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Carroll J, Lopez Manzano C, Tomlinson E, Sadek A, Cooper C, Jones HE, Rowsell L, Knight J, Mumford A, Palmer R, Hollingworth W, Welton NJ, Whiting P. Clinical and cost-effectiveness of clopidogrel resistance genotype testing after ischaemic stroke or transient ischaemic attack: a systematic review and economic model. Health Technol Assess 2024; 28:1-194. [PMID: 39269241 PMCID: PMC11417645 DOI: 10.3310/pwcb4016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024] Open
Abstract
Background Stroke or transient ischaemic attack patients are at increased risk of secondary vascular events. Antiplatelet medications, most commonly clopidogrel, are prescribed to reduce this risk. Factors including CYP2C19 genetic variants can hinder clopidogrel metabolism. Laboratory-based or point-of-care tests can detect these variants, enabling targeted treatment. Objective To assess the effectiveness of genetic testing to identify clopidogrel resistance in people with ischaemic stroke or transient ischaemic attack. Specific objectives: Do people tested for clopidogrel resistance, and treated accordingly, have a reduced risk of secondary vascular events? Do people with loss-of-function alleles associated with clopidogrel resistance have a reduced risk of secondary vascular events if treated with alternative interventions compared to clopidogrel? Do people with loss-of-function alleles associated with clopidogrel resistance have an increased risk of secondary vascular events when treated with clopidogrel? What is the accuracy of point-of-care tests for detecting variants associated with clopidogrel resistance? What is the technical performance and cost of CYP2C19 genetic tests? Is genetic testing for clopidogrel resistance cost-effective compared with no testing? Design Systematic review and economic model. Results Objective 1: Two studies assessed secondary vascular events in patients tested for loss-of-function alleles and treated accordingly. They found a reduced risk, but confidence intervals were wide (hazard ratio 0.50, 95% confidence interval 0.09 to 2.74 and hazard ratio 0.53, 95% confidence interval 0.24 to 1.18). Objective 2: Seven randomised controlled trials compared clopidogrel with alternative treatment in people with genetic variants. Ticagrelor was associated with a lower risk of secondary vascular events than clopidogrel (summary hazard ratio 0.76, 95% confidence interval 0.65 to 0.90; two studies). Objective 3: Twenty-five studies compared outcomes in people with and without genetic variants treated with clopidogrel. People with genetic variants were at an increased risk of secondary vascular events (hazard ratio 1.72, 95% confidence interval 1.43 to 2.08; 18 studies). There was no difference in bleeding risk (hazard ratio 0.98, 95% confidence interval 0.68 to 1.40; five studies). Objective 4: Eleven studies evaluated Genomadix Cube accuracy; no studies evaluated Genedrive. Summary sensitivity and specificity against laboratory reference standards were both 100% (95% confidence interval 94% to 100% and 99% to 100%). Objective 5: Seventeen studies evaluated technical performance of point-of-care tests. Test failure rate ranged from 0.4% to 19% for Genomadix Cube. A survey of 8/10 genomic laboratory hubs revealed variation in preferred technologies for testing, and cost per test ranging from £15 to £250. Most laboratories expected test failure rate to be < 1%. Additional resources could enhance testing capacity and expedite turnaround times. Objective 6: Laboratory and point-of-care CYP2C19 testing strategies were cost-saving and increase quality-adjusted life-years compared with no testing. Both strategies gave similar costs, quality-adjusted life-years and expected net monetary benefit. Conclusions Our results suggest that CYP2C19 testing followed by tailored treatment is likely to be effective and cost-effective in both populations. Future work Accuracy and technical performance of Genedrive. Test failure rate of Genomadix Cube in a National Health Service setting. Value of testing additional loss-of-function alleles. Appropriateness of treatment dichotomy based on loss-of-function alleles. Limitations Lack of data on Genedrive. No randomised 'test-and-treat' studies of dipyramidole plus aspirin. Study registration This study is registered as PROSPERO CRD42022357661. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135620) and is published in full in Health Technology Assessment; Vol. 28, No. 57. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Joe Carroll
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Catalina Lopez Manzano
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Eve Tomlinson
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ayman Sadek
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Cooper
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Rachel Palmer
- South West NHS Genomic Medicine Service Alliance, UK
| | - William Hollingworth
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny Whiting
- Bristol TAG, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Pan Y, Huo X, Jin A, Nguyen TN, Ma G, Tong X, Zhang X, Gao F, Ma N, Mo D, Ren Z, Wang Y, Miao Z. Cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarct in China. J Neurointerv Surg 2024; 16:453-458. [PMID: 37328189 DOI: 10.1136/jnis-2023-020466] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Endovascular therapy administered within 24 hours has been shown to improve outcomes for patients with acute ischemic stroke with large infarction, but the data on its cost-effectiveness are limited. OBJECTIVE To evaluate the cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarction in China, the largest low- and middle-income country. METHODS A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of endovascular therapy for patients with acute ischemic stroke with large infarction. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and published literature. The benefit of endovascular therapy was assessed by the cost per quality-adjusted life-years (QALYs) gained in the short and long term. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the robustness of the results. RESULTS Compared with medical management alone, endovascular therapy for acute ischemic stroke with large infarction was found to be cost-effective from the fourth year onward and during a lifetime. In the long term, endovascular therapy yielded a lifetime gain of 1.33 QALYs at an additional cost of ¥73 900 (US$ 11 400), resulting in an incremental cost of ¥55 500 (US$ 8530) per QALY gained. Probabilistic sensitivity analysis showed that endovascular therapy was cost-effective in 99.5% of the simulation runs at a willingness-to-pay threshold of ¥243 000 (3 × gross domestic product per capita of China in 2021) per QALY gained. CONCLUSIONS Endovascular therapy for acute ischemic stroke with large infarction could be cost-effective in China.
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Affiliation(s)
- Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Aoming Jin
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Gaoting Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xuelei Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zeguang Ren
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Yongjun Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
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Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 PMCID: PMC11179775 DOI: 10.1161/jaha.123.032808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
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Affiliation(s)
- Paul M. Wechsler
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ankur Pandya
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Neal S. Parikh
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Junaid A. Razzak
- Department of Emergency MedicineWeill Cornell MedicineNew YorkNY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Babak B. Navi
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ava L. Liberman
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
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Zhang Z, Bao Y, Gu Y, Zhang M, Li X. Cost-effectiveness analysis of CYP2C19 genotype-guided antiplatelet therapy for patients with acute minor ischemic stroke and high-risk transient ischemic attack in China. Br J Clin Pharmacol 2024; 90:483-492. [PMID: 37795861 DOI: 10.1111/bcp.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/03/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023] Open
Abstract
AIMS The study aimed to estimate the cost-effectiveness of CYP2C19 genotype-guided antiplatelet therapy using cilostazol and ticagrelor as an alternative to clopidogrel, compared to conventional antiplatelet therapy with clopidogrel and aspirin. METHODS A 90-day decision tree and 30-year Markov model were employed to assess the costs and quality-adjusted life years (QALYs) of personalized antiplatelet therapy for patients with minor ischemic stroke and high-risk transient ischemic attack, compared to conventional antiplatelet therapy in the Chinese healthcare system. The primary outcome was the incremental cost-effectiveness ratio (ICER). The data sources included clinical trials, published literature, official documents and local prices. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to confirm the robustness of the findings. RESULTS The base-case analysis indicated that the CYP2C19 genotype-guided antiplatelet strategy was cost-effective, and cilostazol group and ticagrelor group yielded an ICER of 3327.40 US dollars (USD)/QALY and 3426.92 USD/QALY, respectively, which were less than threshold. The one-way sensitivity analysis showed the results were robust, where the most sensitive parameter was the disability distribution in the modified Rankin scale 3-5. The probabilistic analysis showed that the CYP2C19 genotype-guided antiplatelet therapy with either cilostazol or ticagrelor was 100% cost-effective under the willingness-to-pay threshold. CONCLUSIONS CYP2C19 genotype-guided antiplatelet therapy using cilostazol and ticagrelor as an alternative to clopidogrel appeared to be more cost-effective than conventional antiplatelet therapy for acute minor ischemic stroke and high-risk transient ischemic attack patients over 30 years in China.
