1
|
Khan MS, Usman MS, Van Spall HGC, Greene SJ, Baqal O, Felker GM, Bhatt DL, Januzzi JL, Butler J. Endpoint adjudication in cardiovascular clinical trials. Eur Heart J 2023; 44:4835-4846. [PMID: 37935635 DOI: 10.1093/eurheartj/ehad718] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Endpoint adjudication (EA) is a common feature of contemporary randomized controlled trials (RCTs) in cardiovascular medicine. Endpoint adjudication refers to a process wherein a group of expert reviewers, known as the clinical endpoint committee (CEC), verify potential endpoints identified by site investigators. Events that are determined by the CEC to meet pre-specified trial definitions are then utilized for analysis. The rationale behind the use of EA is that it may lessen the potential misclassification of clinical events, thereby reducing statistical noise and bias. However, it has been questioned whether this is universally true, especially given that EA significantly increases the time, effort, and resources required to conduct a trial. Herein, we compare the summary estimates obtained using adjudicated vs. non-adjudicated site designated endpoints in major cardiovascular RCTs in which both were reported. Based on these data, we lay out a framework to determine which trials may warrant EA and where it may be redundant. The value of EA is likely greater when cardiovascular trials have nuanced primary endpoints, endpoint definitions that align poorly with practice, sub-optimal data completeness, greater operator variability, and lack of blinding. EA may not be needed if the primary endpoint is all-cause death or all-cause hospitalization. In contrast, EA is likely merited for more nuanced endpoints such as myocardial infarction, bleeding, worsening heart failure as an outpatient, unstable angina, or transient ischaemic attack. A risk-based approach to adjudication can potentially allow compromise between costs and accuracy. This would involve adjudication of a small proportion of events, with further adjudication done if inconsistencies are detected.
Collapse
Affiliation(s)
- Muhammad Shahzeb Khan
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
| | - Muhammad Shariq Usman
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joe's, Hamilton, Ontario, Canada
| | - Stephen J Greene
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Omar Baqal
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Gary Michael Felker
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, NewYork, NY, USA
| | - James L Januzzi
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, 3434 Oak Street Ste 501, Dallas, TX 75204, USA
- Department of Medicine, University of Mississippi School of Medicine, 2500 N State St, Jackson, MS, USA
| |
Collapse
|
2
|
Zhong L, Quan X, Dang P, Tang M, Yu H, Guo F. Clinical characteristics and risk factors of in-hospital gastrointestinal bleeding in patients with acute myocardial infarction. Front Cardiovasc Med 2022; 9:933597. [PMID: 36237901 PMCID: PMC9550925 DOI: 10.3389/fcvm.2022.933597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Gastrointestinal bleeding (GIB) is one of the most serious complications of acute myocardial infarction (AMI) and is correlated with poor outcomes. Objective To evaluate the prevalence, risk factors and in-hospital mortality of GIB in patients with AMI. Methods This observational case-control study retrospectively enrolled consecutive patients with AMI from the Department of Cardiovascular Medicine and Cardiovascular Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2015 to December 2020. GIB after AMI was identified by International Classification of Diseases (ICD) codes from inpatient medical settings and validated by medical record review. AMI patients without GIB were accordingly classified as the control group. Propensity score matching (PSM) was used to match with the GIB group and the control group. All anonymized clinical data were provided by the Biobank of the First Affiliated Hospital of Xi'an Jiaotong University. Results A total of 5,868 AMI patients were enrolled, 0.87% (51/5,868) of whom developed GIB after AMI. On the univariate analysis, history of diabetes, chronic kidney disease, Killip IV, a lower hemoglobin concentration, a higher serum level of creatinine, blood urea nitrogen and D-dimer were closely associated with the risk of GIB (P < 0.05). On the multivariable analysis, a lower hemoglobin concentration (OR: 0.93, 95% CI: 0.89–0.96, P < 0.001) was independently associated with the risk of GIB. Patients with GIB had a much higher in-hospital mortality rate than those without GIB (14.3 vs. 2.1%, P = 0.047). In-hospital mortality among patients with GIB after AMI appeared to be associated with a decreased hemoglobin concentration (OR: 0.93, 95% CI: 0.86–0.99, P = 0.045) and Killip IV (OR: 51.59, 95% CI: 2.65–1,005.30, P = 0.009). Conclusion The history of diabetes, poor renal function and heart failure were associated with the high risk of GIB in patients experiencing AMI. The in-hospital mortality in patients with AMI complicating GIB was higher than that in patients without GIB and was associated with a decreased hemoglobin concentration and high Killip classification.
