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Hara H, van Klaveren D, Takahashi K, Kogame N, Chichareon P, Modolo R, Tomaniak M, Ono M, Kawashima H, Wang R, Gao C, Niethammer M, Fontos G, Angioi M, Ribeiro VG, Barbato E, Leandro S, Hamm C, Valgimigli M, Windecker S, Jüni P, Steg PG, Verbeeck J, Tijssen JGP, Sharif F, Onuma Y, Serruys PW. Comparative Methodological Assessment of the Randomized GLOBAL LEADERS Trial Using Total Ischemic and Bleeding Events. Circ Cardiovasc Qual Outcomes 2020; 13:e006660. [PMID: 32762446 DOI: 10.1161/circoutcomes.120.006660] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Time-to-first-event analysis considers only the first event irrespective of its severity. There are several methods to assess trial outcomes beyond time-to-first-event analysis, such as analyzing total events and ranking outcomes. In the GLOBAL LEADERS study, time-to-first-event analysis did not show superiority of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention to conventional 12-month DAPT followed by aspirin monotherapy in the reduction of the primary composite end point of all-cause mortality or new Q-wave myocardial infarction. This study sought to explore various analytical approaches in assessing total ischemic and bleeding events after percutaneous coronary intervention in the GLOBAL LEADERS study. METHODS AND RESULTS Total ischemic and bleeding events were defined as all-cause mortality, any stroke, any myocardial infarction, any revascularization, or Bleeding Academic Research Consortium grade 2 or 3 bleeding. We used various analytical approaches to analyze the benefit of ticagrelor monotherapy over conventional DAPT. For ischemic and bleeding events at 2 years after percutaneous coronary intervention, ticagrelor monotherapy demonstrated a 6% risk reduction, compared with conventional 12-month DAPT in time-to-first-event analysis (hazard ratio, 0.94 [95% CI, 0.88-1.01]; log-rank P=0.10). In win ratio analysis, win ratio was 1.05 (95% CI, 0.97-1.13; P=0.20). Negative binomial regression and Andersen-Gill analyses which include repeated events showed statistically significant advantage for ticagrelor monotherapy (rate ratio, 0.92 [95% CI, 0.85-0.99; P=0.020] and hazard ratio, 0.92 [95% CI, 0.85-0.99; P=0.028], respectively), although in weighted composite end point analysis, the hazard ratio was 0.93 (95% CI, 0.84-1.04; log-rank P=0.22). CONCLUSIONS Statistical analyses considering repeated events or event severity showed that ticagrelor monotherapy consistently reduced ischemic and bleeding events by 5% to 8%, compared with conventional 1-year DAPT. Applying multiple statistical methods could emphasize the multiple facets of a trial and result in accurate and more appropriate analyses. Considering the recurrence of ischemic and bleeding events, ticagrelor monotherapy appeared to be beneficial after percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.
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Affiliation(s)
- Hironori Hara
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - David van Klaveren
- Department of Public Health, Center for Medical Decision Making, Erasmus MC, Rotterdam, the Netherlands (D.v.K.).,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (D.v.K.)
| | - Kuniaki Takahashi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Norihiro Kogame
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Ply Chichareon
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.).,Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Thailand (P.C.)
| | - Rodrigo Modolo
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.).,Cardiology Division, Department of Internal Medicine, University of Campinas (UNICAMP), Brazil (R.M.)
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands (M.T.).,First Department of Cardiology, Medical University of Warsaw, Poland (M.T.)
| | - Masafumi Ono
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Hideyuki Kawashima
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Rutao Wang
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Chao Gao
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Margit Niethammer
- Medizinische Klinik I, Herz-Thorax Zentrum, Klinikum Fulda, Germany (M.N.)
| | | | - Michael Angioi
- Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary (G.F.).,Department of Interventional Cardiology Clinique Louis Pasteur Essey-les-Nancy, France (M.A.)
| | | | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy (E.B.)
| | - Sergio Leandro
- Instituto Nacional De Cardiologia, Rio de Janeiro, Brazil (S.L.)
| | - Christian Hamm
- Kerckhoff Heart Center, Campus University of Giessen, Bad Nauheim, Germany (C.H.)
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland (M.V., S.W.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland (M.V., S.W.)
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto, Canada (P.J.)
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, and INSERM Unité 1148, France (P.G.S.).,Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | | | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., P.C., R.M., M.O., H.K., J.G.P.T.)
| | - Faisal Sharif
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.)
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.)
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (F.S., Y.O., P.W.S.).,NHLI, Imperial College London, United Kingdom (P.W.S.)
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