The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88. CONCLUSIONS The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.
Collapse
Affiliation(s)
- Rustem Mustafaoglu
- Istanbul University-Cerrahpasa, Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - Rengin Demir
- Istanbul University-Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey
| | - Goksen Kuran Aslan
- Istanbul University-Cerrahpasa, Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation, Istanbul, Turkey
| | - Umit Yasar Sinan
- Istanbul University-Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey
| | - Melih Zeren
- Izmir Bakircay University, Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation, Izmir, Turkey
| | - Mehmet Serdar Kucukoglu
- Istanbul University-Cerrahpasa, Cardiology Institute, Department of Cardiology, Istanbul, Turkey.
| |
Collapse
|
7
|
Zhao Y, Meng S, Liu T, Dong R. Economic Analysis of Surgical and Interventional Treatments for Patients with Complex Coronary Artery Disease: Insights from a One-Year Single-Center Study. Med Sci Monit 2020; 26:e919374. [PMID: 32097388 PMCID: PMC7059453 DOI: 10.12659/msm.919374] [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] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Surgical treatment methods for patients with complex coronary artery disease (CAD) who have undergone vascular reconstruction mainly include coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). The purpose of the study aimed to compare a 1-year follow-up for the patient clinical outcomes and costs between PCI and CABG treatment. MATERIAL AND METHODS There were 840 patients enrolled in this study from July 2015 to September 2016. Among the study participants, 420 patients underwent PCI treatment and 420 patients underwent off-pump CABG. Patients costs were assessed from the perspective of the China healthcare and medical insurance system. EuroQOL 5-dimension 3 levels (EQ-5D-3L) questionnaire was used to evaluate the general health status, and the Seattle Angina Questionnaire (SAQ) was used to assess the disease-specific health status. RESULTS After a 1-year follow-up, the all-cause mortality (P=0.0337), the incidence of major adverse cardiac and cerebrovascular events (P<0.001), and additional revascularization (P<0.001) in PCI group were significantly higher than those in CABG group. Both groups have significant sustained benefits in the SAQ subscale. The CABG group had a higher score on the frequency of angina than the PCI group. In addition, the quality-adjusted life year value of PCI and CABG resulted was 0.8. The average total cost for PCI was $14 643 versus CABG cost of $13 842 (P=0.0492). CONCLUSIONS In the short-term, among the CAD patients with stable triple-vessel or left-main, costs and clinical outcomes are substantially higher for CABG than PCI. Long-term, economic, and health benefits analysis, is warranted.
Collapse
Affiliation(s)
- Yang Zhao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Shuai Meng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Taoshuai Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ran Dong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| |
Collapse
|
8
|
Economic and Quality-of-Life Outcomes of Natriuretic Peptide-Guided Therapy for Heart Failure. J Am Coll Cardiol 2019; 72:2551-2562. [PMID: 30466512 DOI: 10.1016/j.jacc.2018.08.2184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The GUIDE-IT (GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial prospectively compared the efficacy of an N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided heart failure treatment strategy (target NT-proBNP level <1,000 pg/ml) with optimal medical therapy alone in high-risk patients with heart failure and reduced ejection fraction. When the study was stopped for futility, 894 patients had been enrolled. OBJECTIVES The purpose of this study was to assess treatment-related quality-of-life (QOL) and economic outcomes in the GUIDE-IT trial. METHODS The authors prospectively collected a battery of QOL instruments at baseline and 3, 6, 12, and 24 months post-randomization (collection rates 90% to 99% of those eligible). The principal pre-specified QOL measures were the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score and the Duke Activity Status Index (DASI). Cost data were collected for 735 (97%) U.S. PATIENTS RESULTS Baseline variables were well balanced in the 446 patients randomized to the NT-proBNP-guided therapy and 448 to usual care. Both the KCCQ and the DASI improved over the first 6 months, but no evidence was found for a strategy-related difference (mean difference [biomarker-guided - usual care] at 24 months of follow-up 2.0 for DASI [95% confidence interval (CI): -1.3 to 5.3] and 1.1 for KCCQ [95% CI: -3.7 to 5.9]). Total winsorized costs averaged $5,919 higher in the biomarker-guided strategy (95% CI: -$1,795, +$13,602) over 15-month median follow-up. CONCLUSIONS A strategy of NT-proBNP-guided HF therapy had higher total costs and was not more effective than usual care in improving QOL outcomes in patients with heart failure and a reduced ejection fraction. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840).
Collapse
|
9
|
Stevens ER, Farrell D, Jumkhawala SA, Ladapo JA. Quality of health economic evaluations for the ACC/AHA stable ischemic heart disease practice guideline: A systematic review. Am Heart J 2018; 204:17-33. [PMID: 30077048 DOI: 10.1016/j.ahj.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/30/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American College of Cardiology/American Heart Association (ACC/AHA) recently published a rigorous framework to guide integration of economic data into clinical guidelines. We assessed the quality of economic evaluations in a major ACC/AHA clinical guidance report. METHODS We systematically identified cost-effectiveness analyses (CEAs) of RCTs cited in the ACC/AHA 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. We extracted: (1) study identifiers; (2) parent RCT information; (3) economic analysis characteristics; and (4) study quality using the Quality of Health Economic Studies instrument (QHES). RESULTS Quality scores were categorized as high (≥75 points) or low (<75 points). Of 1,266 citations in the guideline, 219 were RCTs associated with 77 CEAs. Mean quality score was 81 (out of 100) and improved over time, though 29.9% of studies were low-quality. Cost-per-QALY was the most commonly reported primary outcome (39.0%). Low-quality studies were less likely to report study perspective, use appropriate time horizons, or address statistical and clinical uncertainty. Funding was overwhelmingly private (83%). A detailed methodological assessment of high-quality studies revealed domains of additional methodological issues not identified by the QHES. CONCLUSIONS Economic evaluations of RCTs in the 2012 ACC/AHA ischemic heart disease guideline largely had high QHES scores but methodological issues existed among "high-quality" studies. Because the ACC/AHA has generally been more systematic in its integration of scientific evidence compared to other professional societies, it is likely that most societies will need to proceed more cautiously in their integration of economic evidence.
Collapse
|
10
|
Quality of life after coronary artery bypass graft surgery versus percutaneous coronary intervention: what do the trials tell us? Curr Opin Cardiol 2018; 32:707-714. [PMID: 28834794 DOI: 10.1097/hco.0000000000000458] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With an ever-aging population, the treatment of multi-vessel coronary artery disease (CAD) has increasingly become focused not only on mortality, but on symptom relief and improving quality of life (QOL). The purpose of this review is to present a summary on the subject of QOL after percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), highlighting the latest comparative trials in the field. RECENT FINDINGS About 1 month after revascularization, patients recovering from either PCI or CABG report improvements in angina frequency. However, at 6 months and in the years that follow, angina relief is significantly better after CABG compared with PCI. Correspondingly, the use of antiangina medication is significantly higher following PCI, even in recent years with the use of drug-eluting stents. Regarding general health status, at the 1-month time point, PCI patients have recovered faster than those who have had surgery, reporting fewer physical limitations, less bodily pain, and greater QOL and treatment satisfaction. Nevertheless, these differences disappear by 6 months, and in the years thereafter, CABG patients report fewer physical limitations compared with those who have undergone PCI. About 5 years after revascularization, significant benefits remain favoring CABG in term of physical, emotional, and mental health. SUMMARY Patients with multivessel coronary artery disease attain important QOL benefits following revascularization with either PCI or CABG. Percutaneous treatments lead to a more rapid recovery and improved short-term health status compared with CABG at 1 month. However, surgery results in greater angina relief and improved QOL compared with PCI 6 months after revascularization and beyond.
