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Hettinger G, Mitra N, Thom SR, Margolis DJ. An Improved Clinical and Genetics-Based Prediction Model for Diabetic Foot Ulcer Healing. Adv Wound Care (New Rochelle) 2024; 13:281-290. [PMID: 38258807 DOI: 10.1089/wound.2023.0194] [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: 01/24/2024] Open
Abstract
Objective: The goal of this investigation was to use comprehensive prediction modeling tools and available genetic information to try to improve upon the performance of simple clinical models in predicting whether a diabetic foot ulcer (DFU) will heal. Approach: We utilized a cohort study (n = 206) that included clinical factors, measurements of circulating endothelial precursor cells (CEPCs), and fine sequencing of the NOS1AP gene. We derived and selected relevant predictive features from this patient-level information using statistical and machine learning techniques. We then developed prognostic models using machine learning approaches and assessed predictive performance. The presentation is consistent with TRIPOD requirements. Results: Models using baseline clinical and CEPC data had an area under the receiver operating characteristic curve (AUC) of 0.73 (0.66-0.80). Models using only single nucleotide polymorphisms (SNPs) of the NOS1AP gene had an AUC of 0.67 (95% confidence interval, CI: [0.59-0.75]). However, models incorporating baseline and SNP information resulted in improved AUC (0.80, 95% CI [0.73-0.87]). Innovation: We provide a rigorous analysis demonstrating the predictive potential of genetic information in DFU healing. In this process, we present a framework for using advanced statistical and bioinformatics techniques for creating superior prognostic models and identify potentially predictive SNPs for future research. Conclusion: We have developed a new benchmark for which future predictive models can be compared against. Such models will enable wound care experts to more accurately predict whether a patient will heal and aid clinical trialists in designing studies to evaluate therapies for subjects likely or unlikely to heal.
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Affiliation(s)
- Gary Hettinger
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David J Margolis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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2
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Winkel P, Hilden J, Jakobsen JC, Lindschou J, Jensen GB, Kjøller E, Sajadieh A, Kastrup J, Kolmos HJ, Larsson A, Ärnlöv J, Bjerre M, Gluud C. A screening method to spot biomarkers that may warn of serious events in a chronic disease - illustrated by cardiological CLARICOR trial data. Clin Chem Lab Med 2021; 59:1852-1860. [PMID: 34384145 DOI: 10.1515/cclm-2021-0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To develop a crude screening method for detecting biomarkers which frequently exhibit a rise (or fall) in level prior to a serious event (e.g. a stroke) in patients with a chronic disease, signalling that the biomarker may have an alarm-raising or prognostic potential. The subsequent assessment of the marker's clinical utility requires costly, difficult longitudinal studies. Therefore, initial screening of candidate-biomarkers is desirable. METHODS The method exploits a cohort of patients with biomarkers measured at entry and with recording of first serious event during follow-up. Copying those individual records onto a common timeline where a specific event occurs on the same day (Day 0) for all patients, the baseline biomarker level, when plotted against the patient's entry time on the revised timeline, will have a positive (negative) regression slope if biomarker levels generally rise (decline) the closer one gets to the event. As an example, we study 1,958 placebo-treated patients with stable coronary artery disease followed for nine years in the CLARICOR trial (NCT00121550), examining 11 newer biomarkers. RESULTS Rising average serum levels of cardiac troponin T and of N-terminal pro-B-type natriuretic peptide were seen prior to a fatal cardiovascular outcome. C-reactive protein rose prior to non-cardiovascular death. Glomerular filtration rate, seven lipoproteins, and nine newer cardiological biomarkers did not show convincing changes. CONCLUSIONS For early detection of biomarkers with an alarm-raising potential in chronic diseases, we proposed the described easy procedure. Using only baseline biomarker values and clinical course of participants with coronary heart disease, we identified the same cardiovascular biomarkers as those previously found containing prognostic information using longitudinal or survival analysis.
