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Everett CC, Berry C, McCann GP, Fernandez C, Reynolds C, Bucciarelli-Ducci C, Dall'Armellina E, Prasad A, Foley JR, Mangion K, Bijsterveld P, Brown J, Stocken D, Walker S, Sculpher M, Plein S, Greenwood JP. Randomised trial of stable chest pain investigation: 3-year clinical and quality of life results from CE-MARC 2. Open Heart 2023; 10:openhrt-2022-002221. [PMID: 37130657 PMCID: PMC10163591 DOI: 10.1136/openhrt-2022-002221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/11/2023] [Indexed: 05/04/2023] Open
Abstract
AIMS Guidelines for suspected cardiac chest pain have used historical risk stratification tools, advocating invasive coronary angiography (ICA) first-line in those at highest risk. We aimed to determine whether different strategies to manage suspected stable angina affected medium-term cardiovascular event rates and patient-reported quality of life (QoL) measures. METHODS CE-MARC 2, a three-arm parallel group trial, randomised patients with suspected stable cardiac chest pain and a Duke Clinical pretest likelihood of coronary artery disease between 10% and 90%. Patients were randomised to either first-line cardiovascular magnetic resonance (CMR), single-photon emission computed tomography (SPECT) or the UK National Institute for Health and Care Excellence (NICE) CG95 (2010) guidelines-directed care. For the three arms, 1-year and 3-year first major adverse cardiovascular event (MACE) rates and QoL assessed by the Seattle Angina Questionnaire, Short Form 12 (V.12) Questionnaire and EuroQol-5 Dimension Questionnaire were recorded. RESULTS 1202 patients were randomised to CMR (n=481), SPECT (n=481) and NICE (n=240). Forty-two patients (18 CMR, 18 SPECT, 6 NICE) experienced one or more MACEs. The percentage rates (95% CIs) of MACE in the CMR, SPECT and NICE groups at 3 years were 3.7% (2.4%, 5.8%), 3.7% (2.4%, 5.8%) and 2.1% (0.9%, 4.8%), respectively. QoL scores did not significantly differ across domains. CONCLUSION Despite a fourfold increase in referrals for ICA, the NICE CG95 (2010) guidelines risk-stratified care strategy did not significantly reduce 3-year MACE or improve QoL, as compared with functional imaging with CMR or SPECT. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT01664858).
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Affiliation(s)
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | | | | | - Erica Dall'Armellina
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Abhiram Prasad
- Cardiovascular Diseases, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - James R Foley
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Julia Brown
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Sven Plein
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John P Greenwood
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Ajjan RA, Heller SR, Everett CC, Vargas-Palacios A, Higham R, Sharples L, Gorog DA, Rogers A, Reynolds C, Fernandez C, Rodrigues P, Sathyapalan T, Storey RF, Stocken DD. Multicenter Randomized Trial of Intermittently Scanned Continuous Glucose Monitoring Versus Self-Monitoring of Blood Glucose in Individuals With Type 2 Diabetes and Recent-Onset Acute Myocardial Infarction: Results of the LIBERATES Trial. Diabetes Care 2023; 46:441-449. [PMID: 36516054 PMCID: PMC9887626 DOI: 10.2337/dc22-1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/02/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To analyze the impact of modern glucose-monitoring strategies on glycemic and patient-related outcomes in individuals with type 2 diabetes (T2D) and recent myocardial infarction (MI) and assess cost effectiveness. RESEARCH DESIGN AND METHODS LIBERATES was a multicenter two-arm randomized trial comparing self-monitoring of blood glucose (SMBG) with intermittently scanned continuous glucose monitoring (isCGM), also known as flash CGM, in individuals with T2D and recent MI, treated with insulin and/or a sulphonylurea before hospital admission. The primary outcome measure was time in range (TIR) (glucose 3.9-10 mmol/L/day) on days 76-90 post-randomization. Secondary and exploratory outcomes included time in hypoglycemia, hemoglobin A1c (HbA1c), clinical outcome, quality of life (QOL), and cost effectiveness. RESULTS Of 141 participants randomly assigned (median age 63 years; interquartile range 53, 70), 73% of whom were men, isCGM was associated with increased TIR by 17 min/day (95% credible interval -105 to +153 min/day), with 59% probability of benefit. Users of isCGM showed lower hypoglycemic exposure (<3.9 mmol/L) at days 76-90 (-80 min/day; 95% CI -118, -43), also evident at days 16-30 (-28 min/day; 95% CI -92, 2). Compared with baseline, HbA1c showed similar reductions of 7 mmol/mol at 3 months in both study arms. Combined glycemic emergencies and mortality occurred in four isCGM and seven SMBG study participants. QOL measures marginally favored isCGM, and the intervention proved to be cost effective. CONCLUSIONS Compared with SMBG, isCGM in T2D individuals with MI marginally increases TIR and significantly reduces hypoglycemic exposure while equally improving HbA1c, explaining its cost effectiveness. Studies are required to understand whether these glycemic differences translate into longer-term clinical benefit.
