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Westerhout CM, Rathwell S, Anstrom KJ, Hernandez AF, Ponikowski P, Ezekowitz JA, Voors AA, Felker GM, Bakal JA, Blaustein RO, Nkulikiyinka R, O'Connor CM, Armstrong PW. Comparing Analytical Methods for Composite End Points in Clinical Trials: Insights from the Vericiguat Global Study in Subjects with Heart Failure With Reduced Ejection Fraction Trial. J Card Fail 2024:S1071-9164(24)00325-7. [PMID: 39182825 DOI: 10.1016/j.cardfail.2024.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/25/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND In VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction), participants with heart failure (HF) and reduced ejection fraction, vericiguat decreased the primary composite outcome (time to first HF hospitalization [HFH] or cardiovascular death [CVD]) (897 events) compared with placebo (972 events) (hazard ratio, 0.90; 95% confidence interval [CI], 0.82-0.98; P = .02). In this prespecified secondary analysis, we applied the weighted composite end point (WCE) and the win ratio (WR) methods to provide complementary assessments of treatment effect. METHODS AND RESULTS The WCE method estimated the mean HFH-adjusted survival based on prespecified weights from a Delphi panel of the VICTORIA executive committee and national leaders: mild (weight per event, 0.39), moderate (0.5), or severe (0.67) HFH, and CVD (1.0). The unmatched WR was estimated for the descending hierarchy of CVD, then recurrent HFH. The WCE used all 3412 primary clinical events: 875 severe HFH (vericiguat, 416/ placebo, 459), 1614 moderate HFH (767/847), 68 mild HFH (38/30), and 855 CVD (414/441). Improved HFH-adjusted survival occurred with vericiguat (mean 78.2% vs 75.6%, difference 2.4%, 95% CI, 1.7%-3.2%, P < .0001). Based on a comparison of 6,375,624 pairs, the WR of 1.13 (95% CI 1.03-1.24, P = .01) also indicated improved clinical outcomes with vericiguat. CONCLUSIONS The results of the WCE and WR methods were consistent with the primary analysis of the time to first HFH or CVD. Although both WCE and WR assessed recurrent events, the WCE allowed inclusion of all recurrent events, insights on the severity of HFH events, and an absolute measure of the participant-treatment experience. This approach complements conventional assessment, better informing consumers of new therapeutics and future trial designs.
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Affiliation(s)
| | - Sarah Rathwell
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Christopher M O'Connor
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Weatherald J, Fleming TR, Wilkins MR, Cascino TM, Psotka MA, Zamanian R, Seeger W, Galiè N, Gomberg-Maitland M. Clinical trial design, end-points, and emerging therapies in pulmonary arterial hypertension. Eur Respir J 2024:2401205. [PMID: 39209468 DOI: 10.1183/13993003.01205-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 09/04/2024]
Abstract
Clinical trials in pulmonary arterial hypertension (PAH) have led to the approval of several effective treatments that improve symptoms, exercise capacity and clinical outcomes. In phase 3 clinical trials, primary end-points must reflect how a patient "feels, functions or survives". In a rare disease like PAH, with an ever-growing number of treatment options and numerous candidate therapies being studied, future clinical trials are now faced with challenges related to sample size requirements, efficiency and demonstration of incremental benefit on traditional end-points in patients receiving background therapy with multiple drugs. Novel clinical trial end-points, innovative trial designs and statistical approaches and new technologies may be potential solutions to tackle the challenges facing future PAH trials, but these must be acceptable to patients and regulatory bodies while preserving methodological rigour. In this World Symposium on Pulmonary Hypertension task force article, we address emerging trial end-points and designs, biomarkers and surrogate end-point validation, the concept of disease modification, challenges and opportunities to address diversity and representativeness, and the use of new technologies such as artificial intelligence in PAH clinical trials.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Martin R Wilkins
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mitchell A Psotka
- Inova Schar Heart and Vascular, Falls Church, VA, USA
- United States Food and Drug Administration, Silver Spring, MD, USA
| | - Roham Zamanian
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna and Dipartimento DIMEC, Università di Bologna, Bologna, Italy
| | - Mardi Gomberg-Maitland
- Division of Cardiovascular Medicine, Department of Medicine, George Washington University, School of Medicine, Washington, DC, USA
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Bergmark BA, Park JG, Hamershock RA, Melloni GEM, De Caterina R, Antman EM, Ruff CT, Rutman H, Mercuri MF, Lanz HJ, Braunwald E, Giugliano RP. Application of the Win Ratio Method in the ENGAGE AF-TIMI 48 Trial Comparing Edoxaban With Warfarin in Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2024; 17:e010561. [PMID: 38828563 DOI: 10.1161/circoutcomes.123.010561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Cardiovascular trials often use a composite end point and a time-to-first event model. We sought to compare edoxaban versus warfarin using the win ratio, which offers data complementary to time-to-first event analysis, emphasizing the most severe clinical events. METHODS ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) was a double-blind, randomized trial in which patients with atrial fibrillation were assigned 1:1:1 to a higher dose edoxaban regimen (60/30 mg daily), a lower dose edoxaban regimen (30/15 mg daily), or warfarin. In an exploratory analysis, we analyzed the trial outcomes using an unmatched win ratio approach. The win ratio for each edoxaban regimen was the total number of edoxaban wins divided by the number of warfarin wins for the following ranked clinical outcomes: 1: death; 2: hemorrhagic stroke; 3: ischemic stroke/systemic embolic event/epidural or subdural bleeding; 4: noncerebral International Society on Thrombosis and Haemostasis major bleeding; and 5: cardiovascular hospitalization. RESULTS 21 105 patients were randomized to higher dose edoxaban regimen (N=7035), lower dose edoxaban regimen (N=7034), or warfarin (N=7046), yielding >49 million pairs for each treatment comparison. The median age was 72 years, 38% were women, and 59% had prior vitamin K antagonist use. The win ratio was 1.11 (95% CI, 1.05-1.18) for higher dose edoxaban regimen versus warfarin and 1.11 (95% CI, 1.05-1.18) for lower dose edoxaban regimen versus warfarin. The favorable impacts of edoxaban on death (34% of wins) and cardiovascular hospitalization (41% of wins) were the major contributors to the win ratio. Results consistently favored edoxaban in subgroups based on creatine clearance and dose reduction at baseline, with heightened benefit among those without prior vitamin K antagonist use. CONCLUSIONS In a win ratio analysis of the ENGAGE AF-TIMI 48 trial, both dose regimens of edoxaban were superior to warfarin for the net clinical outcome incorporating ischemic and bleeding events. As the win ratio emphasizes the most severe clinical events, this analysis supports the superiority of edoxaban over warfarin in patients with atrial fibrillation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781391.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | | | - Giorgio E M Melloni
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Raffaele De Caterina
- University of Pisa and Cardiology Division, Pisa University Hospital, Italy (R.D.C.)
| | - Elliott M Antman
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Christian T Ruff
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Howard Rutman
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Michele F Mercuri
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Hans-Joachim Lanz
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
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Bakal JA, Wilber D. Patient-Centered Rocket Science: Accurate but Imprecise. J Am Heart Assoc 2024; 13:e035100. [PMID: 38780174 PMCID: PMC11255640 DOI: 10.1161/jaha.124.035100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Jeffrey A. Bakal
- Department of MedicineUniversity of Alberta, Edmonton Alberta and the Alberta Strategy for Patient Oriented Research Data and Research ServicesEdmontonAlbertaCanada
| | - David Wilber
- Department of MedicineLoyola University Chicago Stritch School of MedicineMaywoodILUSA
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Baracaldo-Santamaría D, Feliciano-Alfonso JE, Ramirez-Grueso R, Rojas-Rodríguez LC, Dominguez-Dominguez CA, Calderon-Ospina CA. Making Sense of Composite Endpoints in Clinical Research. J Clin Med 2023; 12:4371. [PMID: 37445406 DOI: 10.3390/jcm12134371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Multiple drugs currently used in clinical practice have been approved by regulatory agencies based on studies that utilize composite endpoints. Composite endpoints are appealing because they reduce sample size requirements, follow-up periods, and costs. However, interpreting composite endpoints can be challenging, and their misuse is not uncommon. Incorrect interpretation of composite outcomes can lead to misleading conclusions that impact patient care. To correctly interpret composite outcomes, several important questions should be considered. Are the individual components of the composite outcome equally important to patients? Did the more and less important endpoints occur with similar frequency? Do the component endpoints exhibit similar relative risk reductions? If these questions receive affirmative answers, the use and interpretation of the composite endpoint would be appropriate. However, if any component of the composite endpoint fails to satisfy the aforementioned criteria, interpretation can become difficult, necessitating additional steps. Regulatory agencies acknowledge these challenges and have specific considerations when approving drugs based on studies employing composite endpoints. In conclusion, composite endpoints are valuable tools for evaluating the efficacy and net clinical benefit of interventions; however, cautious interpretation is advised.