Collapse
|
11
|
Shreibati JB, Manson JE, Margolis KL, Chlebowski RT, Stefanick ML, Hlatky MA. Impact of hormone therapy on Medicare spending in the Women's Health Initiative randomized clinical trials. Am Heart J 2018; 198:108-114. [PMID: 29653631 PMCID: PMC5901884 DOI: 10.1016/j.ahj.2017.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Randomized trials can compare economic as well as clinical outcomes, but economic data are difficult to collect. Linking clinical trial data with Medicare claims could provide novel information on health care utilization and cost. METHODS We linked data from Medicare claims of women ≥65 years old who had Medicare fee-for-service coverage with their clinical data from the Women's Health Initiative trials of conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) versus placebo and of CEE-alone versus placebo. The primary outcome was total Medicare spending during the intervention phase of the trial, and the secondary outcomes were spending on diseases hypothesized a priori to be sensitive to the effects of hormone therapy. RESULTS In the CEE+MPA trial, 4,557 participants ≥65 years old were included. Women randomly assigned to CEE+MPA had 4% higher mean Medicare spending overall ($45,690 vs $43,920, P = .08) but 0.5% lower spending for hormone-sensitive diseases ($3,526 vs $3,547, P = .07), with 73% higher spending for coronary heart disease (P = .045) and 122% higher spending for pulmonary embolism (P = .026). In the CEE-alone trial, 3,107 participants were included. Total spending among women randomly assigned to CEE was 3.3% higher ($75,411 vs $72,997, P = .16), and 1.7% higher spending for hormone-sensitive diseases ($5,213 vs $5,127, P = .57), but with 39% lower spending for hip fracture (p<0.03). CONCLUSIONS Menopausal hormone therapy increased spending for some diseases, but decreased spending for others. These offsetting effects led to modest (3%-4%), nonsignificant increases in overall spending among women aged 65 years and older.
Collapse
Affiliation(s)
| | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA.
| |
Collapse
|
12
|
Baron SJ, Chinnakondepalli K, Magnuson EA, Kandzari DE, Puskas JD, Ben-Yehuda O, van Es GA, Taggart DP, Morice MC, Lembo NJ, Brown WM, Banning A, Simonton CA, Kappetein AP, Sabik JF, Serruys PW, Stone GW, Cohen DJ. Quality-of-Life After Everolimus-Eluting Stents or Bypass Surgery for Left-Main Disease. J Am Coll Cardiol 2017; 70:3113-3122. [DOI: 10.1016/j.jacc.2017.10.036] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/05/2017] [Accepted: 10/17/2017] [Indexed: 11/29/2022]
|
13
|
Abstract
PURPOSE OF REVIEW Stable ischemic heart disease (SIHD) is a highly prevalent condition associated with increased costs, morbidity, and mortality. Management goals of SIHD can broadly be thought of in terms of improving prognosis and/or improving symptoms. Treatment options include medical therapy as well as revascularization, either with percutaneous coronary intervention or coronary artery bypass grafting. Herein, we will review the current evidence base for treatment of SIHD as well as its challenges and discuss ongoing studies to help address some of these knowledge gaps. RECENT FINDINGS There has been no consistent reduction in death or myocardial infarction (MI) with revascularization vs. medical therapy in patients with SIHD in contemporary trials. Angina and quality of life have been shown to be relieved more rapidly with revascularization vs. optimal medical therapy; however, the durability of these results is uncertain. There have been challenges and limitations in several of the trials addressing the optimal treatment strategy for SIHD due to potential selection bias (due to knowledge of coronary anatomy prior to randomization), patient crossover, and advances in medical therapy and revascularization strategies since trial completion. The challenges inherent to prior trials addressing the optimal management strategy for SIHD have impacted the generalizability of results to real-world cohorts. Until the results of additional ongoing trials are available, the decision for revascularization or medical therapy should be based on patients' symptoms, weighing the risks and benefits of each approach, and patient preference.
Collapse
|
14
|
Abdallah MS, Wang K, Magnuson EA, Osnabrugge RL, Kappetein AP, Morice MC, Mohr FA, Serruys PW, Cohen DJ. Quality of Life After Surgery or DES in Patients With 3-Vessel or Left Main Disease. J Am Coll Cardiol 2017; 69:2039-2050. [DOI: 10.1016/j.jacc.2017.02.031] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/15/2017] [Accepted: 02/06/2017] [Indexed: 11/29/2022]
|
15
|
Padala SK, Lavelle MP, Sidhu MS, Cabral KP, Morrone D, Boden WE, Toth PP. Antianginal Therapy for Stable Ischemic Heart Disease. J Cardiovasc Pharmacol Ther 2017; 22:499-510. [DOI: 10.1177/1074248417698224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic angina pectoris is associated with considerable morbidity and mortality, especially if treated suboptimally. For many patients, aggressive pharmacologic intervention is necessary in order to alleviate anginal symptoms. The optimal treatment of stable ischemic heart disease (SIHD) should be the prevention of angina and ischemia, with the goal of maximizing both quality and quantity of life. In addition to effective risk factor modification with lifestyle changes, intensive pharmacologic secondary prevention is the therapeutic cornerstone in managing patients with SIHD. Current guidelines recommend a multifaceted therapeutic approach with β-blockers as first-line treatment. Another important pharmacologic intervention for managing SIHD is nitrates. Nitrates can provide both relief of acute angina and can be used prophylactically before exposure to known triggers of myocardial ischemia to prevent angina. Additional therapeutic options include calcium channel blockers and ranolazine, an inhibitor of the late inward sodium current, that can be used alone or in addition to nitrates or β-blockers when these agents fail to alleviate symptoms. Ranolazine appears to be particularly effective for patients with microvascular angina and endothelial dysfunction. In addition, certain antianginal therapies are approved in Europe and have been shown to improve symptoms, including ivabradine, nicorandil, and trimetazidine; however, these have yet to be approved in the United States. Ultimately, there are several different medications available to the physician for managing the patient with SIHD having chronic angina, when either used alone or in combination. The purpose of this review is to highlight the most important therapeutic approaches to optimizing contemporary treatment in response to individual patient needs.