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Affiliation(s)
- Ramzi A. Ajjan
- Clinical Population and Sciences Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Corresponding author: Ramzi A. Ajjan,
| | - Simon R. Heller
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, U.K
| | - Colin C. Everett
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K
| | | | - Ruchi Higham
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, U.K
| | - Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, U.K
| | - Diana A. Gorog
- School of Life and Medical Science, University of Hertfordshire, Hertfordshire, U.K
- National Heart and Lung Institute, Imperial College London, London, U.K
| | | | - Catherine Reynolds
- Clinical Population and Sciences Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Catherine Fernandez
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, U.K
| | - Pedro Rodrigues
- Academic Unit of Health Economics, University of Leeds, Leeds, U.K
| | - Thozhukat Sathyapalan
- Academic Diabetes, Endocrinology and Metabolism, Allam Diabetes Centre, Hull York Medical School, University of Hull, Hull, U.K
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, U.K
| | - Deborah D. Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K
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Phillips R, Cro S, Wheeler G, Bond S, Morris TP, Creanor S, Hewitt C, Love S, Lopes A, Schlackow I, Gamble C, MacLennan G, Habron C, Gordon AC, Vergis N, Li T, Qureshi R, Everett CC, Holmes J, Kirkham A, Peckitt C, Pirrie S, Ahmed N, Collett L, Cornelius V. Visualising harms in publications of randomised controlled trials: consensus and recommendations. BMJ 2022; 377:e068983. [PMID: 35577357 PMCID: PMC9108928 DOI: 10.1136/bmj-2021-068983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To improve communication of harm in publications of randomised controlled trials via the development of recommendations for visually presenting harm outcomes. DESIGN Consensus study. SETTING 15 clinical trials units registered with the UK Clinical Research Collaboration, an academic population health department, Roche Products, and The BMJ. PARTICIPANTS Experts in clinical trials: 20 academic statisticians, one industry statistician, one academic health economist, one data graphics designer, and two clinicians. MAIN OUTCOME measures A methodological review of statistical methods identified visualisations along with those recommended by consensus group members. Consensus on visual recommendations was achieved (at least 60% of the available votes) over a series of three meetings with participants. The participants reviewed and critically appraised candidate visualisations against an agreed framework and voted on whether to endorse each visualisation. Scores marginally below this threshold (50-60%) were revisited for further discussions and votes retaken until consensus was reached. RESULTS 28 visualisations were considered, of which 10 are recommended for researchers to consider in publications of main research findings. The choice of visualisations to present will depend on outcome type (eg, binary, count, time-to-event, or continuous), and the scenario (eg, summarising multiple emerging events or one event of interest). A decision tree is presented to assist trialists in deciding which visualisations to use. Examples are provided of each endorsed visualisation, along with an example interpretation, potential limitations, and signposting to code for implementation across a range of standard statistical software. Clinician feedback was incorporated into the explanatory information provided in the recommendations to aid understanding and interpretation. CONCLUSIONS Visualisations provide a powerful tool to communicate harms in clinical trials, offering an alternative perspective to the traditional frequency tables. Increasing the use of visualisations for harm outcomes in clinical trial manuscripts and reports will provide clearer presentation of information and enable more informative interpretations. The limitations of each visualisation are discussed and examples of where their use would be inappropriate are given. Although the decision tree aids the choice of visualisation, the statistician and clinical trial team must ultimately decide the most appropriate visualisations for their data and objectives. Trialists should continue to examine crude numbers alongside visualisations to fully understand harm profiles.
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Affiliation(s)
- Rachel Phillips
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
- Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim P Morris
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Siobhan Creanor
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | | | - Sharon Love
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Andre Lopes
- CRUK Cancer Trials Centre, University College London, London, UK
| | - Iryna Schlackow
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Graeme MacLennan
- Centre for Health Care Randomised Trials, University of Aberdeen, Aberdeen, UK
| | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Nikhil Vergis
- Imperial College London and Imperial NHS Trust, London, UK
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Riaz Qureshi
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Holmes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clare Peckitt
- Royal Marsden Clinical Trials Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Norin Ahmed
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Laura Collett
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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Berger VW, Bour LJ, Carter K, Chipman JJ, Everett CC, Heussen N, Hewitt C, Hilgers RD, Luo YA, Renteria J, Ryeznik Y, Sverdlov O, Uschner D. A roadmap to using randomization in clinical trials. BMC Med Res Methodol 2021; 21:168. [PMID: 34399696 PMCID: PMC8366748 DOI: 10.1186/s12874-021-01303-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Randomization is the foundation of any clinical trial involving treatment comparison. It helps mitigate selection bias, promotes similarity of treatment groups with respect to important known and unknown confounders, and contributes to the validity of statistical tests. Various restricted randomization procedures with different probabilistic structures and different statistical properties are available. The goal of this paper is to present a systematic roadmap for the choice and application of a restricted randomization procedure in a clinical trial. METHODS We survey available restricted randomization procedures for sequential allocation of subjects in a randomized, comparative, parallel group clinical trial with equal (1:1) allocation. We explore statistical properties of these procedures, including balance/randomness tradeoff, type I error rate and power. We perform head-to-head comparisons of different procedures through simulation under various experimental scenarios, including cases when common model assumptions are violated. We also provide some real-life clinical trial examples to illustrate the thinking process for selecting a randomization procedure for implementation in practice. RESULTS Restricted randomization procedures targeting 1:1 allocation vary in the degree of balance/randomness they induce, and more importantly, they vary in terms of validity and efficiency of statistical inference when common model assumptions are violated (e.g. when outcomes are affected by a linear time trend; measurement error distribution is misspecified; or selection bias is introduced in the experiment). Some procedures are more robust than others. Covariate-adjusted analysis may be essential to ensure validity of the results. Special considerations are required when selecting a randomization procedure for a clinical trial with very small sample size. CONCLUSIONS The choice of randomization design, data analytic technique (parametric or nonparametric), and analysis strategy (randomization-based or population model-based) are all very important considerations. Randomization-based tests are robust and valid alternatives to likelihood-based tests and should be considered more frequently by clinical investigators.