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Affiliation(s)
- Daniela Baracaldo-Santamaría
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | | | - Raul Ramirez-Grueso
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Luis Carlos Rojas-Rodríguez
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | | | - Carlos Alberto Calderon-Ospina
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
- Research Group in Applied Biomedical Sciences (UR Biomed), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
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Kuno T, Watanabe A, Miyamoto Y, Slipczuk L, Kohsaka S, Bhatt DL. Assessment of Nonfatal Bleeding Events as a Surrogate for Mortality in Coronary Artery Disease. JACC. ADVANCES 2023; 2:100276. [PMID: 38939598 PMCID: PMC11198307 DOI: 10.1016/j.jacadv.2023.100276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 06/29/2024]
Abstract
Background Bleeding events are frequently applied as safety end points for randomized controlled trials (RCTs) investigating the effect of antithrombotic agents in patients with coronary artery disease. However, whether a bleeding event is a valid surrogate for death remain uncertain. Objectives This study aimed to assess the correlation between the treatment effect on bleeding events and mortality. Methods Multiple databases were searched to identify RCTs studying antithrombotic agents for patients with coronary artery disease through August 2022. Major and minor bleeding events were defined in included trials, mostly defined with BARC (Bleeding Academic Research Consortium) or TIMI (Thrombolysis In Myocardial Infarction) criteria. Trial-level correlations between nonfatal bleeding events and mortality were assessed. We performed subgroup analyses by the definitions of bleeding (BARC vs TIMI criteria), study year, and follow-up duration. We used a cutoff with a lower limit of 95% confidence interval of R2 >0.72 as a strong correlation and with an upper limit of 95% confidence interval of R2 <0.50 as a weak correlation. Results A total of 48 RCTs with 181,951 participants were analyzed. Overall, trial-level R2 for major and minor bleeding were 0.09 (95% CI: 0.00-0.26) and 0.09 (95% CI: 0.00-0.27) for all-cause or cardiovascular death, respectively. When confined to major bleeding, R2 were 0.03 (95% CI: 0.00-0.13) and 0.01 (95% CI: 0.00-0.05), respectively. All of the subgroup analyses did not show any significant correlations. Conclusions We demonstrated a trial-defined bleeding event may not be a valid surrogate for mortality in RCTs investigating the effect of antithrombotic agents for coronary artery disease.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Yoshihisa Miyamoto
- National Cancer Center Institute for Cancer Control, Tokyo, Japan
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
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Galimzhanov A, Sabitov Y, Guclu E, Tenekecioglu E, Mamas MA. Phenotyping for percutaneous coronary intervention and long-term recurrent weighted outcomes. Int J Cardiol 2023; 374:12-19. [PMID: 36574846 DOI: 10.1016/j.ijcard.2022.12.035] [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: 09/21/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Percutaneous coronary interventions (PCI) are often performed in multimorbid patients with heterogeneous characteristics and variable clinical outcomes. We aimed to identify distinct clinical phenotypes utilizing machine learning and explore their relationship with long-term recurrent and weighted outcomes. METHODS This prospective observational cohort study enrolled all-comer PCI patients in 2020-2021. Multiple imputation k-means clustering was utilized to detect specific phenotypes. The study endpoints were patient-oriented and device oriented composite endpoints (POCE, DOCE), its individual components, and major bleeding. We applied semiparametric regression models for recurrent and weighted endpoints. RESULTS The study included a total of 643 patients. We unveiled three phenotype clusters: 1) inflammatory (n = 44, with high white blood cell counts, high values of C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio), 2) high erythrocyte sedimentation rate (ESR) (n = 204), and 3) non-inflammatory (n = 395). For ACS-only population, we four distinct phenotypes (high-CRP, high-ESR, high aspartate-aminotransferase, and normal). For all-comer PCI patients, identified phenotypes had a higher risk of POCE (mean ratio (MR) 1.42 (95% confidence interval (CI) 1.11-1.81) and MR 2.01 (95% CI 1.58-2.56), respectively), DOCE (MR 1.61 (95% CI 1.20-2.16), MR 2.60 (95%CI 1.94-3.48), respectively), and stroke (hazard ratio (HR) 2.86 (95% CI 1.10-7.4), 6.83 (95% CI 2.01-23.2)). Similarly, high-ESR and high-CRP phenotypes of ACS patients were significantly associated with the development of clinical composite outcomes. CONCLUSION Machine learning unveiled three distinct phenotype clusters in patients after PCI that were linked with the risk of recurrent and weighted clinical endpoints. German Clinical Trial Registry number: DRKS00020892.
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Affiliation(s)
- Akhmetzhan Galimzhanov
- Department of Propedeutics of Internal Disease, Semey Medical University, Semey, Kazakhstan; Keele Cardiovascular Research Group, Keele University, Keele, UK.
| | - Yersin Sabitov
- Department of Propedeutics of Internal Disease, Semey Medical University, Semey, Kazakhstan
| | - Elif Guclu
- Department of Cardiology, Bursa Education and Research Hospital, Health Sciences University, Bursa, Turkey
| | - Erhan Tenekecioglu
- Department of Cardiology, Bursa Education and Research Hospital, Health Sciences University, Bursa, Turkey; Department of Cardiology, Erasmus MC, Thorax Center, Erasmus University, Rotterdam, the Netherlands
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
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Nabipoor M, Westerhout CM, Rathwell S, Bakal JA. The empirical estimate of the survival and variance using a weighted composite endpoint. BMC Med Res Methodol 2023; 23:35. [PMID: 36740676 PMCID: PMC9901109 DOI: 10.1186/s12874-023-01857-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/01/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Composite endpoints for estimating treatment efficacy are routinely used in several therapeutic areas and have become complex in the number and types of component outcomes included. It is assumed that its components are of similar asperity and chronology between both treatment arms as well as uniform in magnitude of the treatment effect. However, these assumptions are rarely satisfied. Understanding this heterogeneity is important in developing a meaningful assessment of the treatment effect. METHODS We developed the Weighted Composite Endpoint (WCE) method which uses weights derived from stakeholder values for each event type in the composite endpoint. The derivation for the product limit estimator and the variance of the estimate are presented. The method was then tested using data simulated from parameters based on a large cardiovascular trial. Variances from the estimated and traditional approach are compared through increasing sample size. RESULTS The WCE method used all of the events through follow-up and generated a multiple recurrent event survival. The treatment effect was measured as the difference in mean survivals between two treatment arms and corresponding 95% confidence interval, providing a less conservative estimate of survival and variance, giving a higher survival with a narrower confidence interval compared to the traditional time-to-first-event analysis. CONCLUSIONS The WCE method embraces the clinical texture of events types by incorporating stakeholder values as well as all events during follow-up. While the effective number of events is lower in the WCE analysis, the reduction in variance enhances the ability to detect a treatment effect in clinical trials.