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Affiliation(s)
- Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørgen Hilden
- Department of Public Health Research, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gorm Boje Jensen
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Kjøller
- Department of Cardiology S, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Bispebjerg Hospital, University Hospital, Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology B, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Ärnlöv
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institute, Huddinge, Sweden
| | - Mette Bjerre
- Department of Clinical Medicine, The Medical Research Laboratory, Aarhus University, Aarhus, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
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3
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Gao QN. Efficacy of ticagrelor in the treatment of stable coronary heart disease: A protocol of systematic review. Medicine (Baltimore) 2020; 99:e22600. [PMID: 33157917 PMCID: PMC7647616 DOI: 10.1097/md.0000000000022600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study will assess the efficacy and safety of ticagrelor in the treatment of patients with stable coronary heart disease (SCHD). METHODS We will search the following databases for relevant potential studies in Cochrane Library, MEDLINE, EMBASE, Web of Science, Google Scholar, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. We will search all literature sources from inception to the present without limitations of language and publication status. We will only consider randomized controlled trials on exploring the efficacy and safety of ticagrelor for the treatment of SCHD. Investigators will separately examine studies, collect data and appraise study quality. Data synthesis and analysis will be performed using RevMan 5.3 software. RESULTS This study will summarize high quality synthesis of present evidence of ticagrelor for the treatment of SCHD. CONCLUSION The findings of this study will provide evidence to appraise whether ticagrelor is effective for the treatment of patients with SCHD. OSF REGISTRATION NUMBER:: osf.io/fq69u.
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4
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Winkel P, Jakobsen JC, Hilden J, Jensen GB, Kjøller E, Sajadieh A, Kastrup J, Kolmos HJ, Iversen KK, Bjerre M, Larsson A, Ärnlöv J, Gluud C. Prognostic value of 12 novel cardiological biomarkers in stable coronary artery disease. A 10-year follow-up of the placebo group of the Copenhagen CLARICOR trial. BMJ Open 2020; 10:e033720. [PMID: 32819979 PMCID: PMC7443269 DOI: 10.1136/bmjopen-2019-033720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To assess if 12 novel circulating biomarkers, when added to 'standard predictors' available in general practice, could improve the 10-year prediction of cardiovascular events and mortality in patients with stable coronary heart disease. DESIGN The patients participated as placebo receiving patients in the randomised clarithromycin for patients with stable coronary artery disease (CLARICOR) trial at a random time in their disease trajectory. SETTING Five Copenhagen University cardiology departments and a coordinating centre. PARTICIPANTS 1998 participants with stable coronary artery disease. OUTCOMES Death and composite of myocardial infarction, unstable angina pectoris, cerebrovascular disease and death. RESULTS When only 'standard predictors' were included, 83.4% of all-cause death predictions and 68.4% of composite outcome predictions were correct. Log(calprotectin) and log(cathepsin-S) were not associated (p≥0.01) with the outcomes, not even as single predictors. Adding the remaining 10 biomarkers (high-sensitive assay cardiac troponin T; neutrophil gelatinase-associated lipocalin; osteoprotegerin; N-terminal pro-B-type natriuretic peptide; tumour necrosis factor receptor 1 and 2; pregnancy-associated plasma protein A; endostatin; YKL40; cathepsin-B), which were all individually significantly associated with the prediction of the two outcomes, increased the figures to 84.7% and 69.7%. CONCLUSION When 'standard predictors' routinely available in general practices are used for risk assessment in consecutively sampled patients with stable coronary artery disease, the addition of 10 novel biomarkers to the prediction model improved the correct prediction of all-cause death and the composite outcome by <1.5%. TRIAL REGISTRATION NUMBER NCT00121550.