Collapse
Affiliation(s)
- Santosh K. Padala
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Mandeep S. Sidhu
- Department of Medicine, Albany Medical College, Albany, NY, USA
- Albany Stratton VA Medical Center and Albany Medical Center, Albany, NY, USA
| | | | - Doralisa Morrone
- Surgery, Medicine, Molecular, and Critical Area Department, Cardiac-Cardiovascular Disease Section, University of Pisa, Pisa, Italy
| | - William E. Boden
- Department of Medicine, Albany Medical College, Albany, NY, USA
- Albany Stratton VA Medical Center and Albany Medical Center, Albany, NY, USA
| | - Peter P. Toth
- Department of Preventive Cardiology, CGH Medical Center, Sterling, IL, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
16
|
Newer Therapies for Management of Stable Ischemic Heart Disease With Focus on Refractory Angina. Am J Ther 2017; 23:e1842-e1856. [PMID: 25590765 DOI: 10.1097/mjt.0000000000000187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ischemic heart disease remains a major public health problem nationally and internationally. Stable ischemic heart disease (SIHD) is one of the clinical manifestations of ischemic heart disease and is generally characterized by episodes of reversible myocardial demand/supply mismatch, related to ischemia or hypoxia, which are usually inducible by exercise, emotion, or other stress and reproducible-but which may also be occurring spontaneously. Improvements in the treatment of acute coronary syndromes along with increasing prevalence of cardiovascular risk factors, including diabetes and obesity, have led to increasing population of patients with SIHD. A significant number of these continue to have severe angina despite medical management and revascularization procedures performed and may progress to refractory angina. This article reviews the newer therapies in the treatment of SIHD with special focus in treating patients with refractory angina.
Collapse
|
17
|
|
18
|
Douglas PS, De Bruyne B, Pontone G, Patel MR, Norgaard BL, Byrne RA, Curzen N, Purcell I, Gutberlet M, Rioufol G, Hink U, Schuchlenz HW, Feuchtner G, Gilard M, Andreini D, Jensen JM, Hadamitzky M, Chiswell K, Cyr D, Wilk A, Wang F, Rogers C, Hlatky MA. 1-Year Outcomes of FFR CT -Guided Care in Patients With Suspected Coronary Disease. J Am Coll Cardiol 2016; 68:435-445. [DOI: 10.1016/j.jacc.2016.05.057] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/27/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
|
19
|
Mark DB, Anstrom KJ, Sheng S, Baloch KN, Daniels MR, Hoffmann U, Patel MR, Cooper LS, Lee KL, Douglas PS. Quality-of-Life Outcomes With Anatomic Versus Functional Diagnostic Testing Strategies in Symptomatic Patients With Suspected Coronary Artery Disease: Results From the PROMISE Randomized Trial. Circulation 2016; 133:1995-2007. [PMID: 27143676 PMCID: PMC4879021 DOI: 10.1161/circulationaha.115.020259] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial found that initial use of ≥64 detector-row computed tomography angiography versus standard functional testing strategies (exercise ECG, stress nuclear methods, or stress echocardiography) did not improve clinical outcomes in 10 003 stable symptomatic patients with suspected coronary artery disease requiring noninvasive testing. Symptom burden and quality of life (QOL) were major secondary outcomes. METHODS AND RESULTS We prospectively collected a battery of QOL instruments in 5985 patients at baseline and 6, 12, and 24 months postrandomization. The prespecified primary QOL measures were the Duke Activity Status Index and the Seattle Angina Questionnaire frequency and QOL scales. All comparisons were made as randomized. Baseline variables were well balanced in the 2982 patients randomly assigned to computed tomography angiography testing and the 3003 patients randomly assigned to functional testing. The Duke Activity Status Index improved substantially in both groups over the first 6 months following testing, but we found no evidence for a strategy-related difference (mean difference [anatomic - functional] at 24 months of follow-up, 0.1 [95% confidence interval, -0.9 to 1.1]). Similar results were seen for the Seattle Angina Questionnaire frequency scale (mean difference at 24 months, -0.2; 95% confidence interval, -0.8 to 0.4) and QOL scale (mean difference at 24 months, -0.2; 95% confidence interval, -1.3 to 0.9). None of the secondary QOL measures showed a consistent strategy-related difference. CONCLUSIONS In symptomatic patients with suspected coronary artery disease who required noninvasive testing, symptoms and QOL improved significantly. However, a strategy of initial anatomic testing, in comparison with functional testing, did not provide an incremental benefit for QOL over 2 years of follow-up. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01174550.
Collapse
Affiliation(s)
- Daniel B Mark
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.).
| | - Kevin J Anstrom
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Shubin Sheng
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Khaula N Baloch
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Melanie R Daniels
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Udo Hoffmann
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Manesh R Patel
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Lawton S Cooper
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Kerry L Lee
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Pamela S Douglas
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| |
Collapse
|
20
|
Stenvall H, Tierala I, Räsänen P, Laine M, Sintonen H, Roine RP. Long-term clinical outcomes, health-related quality of life, and costs in different treatment modalities of stable coronary artery disease. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 3:74-82. [DOI: 10.1093/ehjqcco/qcw024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/05/2016] [Indexed: 11/15/2022]
|
21
|
Abstract
The field of quality-of-life (QOL) measurement grew out of attempts in the 1960s and 1970s to connect the ever-increasing levels of public expenditure on technology-based health care for chronic diseases with evidence of the benefits and harms to patients. Most of the concepts, methods, and standards for measuring QOL were derived from psychometrics, but the degree to which current tools adhere to these methods varies greatly. Despite the importance of QOL, patient-reported outcomes are not measured in most cardiovascular clinical trials. Lack of familiarity with QOL measures and their interpretation, and unrealistic expectations about the information these measures can provide, are obstacles to their use. Large clinical trials of revascularization therapy for coronary artery disease and medical treatments for heart failure show small-to-moderate QOL effects, primarily detected with disease-specific instruments. Larger treatment effects, seen in trials of device therapy for heart failure and ablation therapy for atrial fibrillation, have been detected with both generic and disease-specific instruments. A large gap remains between the parameters currently being measured in clinical research and the data needed to incorporate the 'patient's voice' into therapeutic decision-making.