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Affiliation(s)
- Zhuolin Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Yuwen Bao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Yajie Gu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Mengdie Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Xin Li
- School of Pharmacy, Nanjing Medical University, Nanjing, China
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
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Chen P, Luo M, Chen Y, Zhang Y, Wang C, Li H. Cost-effectiveness of edaravone dexborneol versus human urinary kallidinogenase for acute ischemic stroke in China. HEALTH ECONOMICS REVIEW 2024; 14:7. [PMID: 38285185 PMCID: PMC10823610 DOI: 10.1186/s13561-024-00479-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Clinical trials have demonstrated the efficacy of edaravone dexborneol in the treatment of acute ischemic stroke. This study aims to determine the cost-effectiveness of edaravone dexborneol compared with human urinary kallidinogenase from China's healthcare system perspective. METHODS A combination of the decision tree and Markov model was constructed to evaluate the cost-effectiveness of edaravone dexborneol versus human urinary kallidinogenase in the treatment of acute ischemic stroke over a lifetime horizon. Efficacy data were derived from pivotal clinical trials of edaravone dexborneol and human urinary kallidinogenase (TASTE trial and RESK trial, respectively) and adjusted using matching-adjusted indirect comparison. Cost and health utility inputs were extracted from published literature and open databases. One-way deterministic sensitivity and probabilistic sensitivity analyses were performed to examine the robustness of the results. RESULTS Compared with human urinary kallidinogenase, edaravone dexborneol generated 0.153 incremental quality-adjusted life years (QALYs) with an incremental cost of ¥856, yielding an incremental cost-effectiveness ratio of ¥5,608 per QALY gained under the willingness-to-pay threshold (one-time gross domestic product per capita). Both one-way deterministic sensitivity analysis and probabilistic sensitivity analysis demonstrated the robustness of the base case results. CONCLUSIONS Edaravone dexborneol is a cost-effective treatment choice for acute ischemic stroke patients compared with human urinary kallidinogenase in China.
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Affiliation(s)
- Pingyu Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, 639 Longmian Road, Jiangning District, Nanjing, 211198, Jiangsu Province, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Mengjie Luo
- School of International Pharmaceutical Business, China Pharmaceutical University, 639 Longmian Road, Jiangning District, Nanjing, 211198, Jiangsu Province, China
| | - Yanqiu Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, 639 Longmian Road, Jiangning District, Nanjing, 211198, Jiangsu Province, China
| | - Yanlei Zhang
- State Key Laboratory of Neurology and Oncology Drug Development (Jiangsu Simcere Pharmaceutical Co.,Ltd., Jiangsu Simcere Diagnostics Co.,Ltd.), Nanjing, Jiangsu, China
| | - Chao Wang
- State Key Laboratory of Neurology and Oncology Drug Development (Jiangsu Simcere Pharmaceutical Co.,Ltd., Jiangsu Simcere Diagnostics Co.,Ltd.), Nanjing, Jiangsu, China
| | - Hongchao Li
- School of International Pharmaceutical Business, China Pharmaceutical University, 639 Longmian Road, Jiangning District, Nanjing, 211198, Jiangsu Province, China.
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China.
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Micieli A, Singh N, Jahn B, Siebert U, Menon BK, Demchuk AM. Cost-effectiveness of testing for CYP2C19 loss-of-function carriers following transient ischemic attack/minor stroke: A Canadian perspective. Int J Stroke 2023; 18:416-425. [PMID: 35739635 DOI: 10.1177/17474930221111898] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The CHANCE-2 study compared 3 weeks of aspirin-ticagrelor to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers following a transient ischemic attack (TIA)/minor stroke and demonstrated a modestly lower risk of stroke recurrence with aspirin-ticagrelor. This stroke protection was largely for minor stroke and came at an increased risk of bleeding. The cost-effectiveness of implementing testing for LOF allele status to personalize antiplatelet regimen for secondary stroke prevention after a TIA/minor stroke in the Canadian health care context is unknown. METHODS Cost-effectiveness analysis using a decision-analytic Markov cohort model with a lifetime horizon was performed to determine the costs and health benefits of testing for LOF allele status compared with no testing (current standard of care). The population of interest was patients living in Canada who suffered a TIA/minor stroke. Outcomes of interest were life-years gained (LYG), quality-adjusted life years (QALY) gained, costs (reported in 2022 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). We adopted the perspective of the Federal, Provincial, and Territorial Ministries of Health and used a 1.5% annual discount rate. Sensitivity analyses were performed to assess uncertainty. RESULTS Compared to standard of care, LOF allele testing leads to 0.14 LYG (undiscounted), 0.12 QALYs gained (undiscounted), and additional lifetime costs of CAD$432 (discounted) per patient. The ICER of the LOF allele testing strategy is CAD$4310 per QALY gained compared with standard of care. The probabilistic sensitivity analyses demonstrated that LOF allele testing was cost-effective in more than 99.99% of simulations using a willingness-to-pay threshold of CAD$50,000 per QALY. CONCLUSION Based on available evidence, testing for LOF allele followed by short duration 3 weeks of aspirin-ticagrelor compared to standard-of-care aspirin-clopidogrel can lead to prolonged life and improved quality of life and can be considered very cost-effective when compared with other well-accepted technologies in health and medicine.
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Affiliation(s)
- Andrew Micieli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Beate Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Wechsler PM, Liberman AL, Restifo D, Abramson EL, Navi BB, Kamel H, Parikh NS. Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack. Stroke 2023; 54:992-1000. [PMID: 36866670 PMCID: PMC10050136 DOI: 10.1161/strokeaha.122.040356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population. METHODS We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty. RESULTS From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs. CONCLUSIONS For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.