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Affiliation(s)
| | | | - Kerstine Carter
- Boehringer-Ingelheim Pharmaceuticals Inc, Ridgefield, CT USA
| | - Jonathan J. Chipman
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City UT, USA
- Cancer Biostatistics, University of Utah Huntsman Cancer Institute, Salt Lake City UT, USA
| | | | - Nicole Heussen
- RWTH Aachen University, Aachen, Germany
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | | | - Jone Renteria
- Open University of Catalonia (UOC) and the University of Barcelona (UB), Barcelona, Spain
- Department of Human Development and Quantitative Methodology, University of Maryland, College Park, MD USA
| | - Yevgen Ryeznik
- BioPharma Early Biometrics & Statistical Innovations, Data Science & AI, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Oleksandr Sverdlov
- Early Development Analytics, Novartis Pharmaceuticals Corporation, NJ East Hanover, USA
| | - Diane Uschner
- Biostatistics Center & Department of Biostatistics and Bioinformatics, George Washington University, DC Washington, USA
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Everett CC, Reynolds C, Fernandez C, Stocken DD, Sharples LD, Sathyapalan T, Heller S, Storey RF, Ajjan RA. Rationale and design of the LIBERATES trial: Protocol for a randomised controlled trial of flash glucose monitoring for optimisation of glycaemia in individuals with type 2 diabetes and recent myocardial infarction. Diab Vasc Dis Res 2020; 17:1479164120957934. [PMID: 33081502 PMCID: PMC7919208 DOI: 10.1177/1479164120957934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hyperglycaemia in individuals with type 2 diabetes (T2D) and myocardial infarction (MI) is associated with guarded clinical prognosis. Studies improving glucose levels in T2D following MI relied on HbA1c as the main glycaemic marker, failing to address potential adverse effects of hypoglycaemia and glucose variability. We describe the design of the LIBERATES trial that investigates the role of flash glucose monitoring in optimising glycaemic markers in high vascular risk individuals with T2D. This multicentre trial is designed to recruit up to 150 insulin and/or sulphonylurea-treated T2D patients, within 5 days of a proven MI. Individuals will be randomised 1:1 into intervention and control groups using flash glucose monitoring sensors and traditional self-monitoring of blood glucose, respectively. The control group will also wear a blinded continuous glucose monitoring sensor. The primary outcome is the difference in time spent in euglycaemia (defined as glucose levels between 3.9-10.0 mmol/l), comparing study groups 3 months following recruitment, assessed daily for 14 days and as an average. Secondary and exploratory end points include time spent in hypoglycaemia and hyperglycaemia, HbA1c, quality of life measures, major adverse cardiac events and cost-effectiveness of the intervention. This study will establish the role of flash glucose monitoring in glycaemic management of individuals with T2D sustaining a cardiac event.(Trial Registration: ISRCTN14974233, registered 12th June 2017).
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Affiliation(s)
- Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Catherine Reynolds
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Deborah D Stocken
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Linda D Sharples
- London School of Hygiene and Tropical Medicine, University of London, Bloomsbury, London, UK
| | | | - Simon Heller
- Department of Oncology and Metabolism, Sheffield Teaching Hospitals Trust, Sheffield, South Yorkshire, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
- Department of Diabetes and Endocirnology, Leeds Teaching Hospitals Trust, Leeds, West Yorkshire, UK
- Ramzi A Ajjan, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, The LIGHT Laboratories, Clarendon Way, Leeds, West Yorkshire LS2 9JT, UK.
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Everett CC, Fox KA, Reynolds C, Fernandez C, Sharples L, Stocken DD, Carruthers K, Hemingway H, Yan AT, Goodman SG, Brieger D, Chew DP, Gale CP. Evaluation of the impact of the GRACE risk score on the management and outcome of patients hospitalised with non-ST elevation acute coronary syndrome in the UK: protocol of the UKGRIS cluster-randomised registry-based trial. BMJ Open 2019; 9:e032165. [PMID: 31492797 PMCID: PMC6731819 DOI: 10.1136/bmjopen-2019-032165] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION For non-ST-segment elevation acute coronary syndrome (NSTEACS) there is a gap between the use of class I guideline recommended therapies and clinical practice. The Global Registry of Acute Coronary Events (GRACE) risk score is recommended in international guidelines for the risk stratification of NSTEACS, but its impact on adherence to guideline-indicated treatments and reducing adverse clinical outcomes is unknown. The objective of the UK GRACE Risk Score Intervention Study (UKGRIS) trial is to assess the effectiveness of the GRACE risk score tool and associated treatment recommendations on the use of guideline-indicated care and clinical outcomes. METHODS AND ANALYSIS The UKGRIS, a parallel-group cluster randomised registry-based controlled trial, will allocate hospitals in a 1:1 ratio to manage NSTEACS by standard care or according to the GRACE risk score and associated international guidelines. UKGRIS will recruit a minimum of 3000 patients from at least 30 English National Health Service hospitals and collect healthcare data from national electronic health records. The co-primary endpoints are the use of guideline-indicated therapies, and the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospitalisation or cardiovascular readmission at 12 months. Secondary endpoints include duration of inpatient hospital stay over 12 months, EQ-5D-5L responses and utilities, unscheduled revascularisation and the components of the composite endpoint over 12 months follow-up. ETHICS AND DISSEMINATION The study has ethical approval (North East - Tyne & Wear South Research Ethics Committee reference: 14/NE/1180). Findings will be announced at relevant conferences and published in peer-reviewed journals in line with the funder's open access policy. TRIAL REGISTRATION NUMBER ISRCTN29731761; Pre-results.
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Affiliation(s)
- Colin C Everett
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Catherine Reynolds
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Linda Sharples
- Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah D Stocken
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kathryn Carruthers
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Harry Hemingway
- Health Data Research UK London, UCL, London, UK
- Institute of Health Informatics, UCL, London, UK
- The National Institute for Health Research UCL Hospitals Biomedical Research Centre, UCL, London, UK
| | | | | | | | - Derek P Chew