Collapse
Affiliation(s)
- Daniel B Mark
- Duke Clinical Research Institute, 2400 Pratt Avenue, Room 0311, PO Box 17969, Durham, North Carolina 27715, USA
| |
Collapse
|
22
|
Osnabrugge RL, Magnuson EA, Serruys PW, Campos CM, Wang K, van Klaveren D, Farooq V, Abdallah MS, Li H, Vilain KA, Steyerberg EW, Morice MC, Dawkins KD, Mohr FW, Kappetein AP, Cohen DJ. Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective. Heart 2015; 101:1980-8. [PMID: 26552756 DOI: 10.1136/heartjnl-2015-307578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 10/05/2015] [Indexed: 11/04/2022] Open
Abstract
AIMS Recent cost-effectiveness analyses of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) have been limited by a short time horizon or were restricted to the US healthcare perspective. We, therefore, used individual patient-level data from the SYNTAX trial to evaluate the cost-effectiveness of PCI versus CABG from a European (Dutch) perspective. METHODS AND RESULTS Between 2005 and 2007, 1800 patients with three-vessel or left main coronary artery disease were randomised to either CABG (n=897) or PCI with drug-eluting stents (DES; n=903). Costs were estimated for all patients based on observed healthcare resource usage over 5 years of follow-up. Health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on Dutch life-tables was used to extrapolate the 5-year in-trial data to a lifetime horizon. Although initial procedural costs were lower for CABG, total initial hospitalisation costs per patient were higher (€17 506 vs €14 037, p<0.001). PCI was more costly during the next 5 years of follow-up, due to more frequent hospitalisations, repeat revascularisation procedures and higher medication costs. Nevertheless, total 5-year costs remained €2465/patient higher with CABG. When the in-trial results were extrapolated to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with gains in both life expectancy and quality-adjusted life expectancy. The incremental cost-effectiveness ratio (ICER) (€5390/quality-adjusted life year (QALY) gained) was favourable and remained <€80 000/QALY in >90% of the bootstrap replicates. Outcomes were similar when incorporating the prognostic impact of non-fatal myocardial infarction and stroke, as well as across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. However, DES-PCI was economically dominant compared with CABG in patients with a SYNTAX Score ≤22 or in those with left main disease. In patients for whom the SYNTAX Score II favoured PCI based on lower predicted 4-year mortality, PCI was also economically dominant, whereas in those patients for whom the SYNTAX Score II favoured surgery, CABG was highly economically attractive (ICER range, €2967 to €3737/QALY gained). CONCLUSIONS For the broad population with three-vessel or left main disease who are candidates for either CABG or PCI, we found that CABG is a clinically and economically attractive revascularisation strategy compared with DES-PCI from a Dutch healthcare perspective. The cost-effectiveness of CABG versus PCI differed according to several anatomic factors, however. The newly developed SYNTAX Score II provides enhanced prognostic discrimination in this population, and may be a useful tool to guide resource allocation as well. TRIAL REGISTRATION NUMBER Clinical trial unique identifier: NCT00114972 (http://www.clinical-trials.gov).
Collapse
Affiliation(s)
- Ruben L Osnabrugge
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Elizabeth A Magnuson
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Patrick W Serruys
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Carlos M Campos
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Kaijun Wang
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vasim Farooq
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Mouin S Abdallah
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Haiyan Li
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Katherine A Vilain
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marie-Claude Morice
- Department of Interventional Cardiology, Institut Jacques Cartier, Massy, France
| | | | - Friedrich W Mohr
- Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany
| | - A Pieter Kappetein
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - David J Cohen
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | |
Collapse
|
23
|
Mark DB, Anstrom KJ, Clapp-Channing NE, Knight JD, Boineau R, Goertz C, Rozema TC, Liu DM, Nahin RL, Rosenberg Y, Drisko J, Lee KL, Lamas GA. Quality-of-life outcomes with a disodium EDTA chelation regimen for coronary disease: results from the trial to assess chelation therapy randomized trial. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2015; 7:508-16. [PMID: 24987051 DOI: 10.1161/circoutcomes.114.000977] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The National Institutes of Health.funded Trial to Assess Chelation Therapy (TACT) randomized 1708 stablecoronary disease patients aged .50 years who were .6 months post.myocardial infarction (2003.2010) to 40 infusions ofa multicomponent EDTA chelation solution or placebo. Chelation reduced the primary composite end point of mortality,recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina (hazard ratio, 0.82; 95%confidence interval, 0.69.0.99; P=0.035). METHODS AND RESULTS In a randomly selected subset of 911 patients, we prospectively collected a battery of quality-of-life(QOL) instruments at baseline and at 6, 12, and 24 months after randomization. The prespecified primary QOL measures were the Duke Activity Status Index (Table I in the Data Supplement) and the Medical Outcomes Study Short-Form 36 Mental Health Inventory-5. All comparisons were by intention to treat. Baseline clinical and QOL variables were well balanced in the 451 patients randomized to chelation and in the 460 patients randomized to placebo. The Duke Activity Status Index improved in both groups during the first 6 months of therapy, but we found no evidence for a treatment-related difference (mean difference [chelation.placebo] during follow-up, 0.9 [95% confidence interval, .0.7 to 2.6; P=0.27]).There was no statistically significant evidence of a treatment-related difference in the Mental Health Inventory-5 during follow-up (mean difference, 1.0; 95% confidence interval, .0.1 to 2.0; P=0.08). None of the secondary QOL measures showed a consistent treatment-related difference. CONCLUSIONS In stable, predominantly asymptomatic coronary disease patients with a history of myocardial infarction,EDTA chelation therapy did not have a detectable effect on QOL during 2 years of follow-up. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00044213.
Collapse
|
24
|
Schwann TA, Hashim SW, Badour S, Obeid M, Engoren M, Tranbaugh RF, Bonnell MR, Habib RH. Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery-based coronary artery bypass graft surgery: a multi-institutional study†. Eur J Cardiothorac Surg 2015; 49:188-95. [PMID: 25762396 DOI: 10.1093/ejcts/ezv093] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 02/03/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG. METHODS Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.
Collapse
Affiliation(s)
- Thomas A Schwann
- University of Toledo Medical Center, Toledo, OH, USA Mercy St. Vincent Medical Center, Toledo, OH, USA
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Coronary bypass surgery versus percutaneous coronary intervention: cost-effectiveness in Iran: a study in patients with multivessel coronary artery disease. Int J Technol Assess Health Care 2014; 30:366-73. [PMID: 25401422 DOI: 10.1017/s0266462314000439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate cost effectiveness of coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) with stenting from Iran society perspective. METHODS A retrospective study was carried out to estimate the annual cost and health related quality of life (HRQoL) of 109 patients who underwent coronary revascularization (PCI [n = 75] and CABG [n = 34]). A Markov model has been developed to determine the cost effectiveness of CABG compared with PCI. We used the model to calculate lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) of each strategy. We also used probabilistic sensitivity analysis to test model robustness. RESULTS We found that discounted QALY lived per person in CABG versus PCI group in 5 years, 10 years, and lifetime time horizon were (3.8 ± 0.13 versus 3.88 ± 0.14), (6.4 ± 0.23 versus 6.33 ± 0.22), and (8.74 ± 0.29 versus 8.33 ± 0.27), respectively. The estimated medical cost of CABG and PCI per patient in 5 years, 10 years, and lifetime time horizon were (USD 6,819 ± 765 versus 9,011 ± 1,816), (USD 8,852 ± 1,348 versus 12,034 ± 2,375), and (USD 14,037± 4,201 versus 18,798 ± 5,821), respectively. The incremental cost-effectiveness ratio results showed CABG is a dominate alternative in 10 years and lifetime time horizon. CONCLUSIONS This study demonstrated that despite higher initial cost and lower HRQoL, CABG is a cost-effective revascularization strategy compared with PCI for patients with multivessel coronary artery disease in long-term.
Collapse
|
26
|
Scudeler TL, Rezende PC, Hueb W. The cost–effectiveness of strategies in coronary artery disease. Expert Rev Pharmacoecon Outcomes Res 2014; 14:805-13. [DOI: 10.1586/14737167.2014.957681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
Cost-Effectiveness of Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Bypass Surgery for Patients With 3-Vessel or Left Main Coronary Artery Disease. Circulation 2014; 130:1146-57. [DOI: 10.1161/circulationaha.114.009985] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background—
The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial demonstrated that in patients with 3-vessel or left main coronary artery disease, coronary artery bypass graft surgery (CABG) was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization compared with percutaneous coronary revascularization with drug-eluting stents (DES-PCI)). The long-term cost-effectiveness of these strategies is unknown.