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Affiliation(s)
- Paul M Wechsler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel Restifo
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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Pomero F, Galli E, Bellesini M, Maroni L, Squizzato A. P2Y12 inhibitors plus aspirin for acute treatment and secondary prevention in minor stroke and high-risk transient ischemic attack: A systematic review and meta-analysis. Eur J Intern Med 2022; 100:46-55. [PMID: 35331593 DOI: 10.1016/j.ejim.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging. OBJECTIVE This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA. METHODS A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach. RESULTS Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis. CONCLUSIONS Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy
| | - Eleonora Galli
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
| | - Marta Bellesini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Lorenzo Maroni
- Department of General Medicine, Hypertension Dyslipidemia and Cardiovascular Risk Clinic, ASST Valle Olona, Sant'Antonio Abate Hospital, Via Eusebio Pastori, 21013 Gallarate, VA, Italy; Ospedale di Circolo, Via Arnaldo da Brescia 1, 21052 Busto Arsizio, VA, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
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Han M, Qin Y, Tong X, Ji L, Zhao S, Liu L, Chen J, Liu A. Cost-effective analysis of mechanical thrombectomy alone in the treatment of acute ischaemic stroke: a Markov modelling study. BMJ Open 2022; 12:e059098. [PMID: 35387833 PMCID: PMC8987747 DOI: 10.1136/bmjopen-2021-059098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Recently, a randomised controlled trial (DIRECT-MT) demonstrated that mechanical thrombectomy (MT) was non-inferior to MT with intravenous alteplase as to the functional outcomes. This study aims to investigate whether MT alone is cost-effective compared with MT with alteplase in China. METHODS A Markov decision analytic model was built from the Chinese healthcare perspective using a lifetime horizon. Probabilities, costs and outcomes data were obtained from the DIRECT-MT trial and other most recent/comprehensive literature. Base case calculation was conducted to compare the costs and effectiveness between MT alone and MT with alteplase. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the results. RESULTS MT alone had a lower cost and higher effectiveness compared with MT with alteplase. The probabilistic sensitivity analysis demonstrated that, over a lifetime horizon, MT alone had a 99.5% probability of being cost-effective under the willingness-to-pay threshold of 1× gross domestic product per capita in China based on data obtained from the DIRECT-MT trial. These results remained robust under one-way sensitivity analysis. CONCLUSIONS MT alone was cost-effective compared with MT with alteplase in China. However, cautions are needed to extend this conclusion to regions outside of China.
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Affiliation(s)
- Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Yongkai Qin
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Linjin Ji
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Songfeng Zhao
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Lang Liu
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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Chen J, Ji L, Tong X, Han M, Zhao S, Qin Y, He Z, Jiang Z, Liu A. Economic Evaluation of Ticagrelor Plus Aspirin Versus Aspirin Alone for Acute Ischemic Stroke and Transient Ischemic Attack. Front Pharmacol 2022; 13:790048. [PMID: 35370758 PMCID: PMC8971565 DOI: 10.3389/fphar.2022.790048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Although ticagrelor plus aspirin is more effective than aspirin alone in preventing the 30-day risk of a composite of stroke or death in patients with an acute mild-to-moderate ischemic stroke (IS) or transient ischemic attack (TIA), the cost-effectiveness of this combination therapy remains unknown. This study aims to determine the cost-effectiveness of ticagrelor plus aspirin compared with aspirin alone. Methods: A combination of decision tree and Markov model was built to estimate the expected costs and quality-adjusted life-years (QALYs) associated with ticagrelor plus aspirin and aspirin alone in the treatment of patients with an acute mild-to-moderate IS or TIA. Model inputs were extracted from published sources. One-way sensitivity, probabilistic sensitivity, and subgroup analyses were performed to test the robustness of the findings. Results: Compared with aspirin alone, ticagrelor plus aspirin gained an additional lifetime QALY of 0.018 at an additional cost of the Chinese Yuan Renminbi (¥) of 269, yielding an incremental cost-effectiveness ratio of ¥15,006 (US$2,207)/QALY. Probabilistic sensitivity analysis showed that ticagrelor plus aspirin had a probability of 99.99% being highly cost-effective versus aspirin alone at the current willingness-to-pay threshold of ¥72,447 (US$10,500)/QALY in China. These findings remain robust under one-way sensitivity and subgroup analyses. Conclusions: The results indicated that early treatment with a 30-days ticagrelor plus aspirin for an acute mild-to-moderate IS or TIA is highly cost-effective in a Chinese setting.
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Affiliation(s)
- Jigang Chen
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Linjin Ji
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Songfeng Zhao
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yongkai Qin
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zilong He
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhiqun Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Aihua Liu, ; Zhiqun Jiang,
| | - Aihua Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China NationalClinical Research Centre for Neurological Diseases, Beijing, China
- *Correspondence: Aihua Liu, ; Zhiqun Jiang,
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Chen J, Tong X, Feng X, Peng F, Niu H, Han M, Liu L, Zhao Y, Wang D, Pan Y, Liu A. Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data. Front Neurol 2022; 12:736127. [PMID: 35153970 PMCID: PMC8830354 DOI: 10.3389/fneur.2021.736127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Unruptured small aneurysms with a size of <7 mm were often followed conservatively. However, it is unknown whether unruptured small multiple intracranial aneurysms (MIAs) are better to be prophylactically treated or conservatively followed. Objective We aim to compare the effectiveness of different strategies regarding their management. Methods A decision-analytic Markov model was built over a entire life cycle. The compared strategies include natural history, treat one aneurysm, treat both aneurysms, annual follow-up, biennial follow-up, and follow-up every 5 years. The inputs for the model were obtained from real-world data and related medical literature. Outcomes were measured in terms of quality-adjusted life-years (QALYs). Results Treat both aneurysms had the highest effectiveness of 15.36 QALYs and treat one aneurysm had the second-highest effectiveness of 15.11 QALYs. Probabilistic sensitivity analysis with 10,000 iterations showed that treat both aneurysms and treat one aneurysm were optimal in 67.28 and 17.91% of all cases, respectively. One-way and two-way sensitivity analyses showed that the result was sensitive to the proportion of moderate to severe disability after treating two aneurysms, mortality after treating two aneurysms, proportion of moderate to severe disability after treating one aneurysm, and rupture rate of small growing aneurysm. Either treat both aneurysms or treat one aneurysm would be the optimal strategy under most of the circumstances with the variations of these parameters. Conclusion For patients with small unruptured MIAs, prophylactic coiling was superior to conservative management and at least one aneurysm should be treated.