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Brown S, Everett CC, Naraghi K, Davies C, Dawkins B, Hulme C, McCabe C, Pavitt S, Emery P, Sharples L, Buch MH. Alternative tumour necrosis factor inhibitors (TNFi) or abatacept or rituximab following failure of initial TNFi in rheumatoid arthritis: the SWITCH RCT. Health Technol Assess 2019; 22:1-280. [PMID: 29900829 DOI: 10.3310/hta22340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA), the most common autoimmune disease in the UK, is a chronic systemic inflammatory arthritis that affects 0.8% of the UK population. OBJECTIVES To determine whether or not an alternative class of biologic disease-modifying antirheumatic drugs (bDMARDs) are comparable to rituximab in terms of efficacy and safety outcomes in patients with RA in whom initial tumour necrosis factor inhibitor (TNFi) bDMARD and methotrexate (MTX) therapy failed because of inefficacy. DESIGN Multicentre, Phase III, open-label, parallel-group, three-arm, non-inferiority randomised controlled trial comparing the clinical and cost-effectiveness of alternative TNFi and abatacept with that of rituximab (and background MTX therapy). Eligible consenting patients were randomised in a 1 : 1 : 1 ratio using minimisation incorporating a random element. Minimisation factors were centre, disease duration, non-response category and seropositive/seronegative status. SETTING UK outpatient rheumatology departments. PARTICIPANTS Patients aged ≥ 18 years who were diagnosed with RA and were receiving MTX, but had not responded to two or more conventional synthetic disease-modifying antirheumatic drug therapies and had shown an inadequate treatment response to a first TNFi. INTERVENTIONS Alternative TNFi, abatacept or rituximab (and continued background MTX). MAIN OUTCOME MEASURES The primary outcome was absolute reduction in the Disease Activity Score of 28 joints (DAS28) at 24 weeks post randomisation. Secondary outcome measures over 48 weeks were additional measures of disease activity, quality of life, cost-effectiveness, radiographic measures, safety and toxicity. LIMITATIONS Owing to third-party contractual issues, commissioning challenges delaying centre set-up and thus slower than expected recruitment, the funders terminated the trial early. RESULTS Between July 2012 and December 2014, 149 patients in 35 centres were registered, of whom 122 were randomised to treatment (alternative TNFi, n = 41; abatacept, n = 41; rituximab, n = 40). The numbers, as specified, were analysed in each group [in line with the intention-to-treat (ITT) principle]. Comparing alternative TNFi with rituximab, the difference in mean reduction in DAS28 at 24 weeks post randomisation was 0.3 [95% confidence interval (CI) -0.45 to 1.05] in the ITT patient population and -0.58 (95% CI -1.72 to 0.55) in the per protocol (PP) population. Corresponding results for the abatacept and rituximab comparison were 0.04 (95% CI -0.72 to 0.79) in the ITT population and -0.15 (95% CI -1.27 to 0.98) in the PP population. General improvement in the Health Assessment Questionnaire Disability Index, Rheumatoid Arthritis Quality of Life and the patients' general health was apparent over time, with no notable differences between treatment groups. There was a marked initial improvement in the patients' global assessment of pain and arthritis at 12 weeks across all three treatment groups. Switching to alternative TNFi may be cost-effective compared with rituximab [incremental cost-effectiveness ratio (ICER) £5332.02 per quality-adjusted life-year gained]; however, switching to abatacept compared with switching to alternative TNFi is unlikely to be cost-effective (ICER £253,967.96), but there was substantial uncertainty in the decisions. The value of information analysis indicated that further research would be highly valuable to the NHS. Ten serious adverse events in nine patients were reported; none were suspected unexpected serious adverse reactions. Two patients died and 10 experienced toxicity. FUTURE WORK The results will add to the randomised evidence base and could be included in future meta-analyses. CONCLUSIONS How to manage first-line TNFi treatment failures remains unresolved. Had the trial recruited to target, more credible evidence on whether or not either of the interventions were non-inferior to rituximab may have been provided, although this remains speculative. TRIAL REGISTRATION Current Controlled Trials ISRCTN89222125 and ClinicalTrials.gov NCT01295151. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 34. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kamran Naraghi
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Claire Davies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, University of Leeds, Leeds, UK
| | - Paul Emery
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,National Institute for Health Research Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Linda Sharples
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Maya H Buch
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,National Institute for Health Research Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Nashef SAM, Fynn S, Abu-Omar Y, Spyt TJ, Mills C, Everett CC, Fox-Rushby J, Singh J, Dalrymple-Hay M, Sudarshan C, Codispoti M, Braidley P, Wells FC, Sharples LD. Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation. Eur J Cardiothorac Surg 2018; 54:729-737. [PMID: 29672731 PMCID: PMC6134441 DOI: 10.1093/ejcts/ezy165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/01/2018] [Accepted: 03/12/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness. METHODS In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20-3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76-5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64-1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321-£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term. Study registration ISRCTN82731440 (project number 07/01/34).
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Affiliation(s)
| | - Simon Fynn
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | | | - Tomasz J Spyt
- Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK
| | | | | | | | - Jeshika Singh
- Department of Health Economics, Brunel University, London, UK
| | - Malcolm Dalrymple-Hay
- Department of Cardiothoracic Surgery, Plymouth Hospital, Derriford Hospital, Plymouth, UK
| | | | | | - Peter Braidley
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | | | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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9
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Fisher BA, Everett CC, Rout J, O'Dwyer JL, Emery P, Pitzalis C, Ng WF, Carr A, Pease CT, Price EJ, Sutcliffe N, Makdissi J, Tappuni AR, Gendi NST, Hall FC, Ruddock SP, Fernandez C, Hulme CT, Davies KA, Edwards CJ, Lanyon PC, Moots RJ, Roussou E, Richards A, Sharples LD, Bombardieri M, Bowman SJ. Effect of rituximab on a salivary gland ultrasound score in primary Sjögren's syndrome: results of the TRACTISS randomised double-blind multicentre substudy. Ann Rheum Dis 2017; 77:412-416. [PMID: 29275334 PMCID: PMC5867400 DOI: 10.1136/annrheumdis-2017-212268] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To compare the effects of rituximab versus placebo on salivary gland ultrasound (SGUS) in primary Sjögren's syndrome (PSS) in a multicentre, multiobserver phase III trial substudy. METHODS Subjects consenting to SGUS were randomised to rituximab or placebo given at weeks 0, 2, 24 and 26, and scanned at baseline and weeks 16 and 48. Sonographers completed a 0-11 total ultrasound score (TUS) comprising domains of echogenicity, homogeneity, glandular definition, glands involved and hypoechoic foci size. Baseline-adjusted TUS values were analysed over time, modelling change from baseline at each time point. For each TUS domain, we fitted a repeated-measures logistic regression model to model the odds of a response in the rituximab arm (≥1-point improvement) as a function of the baseline score, age category, disease duration and time point. RESULTS 52 patients (n=26 rituximab and n=26 placebo) from nine centres completed baseline and one or more follow-up visits. Estimated between-group differences (rituximab-placebo) in baseline-adjusted TUS were -1.2 (95% CI -2.1 to -0.3; P=0.0099) and -1.2 (95% CI -2.0 to -0.5; P=0.0023) at weeks 16 and 48. Glandular definition improved in the rituximab arm with an OR of 6.8 (95% CI 1.1 to 43.0; P=0.043) at week 16 and 10.3 (95% CI 1.0 to 105.9; P=0.050) at week 48. CONCLUSIONS We demonstrated statistically significant improvement in TUS after rituximab compared with placebo. This encourages further research into both B cell depletion therapies in PSS and SGUS as an imaging biomarker. TRIAL REGISTRATION NUMBER 65360827, 2010-021430-64; Results.