Methods and Results—
Between 2005 and 2007, 1800 patients with left main or 3-vessel coronary artery disease were randomized to CABG (n=897) or DES-PCI (n=903). Costs were assessed from a US perspective, and health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life expectancy over a lifetime horizon. Although initial procedural costs were $3415 per patient lower with CABG, total hospitalization costs were $10 036 per patient higher. Over the next 5 years, follow-up costs were higher with DES-PCI as a result of more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES-PCI, but the incremental cost-effectiveness ratio was favorable ($16 537 per quality-adjusted life-year gained) and remained <$20 000 per quality-adjusted life-year in most bootstrap replicates. Results were consistent across a wide range of assumptions about the long-term effect of CABG versus DES-PCI on events and costs. In patients with left main disease or a SYNTAX score ≤22, however, DES-PCI was economically dominant compared with CABG, although these findings were less certain.
Conclusions—
For most patients with 3-vessel or left main coronary artery disease, CABG is a clinically and economically attractive revascularization strategy compared with DES-PCI. However, among patients with less complex disease, DES-PCI may be preferred on both clinical and economic grounds.
Clinical Trial Registration—
URL:
www.clinicaltrials.gov
. Unique identifier: NCT00114972.
Collapse
|
28
|
Fanari Z, A Weiss S, Weintraub WS. Comparative effectiveness of revascularization strategies in stable ischemic heart disease: current perspective and literature review. Expert Rev Cardiovasc Ther 2014; 11:1321-36. [PMID: 24138520 DOI: 10.1586/14779072.2013.840136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple randomized controlled trials and observational studies have compared the impact of the two modalities on the patients' quality of life, mortality and morbidity, as well as the cost-effectiveness of these modalities in different clinical setting. CABG is the preferred strategy for revascularizations in patients with multi-vessel disease, especially in those with higher risk secondary to associated diabetes, left ventricular dysfunction or more complex lesions. PCI is a reasonable revascularization modality in patients with ischemia and single or low-risk multi-vessel disease and those with unprotected left main with low complexity anatomy. Compared with PCI, CABG is associated with less repeat revascularization, better quality of life and improved survival in high-risk patients. Although CABG is associated with higher cost, it is probably associated with a reasonable cost per quality-adjusted life-year gained in many patients. Therefore, CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.
Collapse
|
29
|
Caruba T, Katsahian S, Schramm C, Charles Nelson A, Durieux P, Bégué D, Juillière Y, Dubourg O, Danchin N, Sabatier B. Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies. PLoS One 2014; 9:e98371. [PMID: 24896266 PMCID: PMC4045726 DOI: 10.1371/journal.pone.0098371] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/01/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction and Objectives Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG). Methods RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs. Results Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG. Conclusions Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.
Collapse
Affiliation(s)
- Thibaut Caruba
- Pharmacie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- * E-mail:
| | - Sandrine Katsahian
- URC Hôpital Henri Mondor, APHP, Créteil, France
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
| | | | | | - Pierre Durieux
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
- Département de Santé Publique et Informatique, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Dominique Bégué
- Faculté de Pharmacie, Université René Descartes, Paris, France
| | - Yves Juillière
- Cardiologie, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, Nancy, France
| | - Olivier Dubourg
- Cardiologie, Hôpital Ambroise Paré, APHP, Boulogne Billancourt, France
- Université de Versailles-Saint Quentin, Montigny-Le-Bretonneux, France
| | - Nicolas Danchin
- Cardiologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Faculté de Médecine, Université René Descartes, Paris, France
| | - Brigitte Sabatier
- Pharmacie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Equipe 22, Centre de Recherche des Cordeliers, UMRS 762 INSERM, Paris, France
| |
Collapse
|
30
|
Coutinho-Myrrha MA, Dias RC, Fernandes AA, Araújo CG, Hlatky MA, Pereira DG, Britto RR. Duke Activity Status Index for cardiovascular diseases: validation of the Portuguese translation. Arq Bras Cardiol 2014; 102:383-90. [PMID: 24652056 PMCID: PMC4028943 DOI: 10.5935/abc.20140031] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/16/2013] [Accepted: 08/06/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Duke Activity Status Index (DASI) assesses the functional capacity of patients with cardiovascular disease (CVD), but there is no Portuguese version validated for CVD. OBJECTIVES To translate and adapt cross-culturally the DASI for the Portuguese-Brazil language, and to verify its psychometric properties in the assessment of functional capacity of patients with CVD. METHODS The DASI was translated into Portuguese, then checked by back-translation into English and evaluated by an expert committee. The pre-test version was first evaluated in 30 subjects. The psychometric properties and correlation with exercise testing was performed in a second group of 67 subjects. An exploratory factor analyses was performed in all 97 subjects to verify the construct validity of the DASI. RESULTS The intraclass correlation coefficient for test-retest reliability was 0.87 and for the inter-rater reliability was 0.84. Cronbach's α for internal consistency was 0.93. The concurrent validity was verified by significant positive correlations of DASI scores with the VO2max (r = 0.51, p < 0.001). The factor analysis yielded two factors, which explained 54% of the total variance, with factor 1 accounting for 40% of the variance. Application of the DASI required between one and three and a half minutes per patient. CONCLUSIONS The Brazilian version of the DASI appears to be a valid, reliable, fast and easy to administer tool to assess functional capacity among patients with CVD.
Collapse
Affiliation(s)
- Mariana A. Coutinho-Myrrha
- Ciências da Reabilitação Programa de Pós-Graduação - Universidade
Federal de Minas Gerais (UFMG) - Brazil
| | - Rosângela C. Dias
- Ciências da Reabilitação Programa de Pós-Graduação - Universidade
Federal de Minas Gerais (UFMG) - Brazil
- Departamento de Fisioterapia - UFMG - Brazil
| | - Aline A. Fernandes
- Ciências da Reabilitação Programa de Pós-Graduação - Universidade
Federal de Minas Gerais (UFMG) - Brazil
| | | | | | - Danielle G. Pereira
- Ciências da Reabilitação Programa de Pós-Graduação - Universidade
Federal de Minas Gerais (UFMG) - Brazil
- Departamento de Fisioterapia - UFMG - Brazil
| | - Raquel R. Britto
- Ciências da Reabilitação Programa de Pós-Graduação - Universidade
Federal de Minas Gerais (UFMG) - Brazil
- Departamento de Fisioterapia - UFMG - Brazil
| |
Collapse
|
31
|
Osnabrugge RLJ, Head SJ, Bogers AJJC, Kappetein AP. Multivessel coronary artery disease: quantifying how recent trials should influence clinical practice. Expert Rev Cardiovasc Ther 2014; 11:903-18. [DOI: 10.1586/14779072.2013.811977] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
32
|
Góngora E, Sundt TM. Role of surgical revascularization in diabetic patients with coronary artery disease. Expert Rev Cardiovasc Ther 2014; 3:249-60. [PMID: 15853599 DOI: 10.1586/14779072.3.2.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Diabetes is a well-known risk factor for morbidity and mortality associated with coronary artery disease. Currently, diabetics represent approximately a quarter of patients requiring coronary revascularization in the USA. The purpose of this article is to review and analyze the available data in surgical revascularization of diabetic patients with coronary artery disease. The review will also examine new developments in myocardial revascularization and assess their probable impact on the long-term outcome of diabetic patients.