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Affiliation(s)
- Jigang Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Feng
- Department of Neurosurgery, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Fei Peng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Niu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lang Liu
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuanli Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Daming Wang
- Department of Neurosurgery, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- *Correspondence: Aihua Liu
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Cheng J, Zhang Y, Zhong A, Tian M, Zou G, Chen X, Yu H, Song F, Zhou S. Quality of Health Economic Evaluations in Mainland China: A Comparison of Peer-Reviewed Articles in Chinese and in English. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:35-54. [PMID: 34322862 DOI: 10.1007/s40258-021-00674-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Our objective was to assess the incidence and quality of reporting of published health economic evaluations in mainland China and compare the quality of peer-reviewed articles in Chinese and English. METHODS A comprehensive search was conducted for economic evaluations pertaining to China published from 2006 to 2015 using the PubMed, CBM, CMCC, CNKI, VIP, and Wanfang databases. All studies in English that met the inclusion criteria were included. For studies in Chinese, 200 sampled studies were included according to the random seeds method, and the same number of the most-cited studies in Chinese as those in English were included according to the number of citations and journal grades. Researchers independently assessed the quality of the studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS After literature search and screening, a total of 310 studies were identified. The majority of these studies were cost-effectiveness studies (82.26%). Scores among different CHEERS items varied greatly. There was a gap between the average quality scores of the studies published in Chinese and those published in English (49.78 ± 9.31 vs. 82.48 ± 17.69) and between the average quality scores of the included most-cited studies in Chinese and English, which was slightly smaller (54.08 ± 10.27 vs. 82.48 ± 17.69). The methods, results, and discussion sections of studies published in Chinese were of low quality. CONCLUSION The quality of reporting of health economic evaluations in mainland China has developed slowly. Most of the included studies were incomplete in the presentation of content, making the results less reliable. It is important to standardize and improve the quality of Chinese health economic research.
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Affiliation(s)
- Jiehua Cheng
- School of Public Health and Management, Higher Education Mega Centre, Guangzhou University of Chinese Medicine, No. 232 Wai Huan Dong Road, Panyu District, Guangzhou, 510006, Guangdong, China
| | - Yu Zhang
- School of Public Health and Management, Higher Education Mega Centre, Guangzhou University of Chinese Medicine, No. 232 Wai Huan Dong Road, Panyu District, Guangzhou, 510006, Guangdong, China
| | - Ailin Zhong
- School of Public Health and Management, Higher Education Mega Centre, Guangzhou University of Chinese Medicine, No. 232 Wai Huan Dong Road, Panyu District, Guangzhou, 510006, Guangdong, China
| | - Miao Tian
- Dongfeng Stomatological Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Guanyang Zou
- School of Public Health and Management, Higher Education Mega Centre, Guangzhou University of Chinese Medicine, No. 232 Wai Huan Dong Road, Panyu District, Guangzhou, 510006, Guangdong, China
| | - Xiaping Chen
- Shiyan Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Hongxing Yu
- Shiyan Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Fujian Song
- Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Shangcheng Zhou
- School of Public Health and Management, Higher Education Mega Centre, Guangzhou University of Chinese Medicine, No. 232 Wai Huan Dong Road, Panyu District, Guangzhou, 510006, Guangdong, China.
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Tornyos D, Bálint A, Kupó P, El Abdallaoui OEA, Komócsi A. Antithrombotic Therapy for Secondary Prevention in Patients with Non-Cardioembolic Stroke or Transient Ischemic Attack: A Systematic Review. Life (Basel) 2021; 11:447. [PMID: 34063551 PMCID: PMC8156895 DOI: 10.3390/life11050447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/23/2022] Open
Abstract
Stroke embodies one of the leading causes of death and disability worldwide. We aimed to provide a comprehensive insight into the effectiveness and safety of antiplatelet agents and anticoagulants in the secondary prevention of ischemic stroke or transient ischemic attack. A systematic search for randomized controlled trials, comparing antiplatelet or anticoagulant therapy versus aspirin or placebo among patients with ischemic stroke or transient ischemic attack, was performed in order to summarize data regarding the different regimens. Keyword-based searches in the MEDLINE, EMBASE, and Cochrane Library databases were conducted until the 1st of January 2021. Our search explored 46 randomized controlled trials involving ten antiplatelet agents, six combinations with aspirin, and four anticoagulant therapies. The review of the literature reflects that antiplatelet therapy improves outcome in patients with ischemic stroke or transient ischemic attack. Monotherapy proved to be an effective and safe choice, especially in patients with a high risk of bleeding. Intensified antiplatelet regimens further improve stroke recurrence; however, bleeding rate increases while mortality remains unaffected. Supplementing the clinical judgment of stroke treatment, assessment of bleeding risk is warranted to identify patients with the highest benefit of treatment intensification.
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Affiliation(s)
| | | | | | | | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Ifjúság útja 13, 7624 Pécs, Hungary; (D.T.); (A.B.); (P.K.); (O.E.A.E.A.)
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Cost-effectiveness of CYP2C19 genotyping to guide antiplatelet therapy for acute minor stroke and high-risk transient ischemic attack. Sci Rep 2021; 11:7383. [PMID: 33795788 PMCID: PMC8016871 DOI: 10.1038/s41598-021-86824-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/12/2021] [Indexed: 02/05/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin within 48 h of acute minor strokes and transient ischemic attacks (TIAs) has been indicated to effectively reduce the rate of recurrent strokes. However, the efficacy of clopidogrel has been shown to be affected by cytochrome P450 2C19 (CYP2C19) polymorphisms. Patients carrying loss-of-function alleles (LoFAs) at a low risk of recurrence (ESRS < 3) cannot benefit from clopidogrel plus aspirin at all and may have an increased bleeding risk. In order to optimize antiplatelet therapy for these patients and avoid the waste of medical resources, it is important to identify the subgroups that genuinely benefit from DAPT with clopidogrel plus aspirin through CYP2C19 genotyping. This study sought to assess the cost-effectiveness of CYP2C19 genotyping to guide drug therapy for acute minor strokes or high-risk TIAs in China. A decision tree and Markov model were constructed to evaluate the cost-effectiveness of CYP2C19 genotyping. We used a healthcare payer perspective, and the primary outcomes included quality-adjusted life years (QALYs), costs and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to evaluate the robustness of the results. CYP2C19 genotyping resulted in a lifetime gain of 0.031 QALYs at an additional cost of CNY 420.13 (US$ 59.85), yielding an ICER of CNY 13,552.74 (US$ 1930.59) per QALY gained. Probabilistic sensitivity analysis showed that genetic testing was more cost-effective in 95.7% of the simulations at the willingness-to-pay threshold of CNY 72,100 (GDP per capita, US$ 10,300) per QALY. Therefore, CYP2C19 genotyping to guide antiplatelet therapy for acute minor strokes and high-risk TIAs is highly cost-effective in China.
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Pan Y, Zhang L, Li Z, Meng X, Wang Y, Li H, Liu L, Wang Y. Cost-Effectiveness of a Multifaceted Quality Improvement Intervention for Acute Ischemic Stroke in China. Stroke 2020; 51:1265-1271. [PMID: 32019480 DOI: 10.1161/strokeaha.119.027980] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Multifaceted quality improvement interventions of stroke care have been shown to improve hospital personnel adherence to evidence-based performance measures and subsequent stroke outcomes. This study aimed to evaluate the cost-effectiveness of a multifaceted quality improvement intervention for stroke care in China, the world's largest low- and middle-income country. Methods- A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of a multifaceted quality improvement intervention for patients with acute ischemic stroke. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and the published literature. The benefit of the intervention was assessed by the costs per quality-adjusted life-years gained in the short- and long-term. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the findings. Results- Compared with usual care, a multifaceted quality improvement intervention for stroke care was found to be cost-effective in the first year and highly cost-effective from the second year onward. In the long-term, the intervention yielded a lifetime gain of 0.246 quality-adjusted life-years at an additional cost of Chinese Yuan Renminbi 1510 (US $230), resulting in a cost of Chinese Yuan Renminbi 6138 (US $940) per quality-adjusted life-year gained. Probabilistic sensitivity analysis indicated that the intervention was highly cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of Chinese Yuan Renminbi 59 700 (1× gross domestic product per capita of China in 2017, US $9200) per quality-adjusted life-year. Conclusions- A multifaceted quality improvement intervention for stroke care was highly cost-effective in China. The results of this study may be used as a reference for delivering such interventions in low- and middle-income countries and in underserved areas of high-income countries.