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Affiliation(s)
- Majid Nabipoor
- grid.413574.00000 0001 0693 8815Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta Canada
| | - Cynthia M. Westerhout
- grid.17089.370000 0001 2190 316XCanadian VIGOUR Centre, University of Alberta, Alberta, Canada
| | - Sarah Rathwell
- grid.17089.370000 0001 2190 316XCanadian VIGOUR Centre, University of Alberta, Alberta, Canada
| | - Jeffrey A. Bakal
- grid.413574.00000 0001 0693 8815Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta Canada ,grid.17089.370000 0001 2190 316XCanadian VIGOUR Centre, University of Alberta, Alberta, Canada
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The win ratio: A novel approach to define and analyze postoperative composite outcomes to reflect patient and clinician priorities. Surgery 2022; 172:1484-1489. [PMID: 36038371 DOI: 10.1016/j.surg.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/17/2022] [Accepted: 07/31/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The "win ratio" (WR) is a novel statistical technique that hierarchically weighs various postoperative outcomes (eg, mortality weighted more than complications) into a composite metric to define an overall benefit or "win." We sought to use the WR to assess the impact of social vulnerability on the likelihood of achieving a "win" after hepatopancreatic surgery. METHODS Individuals who underwent an elective hepatopancreatic procedure between 2013 and 2017 were identified using the Medicare database, which was merged with the Center for Disease Control and Prevention's Social Vulnerability Index. The win ratio was defined based on a hierarchy of postoperative outcomes: 90-day mortality, perioperative complications, 90-day readmissions, and length of stay. Patients matched based on procedure type, race, sex, age, and Charlson Comorbidity Index score were compared and assessed relative to win ratio. RESULTS Among 32,557 Medicare beneficiaries who underwent hepatectomy (n = 11,621, 35.7%) or pancreatectomy (n = 20,936, 64.3%), 16,846 (51.7%) patients were male with median age of 72 years (interquartile range 68-77) and median Charlson Comorbidity Index of 3 (interquartile range 2-8), and a small subset of patients were a racial/ethnic minority (n = 3,759, 11.6%). Adverse events associated with lack of a postoperative optimal outcome included 90-day mortality (n = 2,222, 6.8%), postoperative complication (n = 8,029, 24.7%), readmission (n = 6,349, 19.5%), and length of stay (median: 7 days, interquartile range 5-11). Overall, the patients from low Social Vulnerability Index areas were more likely to "win" with a textbook outcome (win ratio 1.07, 95% confidence interval 1.01-1.12) compared with patients from high social vulnerability counties; in contrast, there was no difference in the win ratio among patients living in average versus high Social Vulnerability Index (win ratio 1.04, 95% confidence interval 0.98-1.10). In assessing surgeon volume, patients who had a liver or pancreas procedure performed by a high-volume surgeon had a higher win ratio versus patients who were treated by a low-volume surgeon (win ratio 1.21, 95% confidence interval 1.16-1.25). In contrast, there was no difference in the win ratio (win ratio 1.01, 95% confidence interval 0.97-1.06) among patients relative to teaching hospital status. CONCLUSION Using a novel statistical approach, the win ratio ranked outcomes to create a composite measure to assess a postoperative "win." The WR demonstrated that social vulnerability was an important driver in explaining disparate postoperative outcomes.
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Seeking patient-centered trial outcomes: The case for days alive out of hospital. Am Heart J 2022; 248:172-174. [PMID: 34019888 DOI: 10.1016/j.ahj.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/29/2021] [Indexed: 11/24/2022]
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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12
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Ng AKY, Ng PY, Ip A, Lam LT, Siu CW. Trade-off of major bleeding versus myocardial infarction on mortality after percutaneous coronary intervention. Open Heart 2022; 9:openhrt-2021-001861. [PMID: 35017315 PMCID: PMC8753444 DOI: 10.1136/openhrt-2021-001861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/21/2021] [Indexed: 11/03/2022] Open
Abstract
Background The choice of antithrombotic therapy after percutaneous coronary intervention (PCI) is heavily dependent on the relative trade-off between major bleeding (MB) and myocardial infarction (MI). However, the mortality trade-off was mostly described in Western populations and remained unknown in East Asians. Method This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Participants were patients undergoing first-time PCI and survived for the first year. Patients were stratified by the presence of MB and MI during the first year. The primary endpoint was all-cause mortality between 1 and 5 years after PCI. The secondary endpoint was cardiovascular mortality. Results A total of 32 180 patients were analysed. After adjustment for baseline characteristics and using patients with neither events as reference, the risks of all-cause mortality were increased in patients with MI only (HR, 1.63; 95% CI 1.45 to 1.84; p<0.001), further increased in those with MB only (HR, 2.11, 95% CI 1.86 to 2.39; p<0.001) and highest in those with both (HR, 2.92; 95% CI 2.39 to 3.56; p<0.001). In both Cox regression and propensity score analyses, MB had a stronger impact on all-cause mortality than MI, but similar impact on cardiovascular mortality. Conclusions Both MB and MI within the first year after PCI were associated with increase in all-cause and cardiovascular mortality in Chinese patients, but the impact was stronger with MB.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong.,Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
| | - April Ip
- Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
| | - Lap Tin Lam
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
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13
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Piccolo R, Oliva A, Avvedimento M, Franzone A, Windecker S, Valgimigli M, Esposito G, Jüni P. Mortality after bleeding versus myocardial infarction in coronary artery disease: a systematic review and meta-analysis. EUROINTERVENTION 2021; 17:550-560. [PMID: 33840639 PMCID: PMC9725060 DOI: 10.4244/eij-d-20-01197] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bleeding is the principal safety concern of antithrombotic therapy and occurs frequently among patients with coronary artery disease (CAD). AIMS We aimed to evaluate the prognostic impact of bleeding on mortality compared with that of myocardial infarction (MI) in patients with CAD. METHODS We searched Medline and Embase for studies that included patients with CAD and that reported both the association between the occurrence of bleeding and mortality, and between the occurrence of MI and mortality within the same population. Adjusted hazard ratios (HRs) for mortality associated with bleeding and MI were extracted and ratios of hazard ratios (rHRs) were pooled by using inverse variance weighted random effects meta-analyses. Early events included periprocedural or within 30-day events after revascularisation or acute coronary syndrome (ACS). Late events included spontaneous or beyond 30-day events after revascularisation or ACS. RESULTS A total of 141,059 patients were included across 16 studies; 128,660 (91%) underwent percutaneous coronary intervention. Major bleeding increased the risk of mortality to the same extent as MI (rHRsbleedingvsMI 1.10, 95% CI: 0.71-1.71, p=0.668). Early bleeding was associated with a higher risk of mortality than early MI (rHRsbleedingvsMI 1.46, 95% CI: 1.13-1.89, p=0.004), although this finding was not present when only randomised trials were included. Late bleeding was prognostically comparable to late MI (rHRsbleedingvsMI 1.14, 95% CI: 0.87-1.49, p=0.358). CONCLUSIONS Compared with MI, major and late bleeding is associated with a similar increase in mortality, whereas early bleeding might have a stronger association with mortality.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Corso Umberto I 40, 80138 Naples, Italy
| | - Angelo Oliva
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Cao D, Pepine CJ, Mehran R. First and recurrent events in the ISCHEMIA trial: two sides of the same coin. Eur Heart J 2021; 43:150-152. [PMID: 34514507 DOI: 10.1093/eurheartj/ehab603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
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15
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Brunner E, Vandemeulebroecke M, Mütze T. Win odds: An adaptation of the win ratio to include ties. Stat Med 2021; 40:3367-3384. [PMID: 33860957 DOI: 10.1002/sim.8967] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/03/2021] [Accepted: 03/15/2021] [Indexed: 02/05/2023]
Abstract
The win ratio, a recently proposed measure for comparing the benefit of two treatment groups, allows ties in the data but ignores ties in the inference. In this article, we highlight some difficulties that this can lead to, and we propose to focus on the win odds instead, a modification of the win ratio which takes ties into account. We construct hypothesis tests and confidence intervals for the win odds, and we investigate their properties through simulations and in a case study. We conclude that the win odds should be preferred over the win ratio.
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Affiliation(s)
- Edgar Brunner
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | | | - Tobias Mütze
- Statistical Methodology, Novartis Pharma AG, Basel, Switzerland
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16
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Hara H, van Klaveren D, Kogame N, Chichareon P, Modolo R, Tomaniak M, Ono M, Kawashima H, Takahashi K, Capodanno D, Onuma Y, Serruys PW. Statistical methods for composite endpoints. EUROINTERVENTION 2021; 16:e1484-e1495. [PMID: 32338610 PMCID: PMC9724993 DOI: 10.4244/eij-d-19-00953] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Composite endpoints are commonly used in clinical trials, and time-to-first-event analysis has been the usual standard. Time-to-first-event analysis treats all components of the composite endpoint as having equal severity and is heavily influenced by short-term components. Over the last decade, novel statistical approaches have been introduced to overcome these limitations. We reviewed win ratio analysis, competing risk regression, negative binomial regression, Andersen-Gill regression, and weighted composite endpoint (WCE) analysis. Each method has both advantages and limitations. The advantage of win ratio and WCE analyses is that they take event severity into account by assigning weights to each component of the composite endpoint. These weights should be pre-specified because they strongly influence treatment effect estimates. Negative binomial regression and Andersen-Gill analyses consider all events for each patient -rather than only the first event - and tend to have more statistical power than time-to-first-event analysis. Pre-specified novel statistical methods may enhance our understanding of novel therapy when components vary substantially in severity and timing. These methods consider the specific types of patients, drugs, devices, events, and follow-up duration.