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Affiliation(s)
- Benjamin A Fisher
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin C Everett
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - John Rout
- Birmingham Dental Hospital, Birmingham, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Emery
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Costantino Pitzalis
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Wan-Fai Ng
- Institute of Cellular Medicine, University of Newcastle, Newcastle-upon-Tyne, UK
| | - Andrew Carr
- Newcastle Dental Hospital, Newcastle-upon-Tyne, UK
| | - Colin T Pease
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | | | | | - Jimmy Makdissi
- Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anwar R Tappuni
- Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Frances C Hall
- Department of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Sharon P Ruddock
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire T Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kevin A Davies
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Christopher John Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Peter C Lanyon
- Nottingham University Hospitals NHS Trust, and Nottingham NHS Treatment Centre, Nottingham, UK
| | - Robert J Moots
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Euthalia Roussou
- Barking Havering and Redbridge University Hospitals NHS trust (BHRUT), King George Hospital, Goodmayes, UK
| | | | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michele Bombardieri
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Simon J Bowman
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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10
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Bowman SJ, Everett CC, O'Dwyer JL, Emery P, Pitzalis C, Ng WF, Pease CT, Price EJ, Sutcliffe N, Gendi NST, Hall FC, Ruddock SP, Fernandez C, Reynolds C, Hulme CT, Davies KA, Edwards CJ, Lanyon PC, Moots RJ, Roussou E, Giles IP, Sharples LD, Bombardieri M. Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren's Syndrome. Arthritis Rheumatol 2017; 69:1440-1450. [PMID: 28296257 DOI: 10.1002/art.40093] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 03/07/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate whether rituximab, an anti-B cell therapy, improves symptoms of fatigue and oral dryness in patients with primary Sjögren's syndrome (SS). METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled, parallel-group trial that included health economic analysis. Anti-Ro-positive patients with primary SS, symptomatic fatigue, and oral dryness were recruited from 25 UK rheumatology clinics from August 2011 to January 2014. Patients were centrally randomized to receive either intravenous (IV) placebo (250 ml saline) or IV rituximab (1,000 mg in 250 ml saline) in 2 courses at weeks 0, 2, 24, and 26, with pre- and postinfusion medication including corticosteroids. The primary end point was the proportion of patients achieving a 30% reduction in either fatigue or oral dryness at 48 weeks, as measured by visual analog scale. Other outcome measures included salivary and lacrimal flow rates, quality of life, scores on the European League Against Rheumatism (EULAR) Sjögren's Syndrome Patient Reported Index and EULAR Sjögren's Syndrome Disease Activity Index, symptoms of ocular and overall dryness, pain, globally assessed disease activity, and cost-effectiveness. RESULTS All 133 patients who were randomized to receive placebo (n = 66) or rituximab (n = 67) were included in the primary analysis. Among patients with complete data, 21 of 56 placebo-treated patients and 24 of 61 rituximab-treated patients achieved the primary end point. After multiple imputation of missing outcomes, response rates in the placebo and rituximab groups were 36.8% and 39.8%, respectively (adjusted odds ratio 1.13 [95% confidence interval 0.50, 2.55]). There were no significant improvements in any outcome measure except for unstimulated salivary flow. The mean ± SD costs per patient for rituximab and placebo were £10,752 ± 264.75 and £2,672 ± 241.71, respectively. There were slightly more adverse events (AEs) reported in total for rituximab, but there was no difference in serious AEs (10 in each group). CONCLUSION The results of this study indicate that rituximab is neither clinically effective nor cost-effective in this patient population.
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Affiliation(s)
- Simon J Bowman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | - Wan-Fai Ng
- University of Newcastle, Newcastle-upon-Tyne, UK
| | | | | | | | | | - Frances C Hall
- University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | | | | | | | | | | | - Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Peter C Lanyon
- University of Nottingham and Circle Nottingham, Nottingham NHS Treatment Centre, Nottingham, UK
| | | | - Euthalia Roussou
- King George Hospital, Barking Havering and Redbridge University Hospitals NHS Trust, Essex, UK
| | - Ian P Giles
- University College London Hospital, London, UK
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11
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Foley JRJ, C Everett C, Cairns D, Bijsterveld P, Ripley DP, Plein S, Sharples L, Brown J, Greenwood JP. 89 Development and external validation of a multivariable model of pre-test likelihood of coronary artery disease based on a contemporary uk population, with comparison to existing risk models. Heart 2017. [DOI: 10.1136/heartjnl-2017-311726.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Zhao W, Everett CC, Weng Y, Berger VW. Guessing strategies for treatment prediction under restricted randomization with unequal allocation. Contemp Clin Trials 2017; 59:118-120. [PMID: 28526265 DOI: 10.1016/j.cct.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/14/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite 305H, Charleston, SC 29425, USA.