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Affiliation(s)
- Per Winkel
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Copenhagen, Denmark
| | - Jørgen Hilden
- Section of Biostatistics, Department of Public Health Research, University of Copenhagen, Copenhagen, Denmark
| | - Gorm Boje Jensen
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Kjøller
- Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Kastrup
- Rigshopitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Mette Bjerre
- The Medical Research Laboratory, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Ärnlöv
- Family Medicine and Primary Care, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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5
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Serum osteoprotegerin as a long-term predictor for patients with stable coronary artery disease and its association with diabetes and statin treatment: A CLARICOR trial 10-year follow-up substudy. Atherosclerosis 2020; 301:8-14. [DOI: 10.1016/j.atherosclerosis.2020.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 01/14/2023]
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6
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Schroder J, Jakobsen JC, Winkel P, Hilden J, Jensen GB, Sajadieh A, Larsson A, Ärnlöv J, Harutyunyan M, Johansen JS, Kjøller E, Gluud C, Kastrup J. Prognosis and Reclassification by YKL-40 in Stable Coronary Artery Disease. J Am Heart Assoc 2020; 9:e014634. [PMID: 32114892 PMCID: PMC7335588 DOI: 10.1161/jaha.119.014634] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background The inflammatory biomarker YKL‐40 has previously been studied as a potential risk marker in cardiovascular disease. We aimed to assess the prognostic reclassification potential of serum YKL‐40 in patients with stable coronary artery disease. Methods and Results The main study population was the placebo group of the CLARICOR (Effect of Clarithromycin on Mortality and Morbidity in Patients With Ischemic Heart Disease) trial. The primary outcome was a composite of acute myocardial infarction, unstable angina pectoris, cerebrovascular disease, and all‐cause mortality. We used Cox proportional hazards regression models adjusted for C‐reactive protein level and baseline cardiovascular risk factors. Improvement in prediction by adding serum YKL‐40 to the risk factors was calculated using the Cox‐Breslow method and c‐statistic. A total of 2200 patients were randomized to placebo, with a follow‐up duration of 10 years. YKL‐40 was associated with an increased risk of the composite outcome (hazard ratio per unit increase in (YKL‐40) 1.13, 95% CI 1.03–1.24, P=0.013) and all‐cause mortality (hazard ratio 1.32, 95% CI 1.17–1.49, P<0.0001). Considering whether a composite‐outcome event was more likely to have, or not have, occurred to date, we found 68.4% of such predictions to be correct when based on the standard predictors, and 68.5% when serum YKL‐40 was added as a predictor. Equivalent results were obtained with c‐statistics. Conclusions Higher serum YKL‐40 was independently associated with an increased risk of adverse cardiovascular outcomes and mortality. Addition of YKL‐40 did not improve risk prediction in patients with stable coronary artery disease. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00121550.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark.,Department of Cardiology Holbæk Hospital Holbæk Denmark.,Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Per Winkel
- Copenhagen Trial Unit Centre for Clinical Intervention Research Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Jørgen Hilden
- Section of Biostatistics Department of Public Health Research University of Copenhagen Copenhagen Denmark
| | - Gorm Boje Jensen
- Department of Cardiology Hvidovre Hospital Copenhagen University Hospital Copenhagen Denmark
| | - Ahmad Sajadieh
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Anders Larsson
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Ärnlöv
- Department of Neurobiology, Care Sciences and Society/Division of Family Medicine Karolinska Institute Stockholm Sweden.,Department of Health and Social Sciences Dalarna University Falun Sweden
| | - Marina Harutyunyan
- Department of Cardiology Rigshospitalet University of Copenhagen København Denmark
| | - Julia S Johansen
- Department of Medicine Herlev and Gentofte Hospital Copenhagen Denmark
| | - Erik Kjøller
- Copenhagen Trial Unit Centre for Clinical Intervention Research Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark.,Department of Cardiology S Herlev Hospital University of Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit Centre for Clinical Intervention Research Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Jens Kastrup
- Department of Cardiology Rigshospitalet University of Copenhagen København Denmark
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7
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Nilsson E, Kastrup J, Sajadieh A, Boje Jensen G, Kjøller E, Kolmos HJ, Wuopio J, Nowak C, Larsson A, Jakobsen JC, Winkel P, Gluud C, Iversen KK, Ärnlöv J, Carlsson AC. Pregnancy Associated Plasma Protein-A as a Cardiovascular Risk Marker in Patients with Stable Coronary Heart Disease During 10 Years Follow-Up-A CLARICOR Trial Sub-Study. J Clin Med 2020; 9:jcm9010265. [PMID: 31963719 PMCID: PMC7019890 DOI: 10.3390/jcm9010265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/11/2020] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Elevated pregnancy-associated plasma protein A (PAPP-A) is associated with mortality in acute coronary syndromes. Few studies have assessed PAPP-A in stable coronary artery disease (CAD) and results are conflicting. We assessed the 10-year prognostic relevance of PAPP-A levels in stable CAD. The CLARICOR trial was a randomized controlled clinical trial including outpatients with stable CAD, randomized to clarithromycin versus placebo. The placebo group constituted our discovery cohort (n = 1.996) and the clarithromycin group the replication cohort (n = 1.975). The composite primary outcome was first occurrence of cardiovascular event or death. In the discovery cohort, incidence rates (IR) for the composite outcome were higher in those with elevated PAPP-A (IR 12.72, 95% Confidence Interval (CI) 11.0-14.7 events/100 years) compared to lower PAPP-A (IR 8.78, 8.25-9.34), with comparable results in the replication cohort. Elevated PAPP-A was associated with increased risk of the composite outcome in both cohorts (discovery Hazard Ratio (HR) 1.45, 95% CI 1.24-1.70; replication HR 1.29, 95% CI 1.10-1.52). In models adjusted for established risk factors, these trends were attenuated. Elevated PAPP-A was associated with higher all-cause mortality in both cohorts. We conclude that elevated PAPP-A levels are associated with increased long-term mortality in stable CAD, but do not improve long-term prediction of death or cardiovascular events when added to established predictors.