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Affiliation(s)
- Hironori Hara
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - David van Klaveren
- Department of Public Health, Center for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Norihiro Kogame
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ply Chichareon
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rodrigo Modolo
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands,First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Masafumi Ono
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Hideyuki Kawashima
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Kuniaki Takahashi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoraco-Vascular and Transplant Department, CAST, Rodolico Hospital, AOU “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG) and CORRIB Corelab and Centre for Research and Imaging, University Road, Galway, H91 TK33, Ireland
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17
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Kandzari D, Hickey G, Pocock S, Weber MA, Böhm M, Cohen S, Fahy M, Lamberti G, Mahfoud F. Prioritised endpoints for device-based hypertension trials: the win ratio methodology. EUROINTERVENTION 2021; 16:e1496-e1502. [PMID: 33226002 PMCID: PMC9724872 DOI: 10.4244/eij-d-20-01090] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Multiple endpoints with varying clinical relevance are available to establish the efficacy of device-based treatments. Given the variance among blood pressure measures and medication changes in hypertension trials, we performed a win ratio analysis of outcomes in a sham-controlled, randomised trial of renal denervation (RDN) in patients with uncontrolled hypertension despite commonly prescribed antihypertensive medications. We propose a novel prioritised endpoint framework for determining the treatment benefit of RDN compared with sham control. METHODS AND RESULTS We analysed the SPYRAL HTN-ON MED pilot study data using a prioritised hierarchical endpoint comprised of 24-hour mean ambulatory systolic blood pressure (SBP), office SBP, and medication burden. A generalised pairwise comparisons methodology (win ratio) was extended to examine this endpoint. Clinically relevant thresholds of 5 and 10 mmHg were used for comparisons of ambulatory and office SBP, respectively, and therefore to define treatment "winners" and "losers". For a total number of 1,596 unmatched pairs, the RDN subject was the winner in 1,050 pairs, the RDN subject was the loser in 378 pairs, and 168 pairs were tied. The win ratio in favour of RDN was 2.78 (95% confidence interval [CI]: 1.58 to 5.48; p<0.001) and corresponding net benefit statistic was 0.42 (95% CI: 0.20 to 0.63). Sensitivity analyses performed with differing blood pressure thresholds and according to drug adherence testing demonstrated consistent results. CONCLUSIONS The win ratio method addresses prior limitations by enabling inclusion of more patient-oriented results while prioritising those endpoints considered most clinically important. Applying these methods to the SPYRAL HTN-ON MED pilot study (ClinicalTrials.gov Identifier: NCT02439775), RDN was determined to be superior regarding a hierarchical endpoint and a "winner" compared with sham control patients.
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Affiliation(s)
- David Kandzari
- Piedmont Heart Institute, Suite 2065, 95 Collier Road, Atlanta, GA 30309, USA
| | - Graeme Hickey
- Coronary and Structural Heart Division, Medtronic PLC, Santa Rosa, CA, USA
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael A. Weber
- Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, NY, USA
| | - Michael Böhm
- Department of Internal Medicine III, Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Sidney Cohen
- Coronary and Structural Heart Division, Medtronic PLC, Santa Rosa, CA, USA
| | - Martin Fahy
- Coronary and Structural Heart Division, Medtronic PLC, Santa Rosa, CA, USA
| | | | - Felix Mahfoud
- Department of Internal Medicine III, Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
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18
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de Vries TI, Westerink J, Bots ML, Asselbergs FW, Smulders YM, Visseren FLJ. Relationship between classic vascular risk factors and cumulative recurrent cardiovascular event burden in patients with clinically manifest vascular disease: results from the UCC-SMART prospective cohort study. BMJ Open 2021; 11:e038881. [PMID: 34006017 PMCID: PMC7942272 DOI: 10.1136/bmjopen-2020-038881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The aim of the current study was to assess the relationship between classic cardiovascular risk factors and risk of not only the first recurrent atherosclerotic cardiovascular event, but also the total number of non-fatal and fatal cardiovascular events in patients with recently clinically manifest cardiovascular disease (CVD). DESIGN Prospective cohort study. SETTING Tertiary care centre. PARTICIPANTS 7239 patients with a recent first manifestation of CVD from the prospective UCC-SMART (Utrecht Cardiovascular Cohort - Second Manifestations of ARTerial disease) cohort study. OUTCOME MEASURES Total cardiovascular events, including myocardial infarction, stroke, vascular interventions, major limb events and cardiovascular mortality. RESULTS During a median follow-up of 8.9 years, 1412 patients had one recurrent cardiovascular event, while 1290 patients had two or more recurrent events, with a total of 5457 cardiovascular events during follow-up. The HRs for the first recurrent event and cumulative event burden using Prentice-Williams-Peterson models, respectively, were 1.36 (95% CI 1.25 to 1.48) and 1.26 (95% CI 1.17 to 1.35) for smoking, 1.14 (95% CI 1.11 to 1.18) and 1.09 (95% CI 1.06 to 1.12) for non-high-density lipoprotein (HDL) cholesterol, and 1.05 (95% CI 1.03 to 1.07) and 1.04 (95% CI 1.03 to 1.06) for systolic blood pressure per 10 mm Hg. CONCLUSIONS In a cohort of patients with established CVD, systolic blood pressure, non-HDL cholesterol and current smoking are important risk factors for not only the first, but also subsequent recurrent events during follow-up. Recurrent event analysis captures the full cumulative burden of CVD in patients.
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Affiliation(s)
- Tamar Irene de Vries
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- UMC Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, ICIN-Netherlands Heart Institute, Durrer Center for Cardiogenetic Research, University Medical Centre Utrecht, Utrecht, The Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Yvo M Smulders
- Department of Internal Medicine, Amsterdam UMC, Location VU University, Amsterdam, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, Utrecht University, Utrecht, The Netherlands
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19
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Redfors B, Gregson J, Crowley A, McAndrew T, Ben-Yehuda O, Stone GW, Pocock SJ. The win ratio approach for composite endpoints: practical guidance based on previous experience. Eur Heart J 2020; 41:4391-4399. [PMID: 32901285 DOI: 10.1093/eurheartj/ehaa665] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 02/05/2023] Open
Abstract
The win ratio was introduced in 2012 as a new method for examining composite endpoints and has since been widely adopted in cardiovascular (CV) trials. Improving upon conventional methods for analysing composite endpoints, the win ratio accounts for relative priorities of the components and allows the components to be different types of outcomes. For example, the win ratio can combine the time to death with the number of occurrences of a non-fatal outcome such as CV-related hospitalizations (CVHs) in a single hierarchical composite endpoint. The win ratio can provide greater statistical power to detect and quantify a treatment difference by using all available information contained in the component outcomes. The win ratio can also incorporate quantitative outcomes such as exercise tests or quality-of-life scores. There is a need for more practical guidance on how best to design trials using the win ratio approach. This manuscript provides an overview of the principles behind the win ratio and provides insights into how to implement the win ratio in CV trial design and reporting, including how to determine trial size.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E7HT, UK
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E7HT, UK
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20
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Capodanno D, Morice MC, Angiolillo DJ, Bhatt DL, Byrne RA, Colleran R, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Leon MB, Magee PFA, Mitsutake Y, Mylotte D, Pocock SJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhovel U, Krucoff MW, Urban P, Mehran R. Trial Design Principles for Patients at High Bleeding Risk Undergoing PCI: JACC Scientific Expert Panel. J Am Coll Cardiol 2020; 76:1468-1483. [PMID: 32943165 DOI: 10.1016/j.jacc.2020.06.085] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/26/2020] [Indexed: 01/22/2023]
Abstract
Investigating the balance of risk for thrombotic and bleeding events after percutaneous coronary intervention (PCI) is especially relevant for patients at high bleeding risk (HBR). The Academic Research Consortium for HBR recently proposed a consensus definition in an effort to standardize the patient population included in HBR trials. The aim of this consensus-based document, the second initiative from the Academic Research Consortium for HBR, is to propose recommendations to guide the design of clinical trials of devices and drugs in HBR patients undergoing PCI. The authors discuss the designs of trials in HBR patients undergoing PCI and various aspects of trial design specific to HBR patients, including target populations, intervention and control groups, primary and secondary outcomes, and timing of endpoint reporting.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitario "Policlinico G. Rodolico-San Marco", University of Catania, Catania, Italy.