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds LS29JT, UK
| | - Yanqiu Weng
- Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ 07936, USA
| | - Vance W Berger
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
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13
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Greenwood JP, Herzog BA, Brown JM, Everett CC, Plein S. Cardiovascular Magnetic Resonance and Single-Photon Emission Computed Tomography in Suspected Coronary Heart Disease. Ann Intern Med 2016; 165:830-831. [PMID: 27919091 DOI: 10.7326/l16-0480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- John P Greenwood
- From Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Bernhard A Herzog
- From Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Julia M Brown
- From Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Colin C Everett
- From Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Sven Plein
- From Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
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14
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Greenwood JP, Herzog BA, Brown J, Everett CC, Nixon J, Bijsterveld P, Maredia N, Motwani M, Dickinson C, Ball SG, Plein S. Prognostic value of CMR and SPECT in suspected coronary heart disease: long term follow-up of the CE-MARC study. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032740 DOI: 10.1186/1532-429x-18-s1-o60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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15
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Ripley DP, Brown J, Everett CC, Bijsterveld P, Walker S, Sculpher M, McCann GP, Berry C, Plein S, Greenwood JP. Rationale and design of the Clinical Evaluation of MAgnetic Resonance imaging in Coronary heart disease 2 trial (CE-MARC 2): A prospective, multi-centre, randomized controlled trial of diagnostic strategies for suspected coronary heart disease. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032294 DOI: 10.1186/1532-429x-18-s1-p75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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16
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Greenwood JP, Ripley DP, Berry C, McCann GP, Plein S, Bucciarelli-Ducci C, Dall'Armellina E, Prasad A, Bijsterveld P, Foley JR, Mangion K, Sculpher M, Walker S, Everett CC, Cairns DA, Sharples LD, Brown JM. Effect of Care Guided by Cardiovascular Magnetic Resonance, Myocardial Perfusion Scintigraphy, or NICE Guidelines on Subsequent Unnecessary Angiography Rates: The CE-MARC 2 Randomized Clinical Trial. JAMA 2016; 316:1051-60. [PMID: 27570866 DOI: 10.1001/jama.2016.12680] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Among patients with suspected coronary heart disease (CHD), rates of invasive angiography are considered too high. OBJECTIVE To test the hypothesis that among patients with suspected CHD, cardiovascular magnetic resonance (CMR)-guided care is superior to National Institute for Health and Care Excellence (NICE) guidelines-directed care and myocardial perfusion scintigraphy (MPS)-guided care in reducing unnecessary angiography. DESIGN, SETTING, AND PARTICIPANTS Multicenter, 3-parallel group, randomized clinical trial using a pragmatic comparative effectiveness design. From 6 UK hospitals, 1202 symptomatic patients with suspected CHD and a CHD pretest likelihood of 10% to 90% were recruited. First randomization was November 23, 2012; last 12-month follow-up was March 12, 2016. INTERVENTIONS Patients were randomly assigned (240:481:481) to management according to UK NICE guidelines or to guided care based on the results of CMR or MPS testing. MAIN OUTCOMES AND MEASURES The primary end point was protocol-defined unnecessary coronary angiography (normal fractional flow reserve >0.8 or quantitative coronary angiography [QCA] showing no percentage diameter stenosis ≥70% in 1 view or ≥50% in 2 orthogonal views in all coronary vessels ≥2.5 mm diameter) within 12 months. Secondary end points included positive angiography, major adverse cardiovascular events (MACEs), and procedural complications. RESULTS Among 1202 symptomatic patients (mean age, 56.3 years [SD, 9.0]; women, 564 [46.9%] ; mean CHD pretest likelihood, 49.5% [SD, 23.8%]), number of patients with invasive coronary angiography after 12 months was 102 in the NICE guidelines group (42.5% [95% CI, 36.2%-49.0%])], 85 in the CMR group (17.7% [95% CI, 14.4%-21.4%]); and 78 in the MPS group (16.2% [95% CI, 13.0%-19.8%]). Study-defined unnecessary angiography occurred in 69 (28.8%) in the NICE guidelines group, 36 (7.5%) in the CMR group, and 34 (7.1%) in the MPS group; adjusted odds ratio of unnecessary angiography: CMR group vs NICE guidelines group, 0.21 (95% CI, 0.12-0.34, P < .001); CMR group vs the MPS group, 1.27 (95% CI, 0.79-2.03, P = .32). Positive angiography proportions were 12.1% (95% CI, 8.2%-16.9%; 29/240 patients) for the NICE guidelines group, 9.8% (95% CI, 7.3%-12.8%; 47/481 patients) for the CMR group, and 8.7% (95% CI, 6.4%-11.6%; 42/481 patients) for the MPS group. A MACE was reported at a minimum of 12 months in 1.7% of patients in the NICE guidelines group, 2.5% in the CMR group, and 2.5% in the MPS group (adjusted hazard ratios: CMR group vs NICE guidelines group, 1.37 [95% CI, 0.52-3.57]; CMR group vs MPS group, 0.95 [95% CI, 0.46-1.95]). CONCLUSIONS AND RELEVANCE In patients with suspected angina, investigation by CMR resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline-directed care, with no statistically significant difference between CMR and MPS strategies. There were no statistically significant differences in MACE rates. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01664858.
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Affiliation(s)
- John P Greenwood
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - David P Ripley
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom4NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Sven Plein
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Chiara Bucciarelli-Ducci
- Cardiovascular Magnetic Resonance Unit, National Institute for Health Research Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Erica Dall'Armellina
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Abhiram Prasad
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Petra Bijsterveld
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - James R Foley
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, United Kingdom
| | - Simon Walker
- Centre for Health Economics, University of York, York, United Kingdom
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Linda D Sharples
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
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17
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Greenwood JP, Herzog BA, Brown JM, Everett CC, Nixon J, Bijsterveld P, Maredia N, Motwani M, Dickinson CJ, Ball SG, Plein S. Prognostic Value of Cardiovascular Magnetic Resonance and Single-Photon Emission Computed Tomography in Suspected Coronary Heart Disease: Long-Term Follow-up of a Prospective, Diagnostic Accuracy Cohort Study. Ann Intern Med 2016; 165:1-9. [PMID: 27158921 DOI: 10.7326/m15-1801] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There are no prospective, prognostic data comparing cardiovascular magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) in the same population of patients with suspected coronary heart disease (CHD). OBJECTIVE To establish the ability of CMR and SPECT to predict major adverse cardiovascular events (MACEs). DESIGN Annual follow-up of the CE-MARC (Clinical Evaluation of MAgnetic Resonance imaging in Coronary heart disease) study for a minimum of 5 years for MACEs (cardiovascular death, acute coronary syndrome, unscheduled revascularization or hospital admission for cardiovascular cause). (Current Controlled Trials registration: ISRCTN77246133). SETTING Secondary and tertiary care cardiology services. PARTICIPANTS 752 patients from the CE-MARC study who were being investigated for suspected CHD. MEASUREMENTS Prediction of time to MACE was assessed by using univariable (log-rank test) and multivariable (Cox proportional hazards regression) analysis. RESULTS 744 (99%) of the 752 recruited patients had complete follow-up. Of 628 who underwent CMR, SPECT, and the reference standard test of X-ray angiography, 104 (16.6%) had at least 1 MACE. Abnormal findings on CMR (hazard ratio, 2.77 [95% CI, 1.85 to 4.16]; P < 0.001) and SPECT (hazard ratio, 1.62 [CI, 1.11 to 2.38; P = 0.014) were both strong and independent predictors of MACE. Only CMR remained a significant predictor after adjustment for other cardiovascular risk factors, angiography result, or stratification for initial patient treatment. LIMITATION Data are from a single-center observational study (albeit conducted in a high-volume institution for both CMR and SPECT). CONCLUSION Five-year follow-up of the CE-MARC study indicates that compared with SPECT, CMR is a stronger predictor of risk for MACEs, independent of cardiovascular risk factors, angiography result, or initial patient treatment. This further supports the role of CMR as an alternative to SPECT for the diagnosis and management of patients with suspected CHD. PRIMARY FUNDING SOURCE British Heart Foundation.