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Affiliation(s)
- Erik Nilsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177 Stockholm, Sweden
- School of Medical Sciences, Örebro University, 70182 Örebro, Sweden
- Correspondence:
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital of Bispebjerg and Frederiksberg, 2000 Frederiksberg, Denmark;
| | - Gorm Boje Jensen
- Department of Cardiology, Hvidovre Hospital University of Copenhagen, 2650 Hvidovre, Denmark;
| | - Erik Kjøller
- Department of Cardiology S, Herlev Hospital University of Copenhagen, 2730 Herlev, Denmark; (E.K.); (K.K.I.)
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark; (J.C.J.); (P.W.); (C.G.)
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, 5000 Odense, Denmark;
| | - Jonas Wuopio
- Department of Medicine, Mora County Hospital, 79251 Mora, Sweden;
| | - Christoph Nowak
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14183 Huddinge, Sweden; (C.N.); (A.C.C.)
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden;
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark; (J.C.J.); (P.W.); (C.G.)
- Department of Cardiology, Holbæk Hospital, 4300 Holbæk, Denmark
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark; (J.C.J.); (P.W.); (C.G.)
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark; (J.C.J.); (P.W.); (C.G.)
| | - Kasper K Iversen
- Department of Cardiology S, Herlev Hospital University of Copenhagen, 2730 Herlev, Denmark; (E.K.); (K.K.I.)
| | - Johan Ärnlöv
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14183 Huddinge, Sweden; (C.N.); (A.C.C.)
- School of Health and Social Studies, Dalarna University, 79131 Falun, Sweden;
| | - Axel C. Carlsson
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14183 Huddinge, Sweden; (C.N.); (A.C.C.)
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8
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Circulating endostatin as a risk factor for cardiovascular events in patients with stable coronary heart disease: A CLARICOR trial sub-study. Atherosclerosis 2019; 284:202-208. [PMID: 30959314 DOI: 10.1016/j.atherosclerosis.2019.02.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Raised levels of serum endostatin, a biologically active fragment of collagen XVIII, have been observed in patients with ischemic heart disease but association with incident cardiovascular events in patients with stable coronary heart disease is uncertain. METHODS The CLARICOR-trial is a randomized, placebo-controlled trial of stable coronary heart disease patients evaluating 14-day treatment with clarithromycin. The primary outcome was a composite of acute myocardial infarction, unstable angina pectoris, cerebrovascular disease or all-cause mortality. In the present sub-study using 10-year follow-up data, we investigated associations between serum endostatin at entry (randomization) and the composite outcome and its components during follow-up. The placebo group was used as discovery sample (1204 events, n = 1998) and the clarithromycin-treated group as replication sample (1220 events, n = 1979). RESULTS In Cox regression models adjusting for cardiovascular risk factors, glomerular filtration rate, and current pharmacological treatment, higher serum endostatin was associated with an increased risk of the composite outcome in the discovery sample (hazard ratio per standard deviation increase 1.11, 95% CI 1.03-1.19, p = 0.004), but slightly weaker and not statistically significant in the replication sample (hazard ratio 1.06, 95% CI 1.00-1.14, p = 0.06). In contrast, strong and consistent associations were found between endostatin and cardiovascular and all-cause mortality in all multivariable models and sub-samples. Addition of endostatin to a model with established cardiovascular risk factors provided no substantial improvement of risk prediction (<1%). CONCLUSIONS Raised levels of serum endostatin might be associated with cardiovascular events in patients with stable coronary heart disease. The clinical utility of endostatin measurements remains to be established.