| | - Marie-Claude Morice
- Cardiovascular European Research Center, Massy, France. https://twitter.com/mc_morice
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBhattMD
| | - Robert A Byrne
- Cardiovascular Research Institute Dublin, Mater Private Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland. https://twitter.com/robebyrne
| | - Roisin Colleran
- Cardiovascular Research Institute Dublin, Mater Private Hospital, Dublin, Ireland; Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and Inserm, Inra, Centre de Recherche en Cardiovasculaire et Nutrition, Faculté de Médecine, Aix-Marseille Université, Marseille, France. https://twitter.com/CuissetDr
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DonaldCutlip
| | | | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - C Michael Gibson
- Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Brookline, Massachusetts. https://twitter.com/CMichaelGibson
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus, Neuss, Germany
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Martin B Leon
- Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York. https://twitter.com/MartyMleon
| | - P F Adrian Magee
- U.S. Food and Drug Administration, Silver Spring, Maryland. https://twitter.com/dmylotte
| | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway, Ireland
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina. https://twitter.com/SVRaoMD
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands. https://twitter.com/ernest_spitzer
| | | | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland. https://twitter.com/vlgmrc
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Ute Windhovel
- Cardiovascular European Research Center, Massy, France. https://twitter.com/Urphi
| | - Mitchel W Krucoff
- Duke Clinical Research Institute, Durham, North Carolina; Duke University Medical Center, Durham, North Carolina. https://twitter.com/mwkrucoff
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York. https://twitter.com/Drroxmehran
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21
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Hara H, van Klaveren D, Takahashi K, Kogame N, Chichareon P, Modolo R, Tomaniak M, Ono M, Kawashima H, Wang R, Gao C, Niethammer M, Fontos G, Angioi M, Ribeiro VG, Barbato E, Leandro S, Hamm C, Valgimigli M, Windecker S, Jüni P, Steg PG, Verbeeck J, Tijssen JGP, Sharif F, Onuma Y, Serruys PW. Comparative Methodological Assessment of the Randomized GLOBAL LEADERS Trial Using Total Ischemic and Bleeding Events. Circ Cardiovasc Qual Outcomes 2020; 13:e006660. [PMID: 32762446 DOI: 10.1161/circoutcomes.120.006660] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Time-to-first-event analysis considers only the first event irrespective of its severity. There are several methods to assess trial outcomes beyond time-to-first-event analysis, such as analyzing total events and ranking outcomes. In the GLOBAL LEADERS study, time-to-first-event analysis did not show superiority of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention to conventional 12-month DAPT followed by aspirin monotherapy in the reduction of the primary composite end point of all-cause mortality or new Q-wave myocardial infarction. This study sought to explore various analytical approaches in assessing total ischemic and bleeding events after percutaneous coronary intervention in the GLOBAL LEADERS study. METHODS AND RESULTS Total ischemic and bleeding events were defined as all-cause mortality, any stroke, any myocardial infarction, any revascularization, or Bleeding Academic Research Consortium grade 2 or 3 bleeding. We used various analytical approaches to analyze the benefit of ticagrelor monotherapy over conventional DAPT. For ischemic and bleeding events at 2 years after percutaneous coronary intervention, ticagrelor monotherapy demonstrated a 6% risk reduction, compared with conventional 12-month DAPT in time-to-first-event analysis (hazard ratio, 0.94 [95% CI, 0.88-1.01]; log-rank P=0.10). In win ratio analysis, win ratio was 1.05 (95% CI, 0.97-1.13; P=0.20). Negative binomial regression and Andersen-Gill analyses which include repeated events showed statistically significant advantage for ticagrelor monotherapy (rate ratio, 0.92 [95% CI, 0.85-0.99; P=0.020] and hazard ratio, 0.92 [95% CI, 0.85-0.99; P=0.028], respectively), although in weighted composite end point analysis, the hazard ratio was 0.93 (95% CI, 0.84-1.04; log-rank P=0.22). CONCLUSIONS Statistical analyses considering repeated events or event severity showed that ticagrelor monotherapy consistently reduced ischemic and bleeding events by 5% to 8%, compared with conventional 1-year DAPT. Applying multiple statistical methods could emphasize the multiple facets of a trial and result in accurate and more appropriate analyses. Considering the recurrence of ischemic and bleeding events, ticagrelor monotherapy appeared to be beneficial after percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.
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Affiliation(s)
- Hironori Hara
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - David van Klaveren
- Department of Public Health, Center for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands (D.v.K.).,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (D.v.K.)
| | - Kuniaki Takahashi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Norihiro Kogame
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Ply Chichareon
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.).,Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Thailand (P.C.)
| | - Rodrigo Modolo
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.).,Cardiology Division, Department of Internal Medicine, University of Campinas (UNICAMP), Brazil (R.M.)
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands (M.T.).,First Department of Cardiology, Medical University of Warsaw, Poland (M.T.)
| | - Masafumi Ono
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Hideyuki Kawashima
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Rutao Wang
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Chao Gao
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Margit Niethammer
- Medizinische Klinik I, Herz-Thorax Zentrum, Klinikum Fulda, Germany (M.N.)
| | | | - Michael Angioi
- Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary (G.F.).,Department of Interventional Cardiology Clinique Louis Pasteur Essey-les-Nancy, France (M.A.)
| | | | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy (E.B.)
| | - Sergio Leandro
- Instituto Nacional De Cardiologia, Rio de Janeiro, Brazil (S.L.)
| | - Christian Hamm
- Kerckhoff Heart Center, Campus University of Giessen, Bad Nauheim, Germany (C.H.)
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland (M.V., S.W.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland (M.V., S.W.)
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto, Canada (P.J.)
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, and INSERM Unité 1148, France (P.G.S.).,Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | | | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Faisal Sharif
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.)
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.)
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.).,NHLI, Imperial College London, United Kingdom (P.W.S.)
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22
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
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23
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Fanaroff AC, Cyr D, Neely ML, Bakal J, White HD, Fox KAA, Armstrong PW, Lopes RD, Ohman EM, Roe MT. Days Alive and Out of Hospital: Exploring a Patient-Centered, Pragmatic Outcome in a Clinical Trial of Patients With Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes 2019; 11:e004755. [PMID: 30562068 DOI: 10.1161/circoutcomes.118.004755] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiovascular clinical trials have traditionally incorporated separate time-to-first-event analyses for their primary efficacy and safety comparisons, but this framework has a number of limitations, including limited patient-centeredness and a traditional requirement for central adjudication. Days alive and out of the hospital (DAOH) has the potential to provide additional insight. Methods and Results TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a randomized, multinational clinical trial that compared the effect of prasugrel versus clopidogrel in patients stabilized after non-ST segment elevation acute coronary syndrome treated without revascularization; the trial had a neutral result. DAOH was calculated for each patient using site-submitted adverse event reporting data. We described patterns of DAOH overall, and among younger adults (<75 years old), older adults (≥75 years old), and frail/prefrail patients over 12 months follow-up and used Poisson regression to compare DAOH for patients randomized to prasugrel versus clopidogrel. Of 9249 patients in the overall trial population, 500 (5.4%) died, and 2504 (27.1%) were hospitalized 4150 times over 12 months' follow-up; the mean±SD DAOH was 317±86. The distribution of DAOH over 12 months was left-skewed, with median DAOH 363 days. Among younger adults, older adults, and frail/prefrail patients, mean DAOH were 323, 293, and 304 days, respectively. There were no differences in DAOH by treatment arm in the overall population (rate ratio, 1.00; 95% CI, 0.99-1.01) or any subgroup. Conclusions These results support the feasibility of determining DAOH, a patient-centered outcome that can potentially overcome many of the disadvantages of the traditional time-to-composite-event framework in the clinical trial setting. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00699998.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Derek Cyr
- Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Megan L Neely
- Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Jeffery Bakal
- Division of Cardiology, University of Alberta and the Canadian VIGOUR Centre, Edmonton (J.B., P.W.A.)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital and University of Auckland, New Zealand (H.D.W.)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta and the Canadian VIGOUR Centre, Edmonton (J.B., P.W.A.)
| | - Renato D Lopes
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - E Magnus Ohman
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Matthew T Roe
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
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24
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Kotalik A, Eaton A, Lian Q, Serrano C, Connett J, Neaton JD. A win ratio approach to the re-analysis of Multiple Risk Factor Intervention Trial. Clin Trials 2019; 16:626-634. [DOI: 10.1177/1740774519868233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Composite outcomes, which combine multiple types of clinical events into a single outcome, are common in clinical trials. The usual analysis considers the time to first occurrence of any event in the composite. The major criticisms of such an approach are (1) this implicitly treats the outcomes as if they were of equal importance, but they often vary in terms of clinical relevance and severity, (2) study participants often experience more than one type of event, and (3) often less severe events occur before more severe ones, but the usual analysis disregards any information beyond that first event. Methods: A novel approach, referred to as the win ratio, which addresses the aforementioned criticisms of composite outcomes, is illustrated with a re-analysis of data on fatal and non-fatal cardiovascular disease time-to-event outcomes reported for the Multiple Risk Factor Intervention Trial. In this trial, 12,866 participants were randomized to a special intervention group ( n = 6428) or a usual care ( n = 6438) group. Non-fatal outcomes were ranked by risk of cardiovascular disease death up to 20 years after trial. In one approach, participants in the special intervention and usual care groups were first matched on coronary heart disease risk at baseline and time of enrollment. Each matched pair was categorized as a winner or loser depending on which one experienced a cardiovascular disease death first. If neither died of cardiovascular disease causes, they were evaluated on the most severe non-fatal outcome. This process continued for all the non-fatal outcomes. A second win ratio statistic, obtained from Cox partial likelihood, was also estimated. This statistic provides a valid estimate of the win ratio using multiple events if the marginal and conditional survivor functions of each outcome satisfy proportional hazards. Loss ratio statistics (inverse of win ratios) are compared to hazard ratios from the usual first event analysis. A larger 11-event composite was also considered. Results: For the 7-event cardiovascular disease composite, the previously reported first event analysis based on 581 events in the special intervention group and 652 events in the usual care group yielded a hazard ratio (95% confidence interval) of 0.89 (0.79–0.99), compared to 0.86 (0.77–0.97) and 0.91 (0.81–1.02) for the severity ranked estimates. Results for the 11-event composite also confirmed the findings of the first event analysis. Conclusion: The win ratio analysis was able to leverage information collected past the first experienced event and rank events by severity. The results were similar to and confirmed previously reported traditional first event analysis. The win ratio statistic is a useful adjunct to the traditional first event analysis for trials with composite outcomes.