Collapse
Affiliation(s)
- Liang Zhong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xingpu Quan
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Peizhu Dang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Manyun Tang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hang Yu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- *Correspondence: Hang Yu
| | - Fengwei Guo
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Fengwei Guo
| |
Collapse
|
3
|
Held C, White HD, Stewart RAH, Davies R, Sampson S, Chiswell K, Silverstein A, Lopes RD, Heldestad U, Budaj A, Mahaffey KW, Wallentin L. Characterization of cardiovascular clinical events and impact of event adjudication on the treatment effect of darapladib versus placebo in patients with stable coronary heart disease: Insights from the STABILITY trial. Am Heart J 2019; 208:65-73. [PMID: 30572273 DOI: 10.1016/j.ahj.2018.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/28/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical Endpoint Classification (CEC) in clinical trials allows FOR standardized, systematic, blinded, and unbiased adjudication of investigator-reported events. We quantified the agreement rates in the STABILITY trial on 15,828 patients with stable coronary heart disease. METHODS Investigators were instructed to report all potential events. Each reported event was reviewed independently by 2 reviewers according to prespecified processes and prespecified end point definitions. Concordance between reported and adjudicated cardiovascular (CV) events was evaluated, as well as event classification influence on final study results. RESULTS In total, CEC reviewed 7,096 events: 1,064 deaths (696 CV deaths), 958 myocardial infarctions (MI), 433 strokes, 182 transient ischemic attacks, 2,052 coronary revascularizations, 1,407 hospitalizations for unstable angina, and 967 hospitalizations for heart failure. In total, 71.8% events were confirmed by CEC. Concordance was high (>80%) for cause of death and nonfatal MI and lower for hospitalization for unstable angina (25%) and heart failure (50%). For the primary outcome (composite of CV death, MI, and stroke), investigators reported 2,086 events with 82.5% confirmed by CEC. The STABILITY trial treatment effect of darapladib versus placebo on the primary outcome was consistent using investigator-reported events (hazard ratio 0.96 [95% CI 0.87-1.06]) or adjudicated events (hazard ratio 0.94 [95% CI 0.85-1.03]). CONCLUSIONS The primary outcome results of the STABILITY trial were consistent whether using investigator-reported or CEC-adjudicated events. The proportion of investigator-reported events confirmed by CEC varied by type of event. These results should help improve event identification in clinical trials to optimize ascertainment and adjudication.
Collapse
Affiliation(s)
- Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital and University of Auckland, Auckland, New Zealand
| | - Ralph A H Stewart
- Green Lane Cardiovascular Service, Auckland City Hospital and University of Auckland, Auckland, New Zealand
| | - Richard Davies
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, King of Prussia, PA
| | - Shani Sampson
- Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, King of Prussia, PA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Adam Silverstein
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Ulrika Heldestad
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
4
|
Abstract
Clinical endpoint adjudication (CEA) is a standardized process for assessment of safety and efficacy of pharmacologic or device therapies in clinical trials. CEA plays a key role in many large clinical trials with the aim of achieving consistency and accuracy of the study results, by applying independent and blinded evaluation of suspected clinical events reported by investigators. However, due to high costs there are different opinions regarding the use of central adjudication versus more simplified strategies or site-based assessments and whether the final results differ significantly. There is a lack of scientific evaluation of different adjudication strategies, and more knowledge is needed on the optimal adjudication process and how to achieve the best cost-effectiveness. New methodologies using national registry data and artificial intelligence may challenge the traditional adjudication strategy and could potentially reduce cost considerably with a similar result. Further research and evidence in this field of clinical trials methodology are essential.
Collapse
Affiliation(s)
- Claes Held
- Uppsala Clinical Research Center, Department of Medical Sciences, Cardiology, Uppsala, Sweden
- CONTACT Claes Held Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala, 75185Sweden
| |
Collapse
|