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Wuopio J, Hilden J, Bring C, Kastrup J, Sajadieh A, Jensen GB, Kjøller E, Kolmos HJ, Larsson A, Jakobsen JC, Winkel P, Gluud C, Carlsson AC, Ärnlöv J. Cathepsin B and S as markers for cardiovascular risk and all-cause mortality in patients with stable coronary heart disease during 10 years: a CLARICOR trial sub-study. Atherosclerosis 2018; 278:97-102. [PMID: 30261474 DOI: 10.1016/j.atherosclerosis.2018.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The lysosomal cysteine proteases cathepsin B and S have been implicated in the atherosclerotic process. The present paper investigates the association between serum levels of cathepsin B and S and cardiovascular events and mortality in patients with stable coronary heart disease. METHODS The CLARICOR trial is a randomised, placebo-controlled trial investigating the effect of clarithromycin versus placebo in patients with stable coronary heart disease. The outcome was time to either a cardiovascular event or all-cause mortality. The placebo group was used as discovery sample and the clarithromycin group as replication sample: n = 1998, n = 1979; mean age (years) 65, 65; 31%, 30% women; follow-up for 10 years; number of composite outcomes n = 1204, n = 1220; respectively. We used a pre-defined multivariable Cox regression model adjusting for inflammation, established cardiovascular risk factors, kidney function, and use of cardiovascular drugs. RESULTS Cathepsin B was associated with an increased risk of the composite outcome in both samples after multivariable adjustment (discovery: multivariable ratio (HR) per standard deviation increase 1.12, 95% confidence interval (CI) 1.05-1.19, p < 0.001, replication; HR 1.14, 95% CI 1.07-1.21, p < 0.001). There was no significant association between cathepsin S and the composite outcome in either the discovery or replication sample after multivariable adjustment (p>0.45). Secondary analyses suggest that cathepsin B was predominantly associated with mortality rather than specific cardiovascular events. CONCLUSIONS Cathepsin B, but not serum cathepsin S, was associated with an increased risk of cardiovascular events in patients with stable coronary heart disease. The clinical implications of our findings remain to be established.
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Affiliation(s)
- Jonas Wuopio
- Department of Medicine, Mora County Hospital, Mora, Sweden.
| | - Jørgen Hilden
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Carl Bring
- Department of Medicine, Lindesberg County Hospital, Lindesberg, Sweden
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet University of Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Bispebjerg & Frederiksberg Hospital University of Copenhagen, Denmark
| | - Gorm Boje Jensen
- Department of Cardiology, Hvidovre Hospital University of Copenhagen, Denmark
| | - Erik Kjøller
- Department of Cardiology S, Herlev Hospital University of Copenhagen, Copenhagen, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, Denmark
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Holbæk Hospital, Denmark
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Axel C Carlsson
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden; Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Johan Ärnlöv
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; School of Health and Social Studies, Dalarna University, Falun, Sweden
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10
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Winkel P, Jakobsen JC, Hilden J, Jensen G, Kjøller E, Sajadieh A, Kastrup J, Kolmos HJ, Larsson A, Ärnlöv J, Gluud C. Prognostic value of routinely available data in patients with stable coronary heart disease. A 10-year follow-up of patients sampled at random times during their disease course. Open Heart 2018; 5:e000808. [PMID: 30228904 PMCID: PMC6135459 DOI: 10.1136/openhrt-2018-000808] [Citation(s) in RCA: 7] [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: 02/20/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 01/17/2023] Open
Abstract