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Affiliation(s)
- Ales Kotalik
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Eaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Qinshu Lian
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carlos Serrano
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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25
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Dong G, Hoaglin DC, Qiu J, Matsouaka RA, Chang YW, Wang J, Vandemeulebroecke M. The Win Ratio: On Interpretation and Handling of Ties. Stat Biopharm Res 2019. [DOI: 10.1080/19466315.2019.1575279] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | - David C. Hoaglin
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Junshan Qiu
- Division of Biometrics I, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Roland A. Matsouaka
- Department of Biostatistics and Bioinformatics & Duke Clinical Research Institute (DCRI), Duke University School of Medicine, Durham, NC
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26
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Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, Doyle RT, Juliano RA, Jiao L, Granowitz C, Tardif JC, Gregson J, Pocock SJ, Ballantyne CM. Effects of Icosapent Ethyl on Total Ischemic Events: From REDUCE-IT. J Am Coll Cardiol 2019; 73:2791-2802. [PMID: 30898607 DOI: 10.1016/j.jacc.2019.02.032] [Citation(s) in RCA: 190] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND In time-to-first-event analyses, icosapent ethyl significantly reduced the risk of ischemic events, including cardiovascular death, among patients with elevated triglycerides receiving statins. These patients are at risk for not only first but also subsequent ischemic events. OBJECTIVES Pre-specified analyses determined the extent to which icosapent ethyl reduced total ischemic events. METHODS REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) randomized 8,179 statin-treated patients with triglycerides ≥135 and <500 mg/dl (median baseline of 216 mg/dl) and low-density lipoprotein cholesterol >40 and ≤100 mg/dl (median baseline of 75 mg/dl), and a history of atherosclerosis (71% patients) or diabetes (29% patients) to icosapent ethyl 4 g/day or placebo. The main outcomes were total (first and subsequent) primary composite endpoint events (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) and total key secondary composite endpoint events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke). As a pre-specified statistical method, we determined differences in total events using negative binomial regression. We also determined differences in total events using other statistical models, including Andersen-Gill, Wei-Lin-Weissfeld (Li and Lagakos modification), both pre-specified, and a post hoc joint frailty analysis. RESULTS In 8,179 patients, followed for a median of 4.9 years, 1,606 (55.2%) first primary endpoint events and 1,303 (44.8%) subsequent primary endpoint events occurred (which included 762 second events, and 541 third or more events). Overall, icosapent ethyl reduced total primary endpoint events (61 vs. 89 per 1,000 patient-years for icosapent ethyl versus placebo, respectively; rate ratio: 0.70; 95% confidence interval: 0.62 to 0.78; p < 0.0001). Icosapent ethyl also reduced totals for each component of the primary composite endpoint, as well as the total key secondary endpoint events (32 vs. 44 per 1,000 patient-years for icosapent ethyl versus placebo, respectively; rate ratio: 0.72; 95% confidence interval: 0.63 to 0.82; p < 0.0001). CONCLUSIONS Among statin-treated patients with elevated triglycerides and cardiovascular disease or diabetes, multiple statistical models demonstrate that icosapent ethyl substantially reduces the burden of first, subsequent, and total ischemic events. (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial [REDUCE-IT]; NCT01492361).
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Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université Paris-Diderot, INSERM U-1148, Paris, France; National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Michael Miller
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Terry A Jacobson
- Office of Health Promotion and Disease Prevention, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Ralph T Doyle
- Amarin Pharma, Inc. (Amarin), Bedminster, New Jersey
| | | | - Lixia Jiao
- Amarin Pharma, Inc. (Amarin), Bedminster, New Jersey
| | | | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
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The win ratio approach did not alter study conclusions and may mitigate concerns regarding unequal composite end points in kidney transplant trials. J Clin Epidemiol 2018; 98:9-15. [DOI: 10.1016/j.jclinepi.2018.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 01/20/2018] [Accepted: 02/02/2018] [Indexed: 11/21/2022]
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Li G, Taljaard M, Van den Heuvel ER, Levine MA, Cook DJ, Wells GA, Devereaux PJ, Thabane L. An introduction to multiplicity issues in clinical trials: the what, why, when and how. Int J Epidemiol 2018; 46:746-755. [PMID: 28025257 DOI: 10.1093/ije/dyw320] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 02/05/2023] Open
Abstract
In clinical trials it is not uncommon to face a multiple testing problem which can have an impact on both type I and type II error rates, leading to inappropriate interpretation of trial results. Multiplicity issues may need to be considered at the design, analysis and interpretation stages of a trial. The proportion of trial reports not adequately correcting for multiple testing remains substantial. The purpose of this article is to provide an introduction to multiple testing issues in clinical trials, and to reduce confusion around the need for multiplicity adjustments. We use a tutorial, question-and-answer approach to address the key issues of why, when and how to consider multiplicity adjustments in trials. We summarize the relevant circumstances under which multiplicity adjustments ought to be considered, as well as options for carrying out multiplicity adjustments in terms of trial design factors including Population, Intervention/Comparison, Outcome, Time frame and Analysis (PICOTA). Results are presented in an easy-to-use table and flow diagrams. Confusion about multiplicity issues can be reduced or avoided by considering the potential impact of multiplicity on type I and II errors and, if necessary pre-specifying statistical approaches to either avoid or adjust for multiplicity in the trial protocol or analysis plan.
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Affiliation(s)
- Guowei Li
- Department of Clinical Epidemiology and Biostatistics.,St Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Edwin R Van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands.,Department of Epidemiology, University Medical Center Groningen, Eindhoven, The Netherlands
| | - Mitchell Ah Levine
- Department of Clinical Epidemiology and Biostatistics.,St Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Clinical Epidemiology and Biostatistics.,St Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - George A Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada and
| | - Philip J Devereaux
- Department of Clinical Epidemiology and Biostatistics.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics.,St Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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Optimal Weighted Wilcoxon–Mann–Whitney Test for Prioritized Outcomes. NEW FRONTIERS OF BIOSTATISTICS AND BIOINFORMATICS 2018. [DOI: 10.1007/978-3-319-99389-8_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Affiliation(s)
| | - Junshan Qiu
- Division of Biometrics I, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
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Capodanno D, Gargiulo G, Buccheri S, Chieffo A, Meliga E, Latib A, Park SJ, Onuma Y, Capranzano P, Valgimigli M, Narbute I, Makkar RR, Palacios IF, Kim YH, Buszman PE, Chakravarty T, Sheiban I, Mehran R, Naber C, Margey R, Agnihotri A, Marra S, Leon MB, Moses JW, Fajadet J, Lefèvre T, Morice MC, Erglis A, Alfieri O, Serruys PW, Colombo A, Tamburino C. Computing Methods for Composite Clinical Endpoints in Unprotected Left Main Coronary Artery Revascularization: A Post Hoc Analysis of the DELTA Registry. JACC Cardiovasc Interv 2017; 9:2280-2288. [PMID: 27884354 DOI: 10.1016/j.jcin.2016.08.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/25/2016] [Accepted: 08/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The study sought to investigate the impact of different computing methods for composite endpoints other than time-to-event (TTE) statistics in a large, multicenter registry of unprotected left main coronary artery (ULMCA) disease. BACKGROUND TTE statistics for composite outcome measures used in ULMCA studies consider only the first event, and all the contributory outcomes are handled as if of equal importance. METHODS The TTE, Andersen-Gill, win ratio (WR), competing risk, and weighted composite endpoint (WCE) computing methods were applied to ULMCA patients revascularized by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at 14 international centers. RESULTS At a median follow-up of 1,295 days (interquartile range: 928 to 1,713 days), all analyses showed no difference in combinations of death, myocardial infarction, and cerebrovascular accident between PCI and CABG. When target vessel revascularization was incorporated in the composite endpoint, the TTE (p = 0.03), Andersen-Gill (p = 0.04), WR (p = 0.025), and competing risk (p < 0.001) computing methods showed CABG to be significantly superior to PCI in the analysis of 1,204 propensity-matched patients, whereas incorporating the clinical relevance of the component endpoints using WCE resulted in marked attenuation of the treatment effect of CABG, with loss of significance for the difference between revascularization strategies (p = 0.10). CONCLUSIONS In a large study of ULMCA revascularization, incorporating the clinical relevance of the individual outcomes resulted in sensibly different findings as compared with the conventional TTE approach. In particular, using the WCE computing method, PCI and CABG were no longer significantly different with respect to the composite of death, myocardial infarction, cerebrovascular accident, or target vessel revascularization at a median of 3 years.