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Affiliation(s)
- Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Lei Zhang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,Changping District Hospital, Beijing, China (L.Z.)
| | - Zixiao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.).,China National Clinical Research Centre for Neurological Diseases, Beijing (Y.P., L.Z., Z.L., X.M., Y.W., H.L., L.L., Y.W.)
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Cha YH, Lee YK, Koo KH, Wi C, Lee KH. Difference in Mortality Rate by Type of Anticoagulant in Elderly Patients with Cardiovascular Disease after Hip Fractures. Clin Orthop Surg 2019; 11:15-20. [PMID: 30838103 PMCID: PMC6389530 DOI: 10.4055/cios.2019.11.1.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 12/26/2022] Open
Abstract
Background The purpose of this study was to investigate the difference in mortalilty rate between cardiovascular disease (CVD) patients and non-CVD patients after hip fracture surgery performed in elderly patients. In addition, we compared the effect of CVD medication on mortality after hip fracture surgery. Methods Patients who underwent surgery for femoral intertrochanteric or neck fracture from January 2003 to December 2013 were enrolled in this study. After applying exclusion criteria, we categorized patients into group I (833 patients, non-CVD group) and group II (811 patients, CVD group). The CVD group was subcategorized as group IIa (332 patients, no medication), group IIb (381 patients, antiplatelet agents), and group IIc (98 patients, anticoagulation agents). Cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year were compared between the groups. Results In the 1,644 patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.1%, 0.5%, 0.7%, and 8.2%, respectively, in group I and 1.0%, 1.6%, 2.5%, and 8.8%, respectively, in group II (p = 0.02, p = 0.03. p = 0.01, and p = 0.72, respectively). In the 811 group II patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.3%, 0.6%, 1.2%, and 6.6%, respectively, in group IIa; 0.8%, 1.6%, 2.1%, and 9.4%, respectively, in group IIb; and 4.1%, 5.1%, 8.2%, and 13.3%, respectively, in group IIc (p = 0.003, p = 0.01, p = 0.004, and p = 0.10, respectively). Conclusions CVD increases short-term mortality within 30 days, 60 days, and 3 months in elderly hip fracture patients. The use of anticoagulants in CVD patients increases the rate of surgical delay and short-term mortality within 30 days, 60 days, and 3 months.
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Affiliation(s)
- Yong-Han Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chankuk Wi
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
| | - Kyung-Hag Lee
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
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Sung PH, Lin HS, Lin WC, Chang CC, Pei SN, Ma MC, Chen KH, Chiang JY, Chang HW, Lee FY, Lee MS, Yip HK. Intra-carotid arterial transfusion of autologous circulatory derived CD34+ cells for old ischemic stroke patients - a phase I clinical trial to evaluate safety and tolerability. Am J Transl Res 2018; 10:2975-2989. [PMID: 30323884 PMCID: PMC6176223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
This phase I clinical trial tested the hypothesis that circulatory CD34+ cell therapy might be safe for old ischemic stroke (IS) (defined as IS>6 months) patients and also to evaluate the neurological function after the therapy. Nine old IS patients (with mean IS interval: 8.6 ± 6.4 years) were consecutively enrolled and received intra-carotid artery transfusion of circulatory-derived autologous CD34+ cells (3.0×107 cells/patient) into the ipsilateral brain infarct area at catheterization room by Catheter Looping Technique, after subcutaneous G-CSF injection (5 μg/kg twice a day for 4 days). The results showed that procedural safety was 100% with all patients uneventfully discharged. The circulating number of EPCs and angiogenesis (i.e., by Matrigel assay) were significantly higher at post than at prior to G-CSF treatment (all P<0.001). Time courses (0/5/10/30 minutes) of blood samplings from right-internal jugular vein exhibited significantly increased in levels of SDF-1α and EPCs numbers in time points of 5/10/30 minutes than in the baseline (0 minute) (all P<0.05). Barthel index was increased (defined as ≥5 scores) in 44.4% (4/9) and CASI score was notably improved (all P<0.01) at 6-month follow-up after the cell therapy as compared to the baseline. No recurrent IS or any tumorigenesis was found in these patients with a mean follow-up time interval of 16.5 ± 6.2 months. All of these patients remain survive and are followed up at outpatient department. In conclusion, CD34+ cell therapy is safe and might offer some benefit to old IS patients.