Objective To characterise the long-term prognosis of patients with stable coronary artery heart disease by means of 'standard predictors' defined as demographic, clinical and biochemical quantities routinely available in general practices and ascertained at an interview not prompted by renewed cardiac complaints. Methods This is an observational study based on data from 2199 Copenhagen placebo patients from the 'clarithromycin for patients with stable coronary heart disease' trial of patients with stable coronary heart disease. In the trial, we compared the effects of 14 days of clarithromycin treatment versus placebo. The predictors were based on the interview forms and blood samples collected at entry, along with demographic information from hospital files.We studied 'standard predictors' of a composite outcome (myocardial infarction, unstable angina, cerebrovascular disease or all-cause death) and of all-cause death. Using Cox regression, we compared predictions of status at 3, 6 and 9 years without and with the use of 'standard predictors' and used receiver operating characteristic statistic. Results Few 'standard predictors' were associated (p<0.01) with the composite outcome or with all-cause death. When no 'standard predictors' were included, 63.2% of the model-based predictions of the composite outcome and 79.9% of death predictions were correct. Including all 'standard predictors' in the model increased the figures to 68.4% and 83.4%, respectively. C indices were low, except when all-cause death was assessed as a single outcome where C was 0.79. Conclusion 'Standard predictors' routinely available in general practices contribute only modestly to risk assessment in consecutively sampled patients with stable coronary heart disease as ascertained at a contact not prompted by renewed cardiac complaints. Novel biomarkers may improve the assessment. Trial registration number NCT00121550.
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Affiliation(s)
- Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital Blegdamsvej, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital Blegdamsvej, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Jørgen Hilden
- Section of Biostatistics, Department of Public Health Research, University of Copenhagen, Copenhagen, Denmark
| | - Gorm Jensen
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Erik Kjøller
- Department of Cardiology S, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology B, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Ärnlöv
- School of Health and Social Studies, Dalarna University, Falun, Sweden
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Huddinge, Sweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital Blegdamsvej, Copenhagen, Denmark
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11
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Carlsson AC, Ruge T, Kjøller E, Hilden J, Kolmos HJ, Sajadieh A, Kastrup J, Jensen GB, Larsson A, Nowak C, Jakobsen JC, Winkel P, Gluud C, Ärnlöv J. 10-Year Associations Between Tumor Necrosis Factor Receptors 1 and 2 and Cardiovascular Events in Patients With Stable Coronary Heart Disease: A CLARICOR (Effect of Clarithromycin on Mortality and Morbidity in Patients With Ischemic Heart Disease) Trial Substudy. J Am Heart Assoc 2018; 7:e008299. [PMID: 29686027 PMCID: PMC6015281 DOI: 10.1161/jaha.117.008299] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND We aimed to assess the associations and predictive powers between the soluble receptors for tumor necrosis factor (TNF)-α (TNFR1 and TNFR2) and cardiovascular outcomes in patients with stable coronary heart disease. METHODS AND RESULTS CLARICOR (Effect of Clarithromycin on Mortality and Morbidity in Patients With Ischemic Heart Disease) is a randomized clinical trial comparing clarithromycin with placebo in patients with stable coronary heart disease. The primary outcome was a composite of nonfatal acute myocardial infarction, unstable angina pectoris, cerebrovascular disease, and all-cause mortality. Patients were followed up for 10 years; discovery sample, those assigned placebo (1204 events in n=1998); and replication sample, those assigned clarithromycin (1220 events in n=1979). We used Cox regression adjusted for C-reactive protein level, established cardiovascular risk factors, kidney function, and cardiovascular drugs. After adjustments, higher serum levels of TNFR1 and TNFR2 were associated with the composite outcome in the discovery sample (hazard ratio per SD increase, 1.13; 95% confidence interval, 1.05-1.22; P=0.001 for TNFR1; hazard ratio, 1.16; 95% confidence interval, 1.08-1.24; P<0.001 for TNFR2). The associations were similar in the replication sample. The associations with the composite outcome were mainly driven by acute myocardial infarction, cardiovascular mortality, and noncardiovascular mortality. The addition of TNFR1 and TNFR2 to established cardiovascular risk factors improved prediction only modestly (<1%). CONCLUSIONS Increased concentrations of circulating TNFR1 and TNFR2 were associated with increased risks of cardiovascular events and mortality in patients with stable coronary heart disease. Yet, the utility of measuring TNFR1 and TNFR2 to improve risk prediction in these patients appears limited. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00121550.