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Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy.
| | - Giuseppe Gargiulo
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy; Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Sergio Buccheri
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Alaide Chieffo
- Department of Cardio-Thoracic and Vascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Emanuele Meliga
- Interventional Cardiology Unit, A. O. Ordine Mauriziano Umberto I, Turin, Italy
| | - Azeem Latib
- Department of Cardio-Thoracic and Vascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Seung-Jung Park
- Department of Cardiology, Center for Medical Research and Information, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Yoshinobu Onuma
- Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Piera Capranzano
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
| | | | - Inga Narbute
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, and Institute of Cardiology, University of Latvia, Riga, Latvia
| | - Raj R Makkar
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Igor F Palacios
- Cardiac Catheterization Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Young-Hak Kim
- Department of Cardiology, Center for Medical Research and Information, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Pawel E Buszman
- Center for Cardiovascular Research and Development of American Heart of Poland, Katowice, Poland
| | - Tarun Chakravarty
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Imad Sheiban
- Interventional Cardiology, Division of Cardiology, University of Turin, S. Giovanni Battista Molinette Hospital, Turin, Italy
| | | | - Christoph Naber
- Klinik für Kardiologie und Angiologie, Elisabeth-Krankenhaus, Essen, Germany
| | - Ronan Margey
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Arvind Agnihotri
- Cardiac Catheterization Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sebastiano Marra
- Interventional Cardiology, Division of Cardiology, University of Turin, S. Giovanni Battista Molinette Hospital, Turin, Italy
| | - Martin B Leon
- Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York
| | - Jeffrey W Moses
- Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York
| | | | - Thierry Lefèvre
- Hopital privé Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | | | - Andrejs Erglis
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, and Institute of Cardiology, University of Latvia, Riga, Latvia
| | - Ottavio Alfieri
- Department of Cardio-Thoracic and Vascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Colombo
- Department of Cardio-Thoracic and Vascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Tamburino
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
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Gibson CM, Goldhaber SZ, Cohen AT, Nafee T, Hernandez AF, Hull R, Korjian S, Daaboul Y, Chi G, Yee M, Harrington RA. When academic research organizations and clinical research organizations disagree: Processes to minimize discrepancies prior to unblinding of randomized trials. Am Heart J 2017. [PMID: 28625365 DOI: 10.1016/j.ahj.2017.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Advances in cardiovascular medicine fueled by innovative clinical trials have dramatically improved the lives of patients worldwide. Commensurate with this progress has been a decline in morbid and mortal events. Accordingly, an increased propensity to collate patient outcomes in clinical trials has emerged that combines death and nonfatal complications into a single composite event. Despite the acknowledged benefits in trial efficiency from such an approach, this method assumes uniform directionality of each component, does not distinguish the relative clinical significance of each, and counts only the first occurrence of any event in the final tally within a conventional time to first event analysis. In this article, we evaluate the criticisms that have been leveled at this approach and provide an overview of recently published phase III cardiovascular trials using primary composite end points. We then explore what to anticipate from the large cohort of as-yet unpublished clinical trials in this arena. Last, we propose a variety of novel approaches that use composite end points and suggest a path forward to enhancing their use in future clinical trials.
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Affiliation(s)
- Paul W. Armstrong
- From Canadian VIGOUR Centre, Department of Medicine (Cardiology), University of Alberta, Edmonton, Canada
| | - Cynthia M. Westerhout
- From Canadian VIGOUR Centre, Department of Medicine (Cardiology), University of Alberta, Edmonton, Canada
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Armstrong PW, Ezekowitz JA. Navigating Choices Among a Sea of Comorbidities ∗. J Am Coll Cardiol 2017; 69:2380-2382. [DOI: 10.1016/j.jacc.2017.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/12/2017] [Indexed: 10/19/2022]
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35
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Valgimigli M, Costa F, Lokhnygina Y, Clare RM, Wallentin L, Moliterno DJ, Armstrong PW, White HD, Held C, Aylward PE, Van de Werf F, Harrington RA, Mahaffey KW, Tricoci P. Trade-off of myocardial infarction vs. bleeding types on mortality after acute coronary syndrome: lessons from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) randomized trial. Eur Heart J 2017; 38:804-810. [PMID: 28363222 PMCID: PMC5837470 DOI: 10.1093/eurheartj/ehw525] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/20/2016] [Accepted: 10/06/2016] [Indexed: 11/12/2022] Open
Abstract
AIMS Dual antiplatelet therapy reduces non-fatal ischaemic events after acute coronary syndrome (ACS) but increases bleeding to a similar extent. We sought to determine the prognostic impact of myocardial infarction (MI) vs. bleeding during an extended follow-up period to gain insight into the trade-off between efficacy and safety among patients after ACS. METHODS AND RESULTS In 12 944 patients with non-ST-segment elevation ACS from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial, we investigated the relative impact of MI and bleeding occurring >30 days post-ACS and subsequent all-cause mortality. Bleeding was graded according to Bleeding Academic Research Consortium (BARC) criteria. MI was associated with a five-fold increase in mortality. BARC type 2 and 3, but not type 1, bleeding had a significant impact on mortality. MI was associated with a greater risk of mortality compared with BARC 2 [relative risk (RR) 3.5; 95% confidence interval (CI) 2.08-4.77; P < 0.001] and BARC 3a bleeding (RR 2.23; 95% CI 1.36-3.64; P = 0.001), and a risk similar to BARC 3b bleeding (RR 1.37; 95% CI 0.81-2.30; P = 0.242). Risk of death after MI was significantly lower than after BARC 3c bleeding (RR 0.22; 95% CI 0.13-0.36; P < 0.001). MI and bleeding had similar time-associations with mortality, which remained significant for several months, still being higher early after the event. CONCLUSION In patients treated with antiplatelet therapy after ACS, both MI and bleeding significantly impacted mortality with similar time-dependency. Although BARC 2 and 3a bleeding were less prognostic for death than MI, the risk of mortality was equivalent between BARC 3b bleeding and MI, and was higher following BARC 3c bleeding.
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Affiliation(s)
- Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, CH-3010 Bern, Switzerland
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Francesco Costa
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Clinical and Experimental Medicine, Policlinic ‘G. Martino’, University of Messina, Messina, Italy
| | | | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David J. Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | | | - Harvey D. White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philip E. Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, SA, Australia
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Lüscher TF. Coronary and cerebrovascular interventions. Eur Heart J 2016; 37:3061-3063. [PMID: 27794002 DOI: 10.1093/eurheartj/ehw530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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37
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Dong G, Li D, Ballerstedt S, Vandemeulebroecke M. A generalized analytic solution to the win ratio to analyze a composite endpoint considering the clinical importance order among components. Pharm Stat 2016; 15:430-7. [DOI: 10.1002/pst.1763] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Di Li
- Eisai Inc.; Woodcliff Lake NJ USA
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Kaul P, Ohman EM, Knight JD, Anstrom KJ, Roe MT, Boden WE, Hochman JS, Gašparović V, Armstrong PW, McCollam P, Fakhouri W, Cowper P, Davidson-Ray L, Clapp-Channing N, White HD, Fox KA, Prabhakaran D, Mark DB. Health-related quality of life outcomes with prasugrel among medically managed non-ST-segment elevation acute coronary syndrome patients: Insights from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial. Am Heart J 2016; 178:55-64. [PMID: 27502852 DOI: 10.1016/j.ahj.2016.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 03/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Few studies have assessed treatment effects on health-related quality of life (HRQoL) in patients with acute coronary syndrome (ACS) treated without revascularization. The TRILOGY ACS trial randomized patients with ACS to either prasugrel or clopidogrel therapy plus aspirin. Outcomes showed a complex pattern suggestive of late benefits with respect to repeat clinical events and benefits confined to patients who underwent angiography. Here, we examine the HRQoL correlates of these patterns. METHODS HRQoL was measured at baseline and 3, 12, and 24 months or end of study (EOS) in 7243 patients aged <75 years using the EuroQol 3-level, group 5-dimension index (EQ-5D). Linear mixed effects models for repeated measures were used to examine treatment differences in HRQoL overall, stratified by angiography status, and among patients who did and did not have non-fatal events. RESULTS No baseline differences in HRQoL were seen between patients randomized to prasugrel (n=3620) or clopidogrel (n=3623). At 24 months, remaining patients assigned to prasugrel (n=1450) vs. clopidogrel (n=1443) had higher EQ-5D index scores (86.4 vs. 84.9, P=.01). Mixed effects models found no difference in EQ-5D scores among prasugrel and clopidogrel patients overall across subgroups stratified by angiography status. However, among patients with non-fatal clinical events, patients on clopidogrel reported a larger decrement in HRQoL than patients on prasugrel (79.5±18.1 vs. 80.6±18.0; P=.02). CONCLUSIONS Overall, there was no difference in HRQoL outcomes among patients receiving prasugrel vs. clopidogrel. However, the differential effects of the treatments among patients with non-fatal events require further investigation.