Collapse
Affiliation(s)
- Enrique Góngora
- Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA.
| | | |
Collapse
|
33
|
Abdallah MS, Wang K, Magnuson EA, Spertus JA, Farkouh ME, Fuster V, Cohen DJ. Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease: a randomized clinical trial. JAMA 2013; 310:1581-90. [PMID: 24129463 PMCID: PMC4370776 DOI: 10.1001/jama.2013.279208] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE The FREEDOM trial demonstrated that among patients with diabetes mellitus and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery resulted in lower rates of death and myocardial infarction but a higher risk of stroke when compared with percutaneous coronary intervention (PCI) using drug-eluting stents. Whether there are treatment differences in health status, as assessed from the patient's perspective, is unknown. OBJECTIVES To compare the relative effects of CABG vs PCI using drug-eluting stents on health status among patients with diabetes mellitus and multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS Between 2005 and 2010, 1900 patients from 18 countries with diabetes mellitus and multivessel coronary artery disease were randomized to undergo either CABG surgery (n = 947) or PCI (n = 953) as an initial treatment strategy. Of these, a total of 1880 patients had baseline health status assessed (935 CABG, 945 PCI) and comprised the primary analytic sample. INTERVENTIONS Initial revascularization with CABG surgery or PCI. MAIN OUTCOMES AND MEASURES Health status was assessed using the angina frequency, physical limitations, and quality-of-life domains of the Seattle Angina Questionnaire at baseline, at 1, 6, and 12 months, and annually thereafter. For each scale, scores range from 0 to 100 with higher scores representing better health. The effect of CABG surgery vs PCI was evaluated using longitudinal mixed-effect models. RESULTS At baseline, mean (SD) scores for the angina frequency, physical limitations, and quality-of-life subscales of the Seattle Angina Questionnaire were 70.9 (25.1), 67.3 (24.4), and 47.8 (25.0) for the CABG group and 71.4 (24.7), 69.9 (23.2), and 49.2 (25.7) for the PCI group, respectively. At 2-year follow-up, mean (SD) scores were 96.0 (11.9), 87.8 (18.7), and 82.2 (18.9) after CABG and 94.7 (14.3), 86.0 (19.3), and 80.4 (19.6) after PCI, with significantly greater benefit of CABG on each domain (mean treatment benefit, 1.3 [95% CI, 0.3-2.2], 4.4 [95% CI, 2.7-6.1], and 2.2 [95% CI, 0.7-3.8] points, respectively; P < .01 for each comparison). Beyond 2 years, the 2 revascularization strategies provided generally similar patient-reported outcomes. CONCLUSIONS AND RELEVANCE For patients with diabetes and multivessel CAD, CABG surgery provided slightly better intermediate-term health status and quality of life than PCI using drug-eluting stents. The magnitude of benefit was small, without consistent differences beyond 2 years, in part due to the higher rate of repeat revascularization with PCI. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00086450.
Collapse
Affiliation(s)
- Mouin S Abdallah
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri 64111, USA
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Fearon WF, Shilane D, Pijls NH, Boothroyd DB, Tonino PA, Barbato E, Jüni P, De Bruyne B, Hlatky MA. Cost-Effectiveness of Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease and Abnormal Fractional Flow Reserve. Circulation 2013; 128:1335-40. [DOI: 10.1161/circulationaha.113.003059] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) 2 trial demonstrated a significant reduction in subsequent coronary revascularization among patients with stable angina and at least 1 coronary lesion with a fractional flow reserve ≤0.80 who were randomized to percutaneous coronary intervention (PCI) compared with best medical therapy. The economic and quality-of-life implications of PCI in the setting of an abnormal fractional flow reserve are unknown.
Methods and Results—
We calculated the cost of the index hospitalization based on initial resource use and follow-up costs based on Medicare reimbursements. We assessed patient utility using the EQ-5D health survey with US weights at baseline and 1 month and projected quality-adjusted life-years assuming a linear decline over 3 years in the 1-month utility improvements. We calculated the incremental cost-effectiveness ratio based on cumulative costs over 12 months. Initial costs were significantly higher for PCI in the setting of an abnormal fractional flow reserve than with medical therapy ($9927 versus $3900,
P
<0.001), but the $6027 difference narrowed over 1-year follow-up to $2883 (
P
<0.001), mostly because of the cost of subsequent revascularization procedures. Patient utility was improved more at 1 month with PCI than with medical therapy (0.054 versus 0.001 units,
P
<0.001). The incremental cost-effectiveness ratio of PCI was $36 000 per quality-adjusted life-year, which was robust in bootstrap replications and in sensitivity analyses.
Conclusions—
PCI of coronary lesions with reduced fractional flow reserve improves outcomes and appears economically attractive compared with best medical therapy among patients with stable angina.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01132495.
Collapse
Affiliation(s)
- William F. Fearon
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - David Shilane
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Nico H.J. Pijls
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Derek B. Boothroyd
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Pim A.L. Tonino
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Emanuele Barbato
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Peter Jüni
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Bernard De Bruyne
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| | - Mark A. Hlatky
- From the Division of Cardiovascular Medicine (W.F.F., M.A.H.) and the Department of Health Research and Policy (D.S., D.B.B., M.A.H.), Stanford University School of Medicine, Stanford, CA; Catharina Hospital, Eindhoven, The Netherlands (N.H.J.P., P.A.L.T.); Cardiovascular Center Aalst, Aalst, Belgium (E.B., B.D.B.); and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland and CTU Bern, Department of Clinical Research, University of Bern, Switzerland (P.J.)
| |
Collapse
|
35
|
Magnuson EA, Farkouh ME, Fuster V, Wang K, Vilain K, Li H, Appelwick J, Muratov V, Sleeper LA, Boineau R, Abdallah M, Cohen DJ. Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial. Circulation 2013; 127:820-31. [PMID: 23277307 PMCID: PMC3603704 DOI: 10.1161/circulationaha.112.147488] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/07/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization-particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown. METHODS AND RESULTS Between 2005 and 2010, 1900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n=953) or CABG (n=947). Costs were assessed from the perspective of the U.S. health care system. Health state utilities were assessed using the EuroQOL 5 dimension 3 level questionnaire. A patient-level microsimulation model based on U.S. life-tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10 000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. CONCLUSIONS Despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease. CLINICAL TRIAL REGISTRATION URL: http://www.clinical-trials.gov. Unique identifier: NCT00086450.