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Affiliation(s)
- Axel C Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Toralph Ruge
- Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Kjøller
- Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørgen Hilden
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Hans Jørn Kolmos
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Ahmad Sajadieh
- Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jens Kastrup
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Christoph Nowak
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
- Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- School of Health and Social Studies, Dalarna University, Falun, Sweden
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12
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Winkel P, Bath PM, Gluud C, Lindschou J, van der Worp HB, Macleod MR, Szabo I, Durand-Zaleski I, Schwab S. Statistical analysis plan for the EuroHYP-1 trial: European multicentre, randomised, phase III clinical trial of the therapeutic hypothermia plus best medical treatment versus best medical treatment alone for acute ischaemic stroke. Trials 2017; 18:573. [PMID: 29187242 PMCID: PMC5706304 DOI: 10.1186/s13063-017-2302-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/25/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cooling may reduce infarct size and improve neurological outcomes in patients with ischaemic stroke. In phase II trials, cooling awake patients with ischaemic stroke has been shown to be feasible and safe, but the effects in functional outcomes has not yet been investigated in an adequately sized randomised clinical trial. METHODS/DESIGN The EuroHYP-1 trial is a multinational, randomised, superiority phase III clinical trial with masked outcome assessment testing the benefits and harms of therapeutic cooling in awake adult patients with acute ischaemic stroke. The outcomes dealt with here include the primary outcome the Rankin score (mRS) at day 91 +/-14 days after randomisation. The secondary and exploratory outcomes at day 91 +/-14 days unless otherwise stated encompassing: (1) death or dependency, defined as mRS score > 2; (2) death; (3) National Institutes of Health Stroke Score; (4) brain infarct size at 48 +/-24 hours; (5) EQ-5D-5 L score, and (6) WHODAS 2.0 score. Other outcomes are: the primary safety outcome serious adverse events; and the incremental cost-effectiveness, and cost utility ratios. The analysis sets include (1) the intention-to-treat population, and (2) the per protocol population. The sample size is estimated to 800 patients (5% type 1 and 20% type 2 errors). All analyses are adjusted for the protocol-specified stratification variables (nationality of centre), and the minimisation variables. In the analysis, we use ordinal regression (the primary outcome), logistic regression (binary outcomes), general linear model (continuous outcomes), and the Poisson or negative binomial model (rate outcomes). DISCUSSION Major adjustments compared with the original statistical analysis plan encompass: (1) adjustment of analyses by nationality; (2) power calculations for the secondary outcomes; (3) to address the multiplicity problem using of a fixed-sequence testing procedure starting with the primary outcome followed by the secondary outcomes ordered according to falling power; (4) assignment of worst possible score to patients who are not alive at the planned date of measurement of the continuous scores; (5) improved imputations; (6) outline of a supplementary exploratory analysis of the temperature measurements and time to death; and (7) substantial reduction of sample size. TRIAL REGISTRATION Clinicaltrials.gov, identifier: NCT01833312 . 4 April 2013.
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Affiliation(s)
- Per Winkel
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG5 1PB UK
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Malcolm R. Macleod
- Division of Clinical Neurosciences, University of Edinburgh, FU204, Chancellor’s Building, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Istvan Szabo
- European Stroke Research Network for Hypothermia, Square de Meeus 38/40, 1000 Brussels, Belgium
| | - Isabelle Durand-Zaleski
- ECEVE, UMR 1123, URCEcoIle de France Hôpital de l’Hotel Dieu, 1 Place du parvis de Notre Dame, F 75004 Paris, France
| | - Stefan Schwab
- Neurologische Klinik, Universitætsklinikum Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - for the EuroHYP-1 trial investigators
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG5 1PB UK
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Division of Clinical Neurosciences, University of Edinburgh, FU204, Chancellor’s Building, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA UK
- European Stroke Research Network for Hypothermia, Square de Meeus 38/40, 1000 Brussels, Belgium
- ECEVE, UMR 1123, URCEcoIle de France Hôpital de l’Hotel Dieu, 1 Place du parvis de Notre Dame, F 75004 Paris, France
- Neurologische Klinik, Universitætsklinikum Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
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