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Affiliation(s)
- Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial HospitalKaohsiung, Taiwan
| | - Hung-Sheng Lin
- Department of Neurology, Cognition and Aging Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Cognition and Aging Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Sung-Nan Pei
- Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Ming-Chun Ma
- Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - John Y Chiang
- Department of Computer Science and Engineering, National Sun Yat-Sen UniversityKaohsiung, Taiwan
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical UniversityKaohsiung, Taiwan
| | - Hsueh-Wen Chang
- Department of Biological Sciences, National Sun Yat-Sen UniversityKaohsiung, Taiwan
| | - Fan-Yen Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical CenterKaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiung, Taiwan
| | - Hon-Kan Yip
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial HospitalKaohsiung, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical UniversityTaichung, Taiwan
- Department of Nursing, Asia UniversityTaichung, Taiwan
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18
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Ding L, Peng B. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a systematic review and meta‐analysis. Eur J Neurol 2018; 25:1276-1284. [PMID: 29855121 DOI: 10.1111/ene.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- L. Ding
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - B. Peng
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
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19
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Aminde LN, Takah NF, Zapata-Diomedi B, Veerman JL. Primary and secondary prevention interventions for cardiovascular disease in low-income and middle-income countries: a systematic review of economic evaluations. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:22. [PMID: 29983644 PMCID: PMC6003072 DOI: 10.1186/s12962-018-0108-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/09/2018] [Indexed: 12/12/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of deaths globally, with greatest premature mortality in the low- and middle-income countries (LMIC). Many of these countries, especially in sub-Saharan Africa, have significant budget constraints. The need for current evidence on which interventions offer good value for money to stem this CVD epidemic motivates this study. Methods In this systematic review, we included studies reporting full economic evaluations of individual and population-based interventions (pharmacologic and non-pharmacologic), for primary and secondary prevention of CVD among adults in LMIC. Several medical (PubMed, EMBASE, SCOPUS, Web of Science) and economic (EconLit, NHS EED) databases and grey literature were searched. Screening of studies and data extraction was done independently by two reviewers. Drummond’s checklist and the National Institute for Health and Care Excellence quality rating scale were used in the quality appraisal for all studies used to inform this evidence synthesis. Results From a pool of 4059 records, 94 full texts were read and 50 studies, which met our inclusion criteria, were retained for our narrative synthesis. Most of the studies were from middle-income countries and predominantly of high quality. The majority were modelled evaluations, and there was significant heterogeneity in methods. Primary prevention studies dominated secondary prevention. Most of the economic evaluations were performed for pharmacological interventions focusing on blood pressure, cholesterol lowering and antiplatelet aggregants. The greatest majority were cost-effective. Compared to individual-based interventions, population-based interventions were few and mostly targeted reduction in sodium intake and tobacco control strategies. These were very cost-effective with many being cost-saving. Conclusions This evidence synthesis provides a contemporary update on interventions that offer good value for money in LMICs. Population-based interventions especially those targeting reduction in salt intake and tobacco control are very cost-effective in LMICs with potential to generate economic gains that can be reinvested to improve health and/or other sectors. While this evidence is relevant for policy across these regions, decision makers should additionally take into account other multi-sectoral perspectives, including considerations in budget impact, fairness, affordability and implementation while setting priorities for resource allocation. Electronic supplementary material The online version of this article (10.1186/s12962-018-0108-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leopold Ndemnge Aminde
- 1Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, QLD 4006 Australia.,Non-communicable Diseases Unit, Clinical Research Education, Network & Consultancy, Douala, Cameroon
| | | | - Belen Zapata-Diomedi
- 1Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, QLD 4006 Australia
| | - J Lennert Veerman
- 1Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, QLD 4006 Australia.,4School of Medicine, Griffith University, Gold Coast, QLD 4222 Australia.,5Cancer Research Division, Cancer Council NSW, Woolloomooloo, NSW 2011 Australia
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20
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Pan Y, Cai X, Huo X, Zhao X, Liu L, Wang Y, Miao Z, Wang Y. Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China. BMJ Open 2018; 8:e018951. [PMID: 29472264 PMCID: PMC5855394 DOI: 10.1136/bmjopen-2017-018951] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/29/2017] [Accepted: 01/17/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country. DESIGN A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results. SETTING Hospitals in China. PARTICIPANTS The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours. INTERVENTIONS Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone. OUTCOME MEASURES The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years). RESULTS The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY. CONCLUSIONS Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xueli Cai
- Department of Neurology, Lishui Hospital of Zhejiang University (the Central Hospital of Lishui), Lishui, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Centre of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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21
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Chen KH, Chen CH, Wallace CG, Yuen CM, Kao GS, Chen YL, Shao PL, Chen YL, Chai HT, Lin KC, Liu CF, Chang HW, Lee MS, Yip HK. Intravenous administration of xenogenic adipose-derived mesenchymal stem cells (ADMSC) and ADMSC-derived exosomes markedly reduced brain infarct volume and preserved neurological function in rat after acute ischemic stroke. Oncotarget 2018; 7:74537-74556. [PMID: 27793019 PMCID: PMC5342685 DOI: 10.18632/oncotarget.12902] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/14/2016] [Indexed: 12/16/2022] Open
Abstract
We tested the hypothesis that combined xenogenic (from mini-pig) adipose-derived mesenchymal stem cell (ADMSC) and ADMSC-derived exosome therapy could reduce brain-infarct zone (BIZ) and enhance neurological recovery in rat after acute ischemic stroke (AIS) induced by 50-min left middle cerebral artery occlusion. Adult-male Sprague-Dawley rats (n = 60) were divided equally into group 1 (sham-control), group 2 (AIS), group 3 [AIS-ADMSC (1.2×106 cells)], group 4 [AIS-exosome (100μg)], and group 5 (AIS-exosome-ADMSC). All therapies were provided intravenously at 3h after AIS procedure. BIZ determined by histopathology (by day-60) and brain MRI (by day-28) were highest in group 2, lowest in group 1, higher in groups 3 and 4 than in group 5, but they showed no difference between groups 3 and 4 (all p < 0.0001). By day-28, sensorimotor functional results exhibited an opposite pattern to BIZ among the five groups (p < 0.005). Protein expressions of inflammatory (inducible nitric oxide synthase/tumor necrosis factor-α/nuclear factor-κB/interleukin-1β/matrix metalloproteinase-9/plasminogen activator inhibitor-1/RANTES), oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptotic (caspase-3/ Poly-ADP-ribose polymerase), and fibrotic (Smad3/transforming growth factor-β) biomarkers, and cellular expressions of brain-damaged (γ-H2AX+/ XRCC1-CD90+/p53BP1-CD90+), inflammatory (CD11+/CD68+/glial fibrillary acid protein+) and brain-edema (aquaporin-4+) markers showed a similar pattern of BIZ among the groups (all n < 0.0001). In conclusion, xenogenic ADMSC/ADMSC-derived exosome therapy was safe and offered the additional benefit of reducing BIZ and improving neurological function in rat AIS.
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Affiliation(s)
- Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Chih-Hung Chen
- Department of Internal Medicine, Division of General Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Chun-Man Yuen
- Department of Surgery, Division of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Gour-Shenq Kao
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Ling Chen
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Lin Shao
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Yung-Lung Chen
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Han-Tan Chai
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kun-Chen Lin
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chu-Feng Liu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsueh-Wen Chang
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hon-Kan Yip
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Nursing, Asia University, Taichung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
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22
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Fang YN, Tong MS, Sung PH, Chen YL, Chen CH, Tsai NW, Huang CJ, Chang YT, Chen SF, Chang WN, Lu CH, Yip HK. Higher neutrophil counts and neutrophil-to-lymphocyte ratio predict prognostic outcomes in patients after non-atrial fibrillation-caused ischemic stroke. Biomed J 2017; 40:154-162. [PMID: 28651737 PMCID: PMC6136280 DOI: 10.1016/j.bj.2017.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 02/21/2017] [Accepted: 03/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background We aimed to determine whether higher neutrophil counts (NC) and neutrophil-to-lymphocyte ratio (NLR) were independently predictive of worse in-hospital outcome in patients after acute ischemic stroke (IS). Methods A retrospective observational study with prospective manner of IS registration. Between April 2012 and August 2014, a total number of 1731 patients with post-IS were consecutively enrolled in the study. Blood samples were drawn upon admission. Primary endpoint was in-hospital mortality. Secondary endpoint was severe stroke (≥16 NIHSS). Results The NC progressively increased from mild (NIHSS ≤ 5) to moderate (NIHSS ≥ 6 < 16) and severe (NIHSS ≥ 16) stroke (p = 0.006). NLR was independently associated with in-hospital mortality (p = 0.002). Multiple stepwise linear regression analysis showed that NC (p = 0.001) and NLR (p = 0.002) were independently predictive of higher NIHSS. Multiple stepwise logistic regression analysis showed that NC was independently associated with severe stroke (p < 0.0001). The best discriminating factor for in-hospital mortality with respect to NLR was ≥3.20 (sensitivity 62.7%, specificity 60.3%, likelihood ratio: 12.2). Patients with NLR ≥3.20 had a 2.55-fold increased risk for in-hospital mortality (OR = 1.49–4.37) compared to patients with NLR <3.20. The best discriminating factor for severe stroke (≥16 NIHSS) with respect to NC was ≥74% (sensitivity 47.1%, specificity 74.0%, likelihood ratio: 29.0). Patients with NC >74% had a 2.54-fold increased risk of severe stroke (OR = 1.82–3.54) compared to patients with NC <74%. Conclusion NLR was independently associated with in-hospital mortality and higher NC was independently predictive of severe stroke.