Collapse
Affiliation(s)
| | - Michael E. Farkouh
- Mount Sinai School of Medicine, Cardiology, New York, NY
- Peter Munk Cardiac Centre and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON
| | | | - Kaijun Wang
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | | | - Haiyan Li
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | | | | | | | - Robin Boineau
- National Heart, Lung and Blood Institute, Bethesda, MD
| | - Mouin Abdallah
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| | - David J. Cohen
- Saint Luke’s Mid America Heart Institute, Kansas City, MO
| |
Collapse
|
36
|
Stein AJ. Superioridad de la cirugía coronaria versus intervencionismo coronario en el paciente diabético. CIRUGIA CARDIOVASCULAR 2013. [DOI: 10.1016/s1134-0096(13)70002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
37
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
38
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
39
|
Vieira RD, Hueb W, Hlatky M, Favarato D, Rezende PC, Garzillo CL, Lima EG, Soares PR, Hueb AC, Pereira AC, Ramires JAF, Filho RK. Cost-Effectiveness Analysis for Surgical, Angioplasty, or Medical Therapeutics for Coronary Artery Disease: 5-Year Follow-Up of Medicine, Angioplasty, or Surgery Study (MASS) II Trial. Circulation 2012; 126:S145-50. [DOI: 10.1161/circulationaha.111.084442] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
40
|
Health-Related Quality of Life among Patients with Coronary Artery Disease: A Post-Treatment Follow-Up Study in Iran. Cardiol Res Pract 2012; 2012:973974. [PMID: 22720187 PMCID: PMC3376476 DOI: 10.1155/2012/973974] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/26/2012] [Accepted: 03/11/2012] [Indexed: 11/17/2022] Open
Abstract
Objective. To examine the changes in health-related quality of life (HRQoL) in patients with coronary artery disease (CAD) in terms of age, gender, and treatment strategy in Iran. Methods and Materials. Forty-nine patients responded to the Iranian version of the 36-item short form (SF-36) questionnaire to evaluate the HRQoL at first and third year after treatment. The paired and independent Wilcoxon rank-sum tests were used for within and between comparisons, respectively. Multivariate regression analysis was used to analyze the predictors of changes at HRQoL. Results. In general, during followup, the mental component summary scale improved, and the physical component summary scale declined. The results of multiple regression showed that the score at the first year post-treatment was the main predictor of HRQoL at follow up. Moreover, after adjusting for other covariates, receiving PTCA and being at older age were related to lower scores at followup, but these were not statistically significant in most cases. Conclusion. The HRQoL significantly changed from one to three years after treatment in patients with CAD. While, the physical health deteriorated during two-year follow up, mental health improved at the same time period. Generally, there were no significant differences at changes of HRQoL in terms of treatment, age, and gender.
Collapse
|
41
|
Carter JA, Joshi AD, Kaura S, Botteman MF. Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours. PHARMACOECONOMICS 2012; 30:373-386. [PMID: 22500986 DOI: 10.2165/11631390-000000000-00000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.
Collapse
Affiliation(s)
- John A Carter
- Health Economics, Pharmerit International, Bethesda, MD 20814, USA
| | | | | | | |
Collapse
|
42
|
Blankenship JC, Marshall JJ, Pinto DS, Lange RA, Bates ER, Holper EM, Grines CL, Chambers CE. Effect of percutaneous coronary intervention on quality of life: A consensus statement from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv 2012; 81:243-59. [DOI: 10.1002/ccd.24376] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/12/2012] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Duane S. Pinto
- Beth Israel Deaconess Medical Center; Boston; Massachusetts
| | - Richard A. Lange
- University of Texas Health Science Center at San Antonio; San Antonio; Texas
| | - Eric R. Bates
- University of Michigan Hospitals and Health Centers; Ann Arbor; Michigan
| | | | - Cindy L. Grines
- Detroit Medical Center Cardiovascular Institute; Detroit; Michigan
| | | |
Collapse
|
43
|
Suri RM, Antiel RM, Burkhart HM, Huebner M, Li Z, Eton DT, Topilsky T, Sarano ME, Schaff HV. Quality of life after early mitral valve repair using conventional and robotic approaches. Ann Thorac Surg 2012; 93:761-9. [PMID: 22364970 DOI: 10.1016/j.athoracsur.2011.11.062] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 01/05/2023]
Abstract
BACKGROUND Early mitral valve (MV) repair of degenerative mitral regurgitation is associated with superior clinical outcomes compared with prosthetic replacement and restores normal life expectancy, even in those without symptoms. Although current guidelines recommend prompt referral for effective MV repair in those with severe mitral regurgitation, some are reluctant to pursue early correction due to the perception that short-term quality of life (QOL) may be adversely affected by the operation. METHODS Between January 2008 and November 2009, 202 patients underwent conventional transsternotomy or minimally invasive port-access robot-assisted MV repair, with or without patent foramen ovale closure or left Maze, and were mailed a postsurgical QOL survey. RESULTS Unadjusted QOL scores for patients undergoing MV repair were excellent early after the operation using both approaches. Robotic repair was associated with slightly improved scores on the Duke Activity Status Index, the Short Form-12 Item Health Survey Physical domain, and the Linear Analogue Self-Assessment frequency of chest pain and fatigue indices during the first postoperative year; however, differences between treatment groups became indistinguishable after 1 year. Robotic repair patients returned to work slightly quicker (median, 33 vs 54 days, p<0.001). CONCLUSIONS Functional QOL outcomes within the first 2 years after early MV repair are excellent using open and robotic platforms. A robotic approach may be associated with slightly improved early QOL and return to employment-based activities. These results may have implications regarding future evolution of clinical guidelines and economic health care policy.
Collapse
Affiliation(s)
- Rakesh M Suri
- Division of Cardiovascular Surgery, Mayo Medical School, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
45
|
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
46
|
Chung SC, Hlatky MA, Faxon D, Ramanathan K, Adler D, Mooradian A, Rihal C, Stone RA, Bromberger JT, Kelsey SF, Brooks MM. The effect of age on clinical outcomes and health status BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes). J Am Coll Cardiol 2011; 58:810-9. [PMID: 21835316 DOI: 10.1016/j.jacc.2011.05.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 04/12/2011] [Accepted: 05/06/2011] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the extent to which effectiveness of cardiac and diabetes treatment strategies varies by patient age. BACKGROUND The impact of age on the effectiveness of revascularization and hyperglycemia treatments has not been thoroughly investigated. METHODS In the BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes) trial, 2,368 patients with documented stable heart disease and type 2 diabetes were randomized to receive prompt revascularization versus initial medical therapy with deferred revascularization and insulin sensitization versus insulin provision for hyperglycemia treatment. Patients were followed for an average of 5.3 years. Cox regression and mixed models were used to investigate the effect of age and randomized treatment assignment on clinical and health status outcomes. RESULTS The effect of prompt revascularization versus medical therapy did not differ by age for death (interaction p = 0.99), major cardiovascular events (interaction p = 0.081), angina (interaction p = 0.98), or health status outcomes. After intervention, participants of all ages had significant angina and health status improvement. Younger participants experienced a smaller decline in health status during follow-up than older participants (age by time interaction p < 0.01). The effect of the randomized glycemia treatment on clinical and health status outcomes was similar for patients of different ages. CONCLUSIONS Among patients with stable heart disease and type 2 diabetes, the relative beneficial effects of a strategy of prompt revascularization versus initial medical therapy and insulin-sensitizing versus insulin-providing therapy on clinical endpoints, symptom relief, and perceived health status outcomes do not vary by age. Health status improved significantly after treatment for all ages, and this improvement was sustained longer among younger patients. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).