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Reduction in Total Cardiovascular Events With Ezetimibe/Simvastatin Post-Acute Coronary Syndrome: The IMPROVE-IT Trial. J Am Coll Cardiol 2016; 67:353-361. [PMID: 26821621 DOI: 10.1016/j.jacc.2015.10.077] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/20/2015] [Accepted: 10/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intensive low-density lipoprotein cholesterol therapy with ezetimibe/simvastatin in IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) significantly reduced the first primary endpoint (PEP) in patients post-acute coronary syndrome (ACS) compared to placebo/simvastatin. OBJECTIVES This analysis tested the hypothesis that total events, including those beyond the first event, would also be reduced with ezetimibe/simvastatin therapy. METHODS All PEP events (cardiovascular [CV] death, myocardial infarction [MI], stroke, unstable angina [UA] leading to hospitalization, coronary revascularization ≥30 days post-randomization) during a median 6-year follow-up were analyzed in patients randomized to receive ezetimibe/simvastatin or placebo/simvastatin in IMPROVE-IT. Negative binomial regression was used for the primary analysis. RESULTS Among 18,144 patients, there were 9,545 total PEP events (56% were first events and 44% subsequent events). Total PEP events were significantly reduced by 9% with ezetimibe/simvastatin vs placebo/simvastatin (incidence-rate ratio [RR]: 0.91; 95% confidence interval [CI]: 0.85 to 0.97; p = 0.007), as were the 3 pre-specified secondary composite endpoints and the exploratory composite endpoint of CV death, MI, or stroke (RR: 0.88; 95% CI: 0.81 to 0.96; p = 0.002). The reduction in total events was driven by decreases in total nonfatal MI (RR: 0.87; 95% CI: 0.79 to 0.96; p = 0.004) and total NF stroke (RR: 0.77; 95% CI: 0.65 to 0.93; p = 0.005). CONCLUSIONS Lipid-lowering therapy with ezetimibe plus simvastatin improved clinical outcomes. Reductions in total PEP events, driven by reductions in MI and stroke, more than doubled the number of events prevented compared with examining only the first event. These data support continuation of intensive combination lipid-lowering therapy after an initial CV event. (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial [IMPROVE-IT]; NCT00202878).
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Bebu I, Lachin JM. Large sample inference for a win ratio analysis of a composite outcome based on prioritized components. Biostatistics 2015; 17:178-87. [PMID: 26353896 DOI: 10.1093/biostatistics/kxv032] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 08/11/2015] [Indexed: 11/14/2022] Open
Abstract
Composite outcomes are common in clinical trials, especially for multiple time-to-event outcomes (endpoints). The standard approach that uses the time to the first outcome event has important limitations. Several alternative approaches have been proposed to compare treatment versus control, including the proportion in favor of treatment and the win ratio. Herein, we construct tests of significance and confidence intervals in the context of composite outcomes based on prioritized components using the large sample distribution of certain multivariate multi-sample U-statistics. This non-parametric approach provides a general inference for both the proportion in favor of treatment and the win ratio, and can be extended to stratified analyses and the comparison of more than two groups. The proposed methods are illustrated with time-to-event outcomes data from a clinical trial.
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Affiliation(s)
- Ionut Bebu
- The Biostatistics Center, The George Washington University, 6110 Executive Blvd., Rockville, MD 20852, USA
| | - John M Lachin
- The Biostatistics Center, The George Washington University, 6110 Executive Blvd., Rockville, MD 20852, USA
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Giuseppe C, Paul J, Hans-Ulrich I. Use of nitrates in ischemic heart disease. Expert Opin Pharmacother 2015; 16:1567-72. [DOI: 10.1517/14656566.2015.1052742] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ahmad Y, Nijjer S, Cook CM, El-Harasis M, Graby J, Petraco R, Kotecha T, Baker CS, Malik IS, Bellamy MF, Sethi A, Mikhail GW, Al-Bustami M, Khan M, Kaprielian R, Foale RA, Mayet J, Davies JE, Francis DP, Sen S. A new method of applying randomised control study data to the individual patient: A novel quantitative patient-centred approach to interpreting composite end points. Int J Cardiol 2015; 195:216-24. [PMID: 26048380 DOI: 10.1016/j.ijcard.2015.05.109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/06/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Modern randomised controlled trials typically use composite endpoints. This is only valid if each endpoint is equally important to patients but few trials document patient preference and seek the relative importance of components of combined endpoints. If patients weigh endpoints differentially, our interpretation of trial data needs to be refined. METHODS AND RESULTS We derive a quantitative, structured tool to determine the relative importance of each endpoint to patients. We then apply this tool to data comparing angioplasty with drug-eluting stents to bypass surgery. The survey was administered to patients undergoing cardiac catheterisation. A meta-analysis comparing coronary artery bypass grafting (CABG) to percutaneous coronary interventuin (PCI) was then performed using (a) standard MACE and (b) patient-centred MACE. Patients considered stroke worse than death (stroke 102.3 ± 19.6%, p < 0.01), and MI and repeat revascularisation less severe than death (61.9 ± 26.8% and 41.9 ± 25.4% respectively p < 0.01 for both). 7 RCTs (5251 patients) were eligible. Meta-analysis demonstrated that standard MACE occurs more frequently with PCI than surgery (OR 1.44; 95% CI 1.10 to 1.87; p = 0.007). Re-analysis using patient-centred MACE found no significant difference between PCI and CABG (OR 1.22, 95% CI 0.97 to 1.53; p = 0.10). CONCLUSIONS Patients do not consider the constituent endpoints of MACE equal. We derive a novel patient-centred metric that recognises and quantifies the differences attributed to each endpoint. When patient preference data are applied to contemporary trial results, there is no significant difference between PCI and CABG. Responses from individual patients in clinic could be used to give individual patients a recommendation that is truly personalised.
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Affiliation(s)
- Yousif Ahmad
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Sukhjinder Nijjer
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Christopher M Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Majd El-Harasis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - John Graby
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Ricardo Petraco
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Tushar Kotecha
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Christopher S Baker
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Iqbal S Malik
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Michael F Bellamy
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Amarjit Sethi
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Ghada W Mikhail
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Mahmud Al-Bustami
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Masood Khan
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Raffi Kaprielian
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Rodney A Foale
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Justin E Davies
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Sayan Sen
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK.
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Luscher TF. Acute coronary syndromes and coronary intervention. Eur Heart J 2015; 36:323-4. [DOI: 10.1093/eurheartj/ehu508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Diamond GA. A kinetic model for the integrated assessment of safety and efficacy in clinical trials. Am J Cardiol 2014; 114:1456-63. [PMID: 25200341 DOI: 10.1016/j.amjcard.2014.07.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/24/2014] [Accepted: 07/30/2014] [Indexed: 11/25/2022]
Abstract
Regulatory agencies, professional societies, and clinical trialists commonly base judgments of treatment benefit on separate assessments of efficacy and safety. When separate assessments were compared with an integrated assessment using a kinetic model of a hypothetical randomized trial of antiplatelet agents in patients with acute coronary syndrome, the former showed treatment A to be superior to treatment B, whereas the latter showed treatment B to be superior to treatment A. In conclusion, comparative judgments regarding the balance between efficacy and safety depend on the model chosen for analysis; kinetic models are particularly suited to the integrated assessment of efficacy and safety relative to regulatory decisions, public policy, guideline development, and clinical care.
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