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Affiliation(s)
- Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Shen Tong
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hung Chen
- Division of General Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Nei-Wen Tsai
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Jen Huang
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ya-Ting Chang
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shu-Fang Chen
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Neng Chang
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan; Department of Nursing, Asia University, Taichung, Taiwan.
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23
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Yuen CM, Yeh KH, Wallace CG, Chen KH, Lin HS, Sung PH, Chai HT, Chen YL, Sun CK, Chen CH, Kao GS, Ko SF, Yip HK. EPO-cyclosporine combination therapy reduced brain infarct area in rat after acute ischemic stroke: role of innate immune-inflammatory response, micro-RNAs and MAPK family signaling pathway. Am J Transl Res 2017; 9:1651-1666. [PMID: 28469772 PMCID: PMC5411915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/01/2017] [Indexed: 06/07/2023]
Abstract
This study tested the hypothesis that erythropoietin (EPO) and cyclosporine (CsA) could effectively reduce brain infarct area (BIA) in rat after acute ischemic stroke (AIS) through regulating inflammation, oxidative stress, MAPK family signaling and microRNA (miR-223/miR-30a/miR-383). Adult male Sprague-Dawley rats (n = 48) were equally divided into group 1 (sham control), group 2 (AIS), group 3 [AIS+EPO (5,000 IU/kg at 0.5/24/48 h, subcutaneous)] and group 4 [AIS+CsA (20.0 mg/kg at 0.5/24/48 h, intra-peritoneal)]. By 72 h, histopathology showed that BIA was largest in group 2 and smallest in group 1, and significantly larger in group 4 than group 3 (all P<0.0001). The three microRNAs expressed were higher in group 2 than in the other three groups (all P<0.04); between these three latter groups there were no significant differences. The protein expressions of MAPK family [phosphorylated (p)-ERK1/2, p-p38/p-JNK], inflammatory (iNOS/MMP-9/TNF-α/NF-κB/IL-12/MIP-1α/CD14/CD68/Ly6g), apoptotic (caspase-3/PARP/mitochondrial-Bax), oxidative-stress (NOX-1/NOX-2/oxidized protein) and mitochondrial-damaged (cytosolic cytochrome-C) biomarkers exhibited an identical pattern to BIA findings (all P<0.0001). The cellular expressions of brain edema (AQP4+), inflammation (CD11+/glial-fibrillary-acid protein+), and cellular damage (TUNEL assay/positive Periodic acid-Schiff stain) biomarkers exhibited an identical pattern, whereas the cellular-integrity markers (neuN+/MAP2+/doublecorin+) exhibited an opposite pattern to BIA (all P value <0.001). EPO-CsA therapy markedly reduced BIA mainly by suppressing the innate immune response to inflammation, oxidative stress, microRNAs (miR-223/miR-30a/miR-383) and MAPK family signaling.
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Affiliation(s)
- Chun-Man Yuen
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Kuo-Ho Yeh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | | | - Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Hung-Sheng Lin
- Division of Neurology, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Han-Tan Chai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University School of Medicine for International StudentsKaohsiung 82445, Taiwan
| | - Chih-Hung Chen
- Divisions of General Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Gour-Shenq Kao
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Sheung-Fat Ko
- Department of Radiology, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
| | - Hon-Kan Yip
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial HospitalKaohsiung 83301, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical UniversityTaichung 40402, Taiwan
- Department of Nursing, Asia UniversityTaichung 41354, Taiwan
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24
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Kakkos SK, Ellul J, Ntouvas I, Papadoulas SI. Dual antiplatelet therapy for acute minor ischemic stroke or transient ischemic attack. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:176. [PMID: 26366393 DOI: 10.3978/j.issn.2305-5839.2015.07.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Stavros K Kakkos
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - John Ellul
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - Ioannis Ntouvas
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - Spyros I Papadoulas
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
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25
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Zhang L, Desai NR, Li J, Hu S, Wang Q, Li X, Masoudi FA, Spertus JA, Nuti SV, Wang S, Krumholz HM, Jiang L. National Quality Assessment of Early Clopidogrel Therapy in Chinese Patients With Acute Myocardial Infarction (AMI) in 2006 and 2011: Insights From the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective AMI Study. J Am Heart Assoc 2015; 4:JAHA.115.001906. [PMID: 26163041 PMCID: PMC4608074 DOI: 10.1161/jaha.115.001906] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Early clopidogrel administration to patients with acute myocardial infarction (AMI) has been demonstrated to improve outcomes in a large Chinese trial. However, patterns of use of clopidogrel for patients with AMI in China are unknown. Methods and Results From a nationally representative sample of AMI patients from 2006 and 2011, we identified 11 944 eligible patients for clopidogrel therapy and measured early clopidogrel use, defined as initiation within 24 hours of hospital admission. Among the patients eligible for clopidogrel, the weighted rate of early clopidogrel therapy increased from 45.7% in 2006 to 79.8% in 2011 (P<0.001). In 2006 and 2011, there was significant variation in early clopidogrel use by region, ranging from 1.5% to 58.0% in 2006 (P<0.001) and 48.7% to 87.7% in 2011 (P<0.001). While early use of clopidogrel was uniformly high in urban hospitals in 2011 (median 89.3%; interquartile range: 80.1% to 94.5%), there was marked heterogeneity among rural hospitals (median 50.0%; interquartile range: 11.5% to 84.4%). Patients without reperfusion therapy and those admitted to rural hospitals were less likely to be treated with clopidogrel. Conclusions Although the use of early clopidogrel therapy in patients with AMI has increased substantially in China, there is notable wide variation across hospitals, with much less adoption in rural hospitals. Quality improvement initiatives are needed to increase consistency of early clopidogrel use for patients with AMI. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624883.
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Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (N.R.D., H.M.K.)