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Affiliation(s)
- John P. Greenwood
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Bernhard A. Herzog
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Julia M. Brown
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Colin C. Everett
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Jane Nixon
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Petra Bijsterveld
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Neil Maredia
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Manish Motwani
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Catherine J. Dickinson
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Stephen G. Ball
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
| | - Sven Plein
- From the Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds; and Leeds General Infirmary, Leeds, United Kingdom
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Kidambi A, Sourbron S, Maredia N, Motwani M, Brown JM, Nixon J, Everett CC, Plein S, Greenwood JP. Factors associated with false-negative cardiovascular magnetic resonance perfusion studies: A Clinical evaluation of magnetic resonance imaging in coronary artery disease (CE-MARC) substudy. J Magn Reson Imaging 2015; 43:566-73. [PMID: 26285057 PMCID: PMC4762538 DOI: 10.1002/jmri.25032] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/01/2015] [Accepted: 08/04/2015] [Indexed: 12/28/2022] Open
Abstract
Purpose To examine factors associated with false‐negative cardiovascular magnetic resonance (MR) perfusion studies within the large prospective Clinical Evaluation of MR imaging in Coronary artery disease (CE‐MARC) study population. Myocardial perfusion MR has excellent diagnostic accuracy to detect coronary heart disease (CHD). However, causes of false‐negative MR perfusion studies are not well understood. Materials and Methods CE‐MARC prospectively recruited patients with suspected CHD and mandated MR, myocardial perfusion scintigraphy, and invasive angiography. This subanalysis identified all patients with significant coronary stenosis by quantitative coronary angiography (QCA) and MR perfusion (1.5T, T1‐weighted gradient echo), using the original blinded image read. We explored patient and imaging characteristics related to false‐negative or true‐positive MR perfusion results, with reference to QCA. Multivariate regression analysis assessed the likelihood of false‐negative MR perfusion according to four characteristics: poor image quality, triple‐vessel disease, inadequate hemodynamic response to adenosine, and Duke jeopardy score (angiographic myocardium‐at‐risk score). Results In all, 265 (39%) patients had significant angiographic disease (mean age 62, 79% male). Thirty‐five (5%) had false‐negative and 230 (34%) true‐positive MR perfusion. Poor MR perfusion image quality, triple‐vessel disease, and inadequate hemodynamic response were similar between false‐negative and true‐positive groups (odds ratio, OR [95% confidence interval, CI]: 4.1 (0.82–21.0), P = 0.09; 1.2 (0.20–7.1), P = 0.85, and 1.6 (0.65–3.8), P = 0.31, respectively). Mean Duke jeopardy score was significantly lower in the false‐negative group (2.6 ± 1.7 vs. 5.4 ± 3.0, OR 0.34 (0.21–0.53), P < 0.0001). Conclusion False‐negative cardiovascular MR perfusion studies are uncommon, and more common in patients with lower angiographic myocardium‐at‐risk. In CE‐MARC, poor image quality, triple‐vessel disease, and inadequate hemodynamic response were not significantly associated with false‐negative MR perfusion. J. MAGN. RESON. IMAGING 2016;43:566–573.
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Affiliation(s)
- Ananth Kidambi
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Neil Maredia
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Manish Motwani
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Jane Nixon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & the Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Ripley DP, Motwani M, Brown JM, Nixon J, Everett CC, Bijsterveld P, Maredia N, Plein S, Greenwood JP. Individual component analysis of the multi-parametric cardiovascular magnetic resonance protocol in the CE-MARC trial. J Cardiovasc Magn Reson 2015; 17:59. [PMID: 26174854 PMCID: PMC4502933 DOI: 10.1186/s12968-015-0169-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/01/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The CE-MARC study assessed the diagnostic performance investigated the use of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). The study used a multi-parametric CMR protocol assessing 4 components: i) left ventricular function; ii) myocardial perfusion; iii) viability (late gadolinium enhancement (LGE)) and iv) coronary magnetic resonance angiography (MRA). In this pre-specified CE-MARC sub-study we assessed the diagnostic accuracy of the individual CMR components and their combinations. METHODS All patients from the CE-MARC population (n = 752) were included using data from the original blinded-read. The four individual core components of the CMR protocol was determined separately and then in paired and triplet combinations. Results were then compared to the full multi-parametric protocol. RESULTS CMR and X-ray angiography results were available in 676 patients. The maximum sensitivity for the detection of significant CAD by CMR was achieved when all four components were used (86.5%). Specificity of perfusion (91.8%), function (93.7%) and LGE (95.8%) on its own was significantly better than specificity of the multi-parametric protocol (83.4%) (all P < 0.0001) but with the penalty of decreased sensitivity (86.5% vs. 76.9%, 47.4% and 40.8% respectively). The full multi-parametric protocol was the optimum to rule-out significant CAD (Likelihood Ratio negative (LR-) 0.16) and the LGE component alone was the best to rue-in CAD (LR+ 9.81). Overall diagnostic accuracy was similar with the full multi-parametric protocol (85.9%) compared to paired and triplet combinations. The use of coronary MRA within the full multi-parametric protocol had no additional diagnostic benefit compared to the perfusion/function/LGE combination (overall accuracy 84.6% vs. 84.2% (P = 0.5316); LR- 0.16 vs. 0.21; LR+ 5.21 vs. 5.77). CONCLUSIONS From this pre-specified sub-analysis of the CE-MARC study, the full multi-parametric protocol had the highest sensitivity and was the optimal approach to rule-out significant CAD. The LGE component alone was the optimal rule-in strategy. Finally the inclusion of coronary MRA provided no additional benefit when compared to the combination of perfusion/function/LGE. TRIAL REGISTRATION Current Controlled Trials ISRCTN77246133.