Collapse
|
47
|
Cohen DJ, Lavelle TA, Van Hout B, Li H, Lei Y, Robertus K, Pinto D, Magnuson EA, Mcgarry TF, Lucas SK, Horwitz PA, Henry CA, Serruys PW, Mohr FW, Kappetein AP. Economic outcomes of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients with left main or three-vessel coronary artery disease: one-year results from the SYNTAX trial. Catheter Cardiovasc Interv 2011; 79:198-209. [PMID: 21542113 DOI: 10.1002/ccd.23147] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/19/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of alternative approaches to revascularization for patients with three-vessel or left main coronary artery disease (CAD). BACKGROUND Previous studies have demonstrated that, despite higher initial costs, long-term costs with bypass surgery (CABG) in multivessel CAD are similar to those for percutaneous coronary intervention (PCI). The impact of drug-eluting stents (DES) on these results is unknown. METHODS The SYNTAX trial randomized 1,800 patients with left main or three-vessel CAD to either CABG (n = 897) or PCI using paclitaxel-eluting stents (n = 903). Resource utilization data were collected prospectively for all patients, and cumulative 1-year costs were assessed from the perspective of the U.S. healthcare system. RESULTS Total costs for the initial hospitalization were $5,693/patient higher with CABG, whereas follow-up costs were $2,282/patient higher with PCI due mainly to more frequent revascularization procedures and higher outpatient medication costs. Total 1-year costs were thus $3,590/patient higher with CABG, while quality-adjusted life expectancy was slightly higher with PCI. Although PCI was an economically dominant strategy for the overall population, cost-effectiveness varied considerably according to angiographic complexity. For patients with high angiographic complexity (SYNTAX score > 32), total 1-year costs were similar for CABG and PCI, and the incremental cost-effectiveness ratio for CABG was $43,486 per quality-adjusted life-year gained. CONCLUSIONS Among patients with three-vessel or left main CAD, PCI is an economically attractive strategy over the first year for patients with low and moderate angiographic complexity, while CABG is favored among patients with high angiographic complexity.
Collapse
Affiliation(s)
- David J Cohen
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri 64111, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Michalakeas CA, Parissis JT, Douzenis A, Nikolaou M, Varounis C, Andreadou I, Antonellos N, Markantonis-Kiroudis S, Paraskevaidis I, Ikonomidis I, Lykouras E, Kremastinos D. Effects of Sertraline on Circulating Markers of Oxidative Stress in Depressed Patients With Chronic Heart Failure: A Pilot Study. J Card Fail 2011; 17:748-54. [DOI: 10.1016/j.cardfail.2011.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 05/05/2011] [Accepted: 05/05/2011] [Indexed: 12/13/2022]
|
49
|
Chung SC, Hlatky MA, Stone RA, Rana JS, Escobedo J, Rogers WJ, Bromberger JT, Kelsey SF, Brooks MM. Body mass index and health status in the Bypass Angioplasty Revascularization Investigation 2 Diabetes Trial (BARI 2D). Am Heart J 2011; 162:184-92.e3. [PMID: 21742107 DOI: 10.1016/j.ahj.2011.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 03/12/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The longitudinal association between obesity, weight variability, and health status outcomes is important for patients with coronary disease and diabetes. METHODS The BARI 2D was a multicenter randomized clinical trial designed to evaluate treatment strategies for patients with both documented stable ischemic heart disease and type 2 diabetes. We examined BARI 2D participants for 4 years to study how body mass index (BMI) was associated with health status outcomes. Health status was evaluated by the Duke Activity Status Index (DASI), RAND Energy/fatigue, Health Distress, and Self-rated Health. Body mass index was measured quarterly throughout follow-up years, and health status was assessed at each annual follow-up visit. Variation in BMI measures was separated into between-person and within-person change in longitudinal analysis. RESULTS Higher mean BMI during follow-up years (the between-person BMI) was associated with poorer health status outcomes. Decreasing BMI (the within-person BMI change) was associated with better Self-rated health. The relationships between BMI variability and DASI or Energy appeared to be curvilinear and differed by baseline obesity status. Decreasing BMI was associated with better outcomes if patients were obese at baseline but was associated with poorer DASI and Energy outcomes if patients were nonobese at baseline. CONCLUSIONS For patients with stable ischemic heart disease and diabetes, weight gain was associated with poorer health status outcomes, independent of obesity-related comorbidities. Weight reduction is associated with better functional capacity and perceived energy for obese patients but not for nonobese patients at baseline.
Collapse
|
50
|
Cohen DJ, Van Hout B, Serruys PW, Mohr FW, Macaya C, den Heijer P, Vrakking MM, Wang K, Mahoney EM, Audi S, Leadley K, Dawkins KD, Kappetein AP. Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med 2011; 364:1016-26. [PMID: 21410370 DOI: 10.1056/nejmoa1001508] [Citation(s) in RCA: 197] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies have shown that among patients undergoing multivessel revascularization, coronary-artery bypass grafting (CABG), as compared with percutaneous coronary intervention (PCI) either by means of balloon angioplasty or with the use of bare-metal stents, results in greater relief from angina and improved quality of life. The effect of PCI with the use of drug-eluting stents on these outcomes is unknown. METHODS In a large, randomized trial, we assigned 1800 patients with three-vessel or left main coronary artery disease to undergo either CABG (897 patients) or PCI with paclitaxel-eluting stents (903 patients). Health-related quality of life was assessed at baseline and at 1, 6, and 12 months with the use of the Seattle Angina Questionnaire (SAQ) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The primary end point was the score on the angina-frequency subscale of the SAQ (on which scores range from 0 to 100, with higher scores indicating better health status). RESULTS The scores on each of the SAQ and SF-36 subscales were significantly higher at 6 and 12 months than at baseline in both groups. The score on the angina-frequency subscale of the SAQ increased to a greater extent with CABG than with PCI at both 6 and 12 months (P=0.04 and P=0.03, respectively), but the between-group differences were small (mean treatment effect of 1.7 points at both time points). The proportion of patients who were free from angina was similar in the two groups at 1 month and 6 months and was higher in the CABG group than in the PCI group at 12 months (76.3% vs. 71.6%, P=0.05). Scores on all the other SAQ and SF-36 subscales were either higher in the PCI group (mainly at 1 month) or were similar in the two groups throughout the follow-up period. CONCLUSIONS Among patients with three-vessel or left main coronary artery disease, there was greater relief from angina after CABG than after PCI at 6 and 12 months, although the extent of the benefit was small. (Funded by Boston Scientific; ClinicalTrials.gov number, NCT00114972.).
Collapse
Affiliation(s)
- David J Cohen
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO 64111, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|