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Shuang Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Qing Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO (J.A.S.)
| | - Sudhakar V Nuti
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.)
| | - Sisi Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (N.R.D., H.M.K.) Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.) Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
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Chen YL, Tsai TH, Wallace CG, Chen YL, Huang TH, Sung PH, Yuen CM, Sun CK, Lin KC, Chai HT, Sheu JJ, Lee FY, Yip HK. Intra-carotid arterial administration of autologous peripheral blood-derived endothelial progenitor cells improves acute ischemic stroke neurological outcomes in rats. Int J Cardiol 2015; 201:668-83. [PMID: 26363631 DOI: 10.1016/j.ijcard.2015.03.137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/05/2015] [Accepted: 03/07/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We tested the hypothesis that transfusion of autologous peripheral blood-derived endothelial progenitor cells (PBDEPC) via the internal carotid artery could reduce brain-infarct zone (BIZ) and neurological deficit in rats following acute ischemic stroke (IS) induced by 50-min left middle cerebral artery occlusion. DESIGN Adult male Sprague-Dawley rats (n=60) were equally divided into group 1 [sham control (SC)], group 2 [SC-PBDEPC (5.7 × 10(6)/kg)], group 3 (IS), group 4 [IS-low-dose PBDEPC (1.7 × 10(6)/kg)], group 5 [IS-high-dose PBDEPC (5.7×10(6)/kg)]. Groups 2 to 5 received G-CSF (35 μg/kg subcutaneously) for 4 days before drawing blood for PBDEPC culture. MEASUREMENTS AND MAIN RESULTS By day 90, BIZ determined by histopathology (area) and brain MRI (volume) were highest in group 3, lowest in groups 1 and 2, higher in group 4 than in group 5 (all p<0.0001), and not significantly different between groups 1 and 2. Sensorimotor functional results exhibited an opposite pattern of BIZ among groups 3 to 5 (p<0.005). Angiogenesis biomarkers (SDF-1α, CXCR4, VEGF, angiopoietin-1) significantly increased progressively from groups 1 and 2 to group 5 (all p<0.0001). Oxidative-stress (NOX-1, NOX-2, oxidized protein), apoptotic (cleaved caspase 3 and PARP, mitochondrial Bax), inflammatory (MMP-9, TNF-α, AQP-4, GFAP, iNOS), and brain-damaged (cytosolic cytochrome-C) biomarkers showed an identical pattern, whereas anti-inflammatory (Bcl-2), mitochondrial preservation (mitochondrial cytochrome-C, PGC-1α), and endothelial function (CD31+, vWF+, eNOS) biomarkers, and vessel density showed an opposite pattern of BIZ among these five groups (all p<0.001). CONCLUSION Higher-dose was superior to lower-dose EPC treatment for reducing BIZ and improving neurological functional outcome.
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Affiliation(s)
- Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | | | - Yi-Ling Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tien-Hung Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chun-Man Yuen
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, Department of Medical Research, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Kun-Chen Lin
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Han-Tan Chai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jiunn-Jye Sheu
- Division of thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Fan-Yen Lee
- Division of thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.
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27
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Tsai TH, Lu CH, Wallace CG, Chang WN, Chen SF, Huang CR, Tsai NW, Lan MY, Sung PH, Liu CF, Yip HK. Erythropoietin improves long-term neurological outcome in acute ischemic stroke patients: a randomized, prospective, placebo-controlled clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:49. [PMID: 25888250 PMCID: PMC4349661 DOI: 10.1186/s13054-015-0761-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/20/2015] [Indexed: 11/25/2022]
Abstract
Introduction Mortality and disability following ischemic stroke (IS) remains unacceptably high with respect to the conventional therapies. This study tested the effect of erythropoietin (EPO) on long-term neurological outcome in patients after acute IS. This study aimed to evaluate the safety and efficacy of two consecutive doses of EPO (5,000 IU/dose, subcutaneously administered at 48 hours and 72 hours after acute IS) on improving the 90-day combined endpoint of recurrent stroke or death that has been previously reported. A secondary objective was to evaluate the long-term (that is, five years) outcome of patients who received EPO. Methods This was a prospective, randomized, placebo-controlled trial that was conducted between October 2008 and March 2010 in a tertiary referral center. IS stroke patients who were eligible for EPO therapy were enrolled into the study. Results The results showed that long-term recurrent stroke and mortality did not differ between group 1 (placebo-control; n = 71) and group 2 (EPO-treated; n = 71). Long-term Barthel index of <35 (defining a severe neurological deficit) was lower in group 2 than group 1 (P = 0.007). Multiple-stepwise logistic-regression analysis showed that EPO therapy was significantly and independently predictive of freedom from a Barthel index of <35 (P = 0.029). Long-term major adverse neurological event (MANE; defined as: death, recurrent stroke, or long-term Barthel index < 35) was lower in group 2 than group 1 (P = 0.04). Log-Rank test showed that MANE-free rate was higher in group 2 than group 1 (P = 0.031). Multiple-stepwise Cox-regression analysis showed that EPO therapy and higher Barthel Index at day 90 were independently predictive of freedom from long-term MANE (all P <0.04). Conclusion EPO therapy significantly improved long-term neurological outcomes in patients after IS. Trial registration ISRCTN71371114. Registered 10 October 2008.
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Affiliation(s)
- Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Cheng-Hsien Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Christopher Glenn Wallace
- Department of Plastic Surgery, University Hospital of South Manchester, Southmoor Road, Manchester, M23 9LT, UK.
| | - Wen-Neng Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Shu-Feng Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Chi-Ren Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Nai-Wen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Min-Yu Lan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Chu-Feng Liu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan. .,Center for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan. .,Institute of Shock Wave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan. .,Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Hsien, 83301, Taiwan.
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Wang YL, Pan YS, Zhao XQ, Wang D, Johnston SC, Liu LP, Meng X, Wang AX, Wang CX, Wang YJ. Recurrent stroke was associated with poor quality of life in patients with transient ischemic attack or minor stroke: finding from the CHANCE trial. CNS Neurosci Ther 2014; 20:1029-35. [PMID: 25307297 DOI: 10.1111/cns.12329] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 11/27/2022] Open
Abstract
AIMS To examine the health-related quality of life (HRQOL) in patients with transient ischemic attack (TIA) or minor stroke and assess the impact of recurrent stroke on HRQOL. METHODS Health-related quality of life data on patients participated in the Clopidogrel in High-risk patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial were analyzed. The available 90-day EuroQoL data (EQ-5D) were used to calculate EQ-5D index score. Poor HRQOL was defined as an EQ-5D index score ≤0.5. The characteristics of HRQOL and factors predicting poor HRQOL in these patients were then explored. RESULTS Among the total 5170 patients enrolled, 90-day HRQOL data were obtained from 5104 patients for analysis. The mean EQ-5D index score at day 90 was 0.88 ± 0.21 for all patients, but only 0.42 ± 0.35 for those with recurrent strokes. Poor 90-day HRQOL was found in 294 (5.8%) patients. Patients with poor HRQOL had more strokes during follow-up than patients with good HRQOL (94.9 vs. 4.7%, P < 0.001). Age, history of hypertension and diabetes, and NIHSS at baseline were independent risk factors for predicting poor HRQOL. Stroke recurrence, NIHSS at baseline, age, and minor stroke on admission became independent risk factors once stroke recurrence was added into the model. CONCLUSIONS Stroke recurrence was associated with poor HRQOL in patients with TIA or minor strokes. Interventions focusing on controlling risk factors and prevention of worsening of neurological function may prevent poor HRQOL in these patients.
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Affiliation(s)
- Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
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