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Affiliation(s)
- David P Ripley
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Manish Motwani
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Julia M Brown
- Clinical Trials Research Unit, University of Leeds, Clinical Trials Research House, 71-75 Clarendon Rd, Leeds, UK.
| | - Jane Nixon
- Clinical Trials Research Unit, University of Leeds, Clinical Trials Research House, 71-75 Clarendon Rd, Leeds, UK.
| | - Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Clinical Trials Research House, 71-75 Clarendon Rd, Leeds, UK.
| | - Petra Bijsterveld
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Neil Maredia
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
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Ripley DP, Brown JM, Everett CC, Bijsterveld P, Walker S, Sculpher M, McCann GP, Berry C, Plein S, Greenwood JP. Rationale and design of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary heart disease 2 trial (CE-MARC 2): a prospective, multicenter, randomized trial of diagnostic strategies in suspected coronary heart disease. Am Heart J 2015; 169:17-24.e1. [PMID: 25497243 PMCID: PMC4277294 DOI: 10.1016/j.ahj.2014.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 10/10/2014] [Indexed: 12/21/2022]
Abstract
Background A number of investigative strategies exist for the diagnosis of coronary heart disease (CHD). Despite the widespread availability of noninvasive imaging, invasive angiography is commonly used early in the diagnostic pathway. Consequently, approximately 60% of angiograms reveal no evidence of obstructive coronary disease. Reducing unnecessary angiography has potential financial savings and avoids exposing the patient to unnecessary risk. There are no large-scale comparative effectiveness trials of the different diagnostic strategies recommended in international guidelines and none that have evaluated the safety and efficacy of cardiovascular magnetic resonance. Trial Design CE-MARC 2 is a prospective, multicenter, 3-arm parallel group, randomized controlled trial of patients with suspected CHD (pretest likelihood 10%-90%) requiring further investigation. A total of 1,200 patients will be randomized on a 2:2:1 basis to receive 3.0-T cardiovascular magnetic resonance–guided care, single-photon emission computed tomography–guided care (according to American College of Cardiology/American Heart Association appropriate-use criteria), or National Institute for Health and Care Excellence guidelines–based management. The primary (efficacy) end point is the occurrence of unnecessary angiography as defined by a normal (>0.8) invasive fractional flow reserve. Safety of each strategy will be assessed by 3-year major adverse cardiovascular event rates. Cost-effectiveness and health-related quality-of-life measures will be performed. Conclusions The CE-MARC 2 trial will provide comparative efficacy and safety evidence for 3 different strategies of investigating patients with suspected CHD, with the intension of reducing unnecessary invasive angiography rates. Evaluation of these management strategies has the potential to improve patient care, health-related quality of life, and the cost-effectiveness of CHD investigation.
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Navarro Coy NC, Brown S, Bosworth A, Davies CT, Emery P, Everett CC, Fernandez C, Gray JC, Hartley S, Hulme C, Keenan AM, McCabe C, Redmond A, Reynolds C, Scott D, Sharples LD, Pavitt S, Buch MH. The 'Switch' study protocol: a randomised-controlled trial of switching to an alternative tumour-necrosis factor (TNF)-inhibitor drug or abatacept or rituximab in patients with rheumatoid arthritis who have failed an initial TNF-inhibitor drug. BMC Musculoskelet Disord 2014; 15:452. [PMID: 25539805 PMCID: PMC4391115 DOI: 10.1186/1471-2474-15-452] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/17/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases, affecting approximately 1% of the UK adult population. Patients suffer considerable pain, stiffness and swelling and can sustain various degrees of joint destruction, deformity, and significant functional decline. In addition, the economic burden due to hospitalisation and loss of employment is considerable, with over 50% of patients being work-disabled within 10 years of diagnosis. Despite several biologic disease modifying anti-rheumatic drugs (bDMARD) now available, there is a lack of data to guide biologic sequencing. In the UK, second-line biologic treatment is restricted to a single option, rituximab. The aim of the SWITCH trial is to establish whether an alternative-mechanism-TNF-inhibitor (TNFi) or abatacept are as effective as rituximab in patients with RA who have failed an initial TNFi drug. METHODS/DESIGN SWITCH is a pragmatic, phase IV, multi-centre, parallel-group design, open-label, randomised, controlled trial (RCT) comparing alternative-mechanism-TNFi and abatacept with rituximab in patients with RA who have failed an initial TNFi drug. Participants are randomised in a 1:1:1 ratio to receive alternative mechanism TNFi, (monoclonal antibodies: infliximab, adalimumab, certolizumab or golimumab or the receptor fusion protein, etanercept), abatacept or rituximab during the interventional phase (from randomisation up to week 48). Participants are subsequently followed up to a maximum of 96 weeks, which constitutes the observational phase. The primary objective is to establish whether an alternative-mechanism-TNFi or abatacept are non-inferior to rituximab in terms of disease response at 24 weeks post randomisation. The secondary objectives include the comparison of alternative-mechanism-TNFi and abatacept to rituximab in terms of disease response, quality of life, toxicity, safety and structural and bone density outcomes over a 12-month period (48 weeks) and to evaluate the cost-effectiveness of switching patients to alternative active therapies compared to current practice. DISCUSSION SWITCH is a well-designed trial in this therapeutic area that aims to develop a rational treatment algorithm to potentially inform personalised treatment regimens (as opposed to switching all patients to only one available (and possibly unsuccessful) therapy), which may lead to long-term improved patient outcomes and gains in population health. TRIAL REGISTRATION UKCRN Portfolio ID: 12343; ISRCTN89222125 ; NCT01295151.
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Affiliation(s)
- Nuria C Navarro Coy
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, LS7 4SA, UK.
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Ailsa Bosworth
- National Rheumatoid Arthritis Society (NRAS), Maidenhead, Berkshire, SL6 3RT, UK.
| | - Claire T Davies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, LS7 4SA, UK.
| | - Colin C Everett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Catherine Fernandez
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Janine C Gray
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9LJ, UK.
| | - Anne-Maree Keenan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, LS7 4SA, UK.
| | | | - Anthony Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, LS7 4SA, UK.
| | - Catherine Reynolds
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - David Scott
- School of Medicine, University of East Anglia, Norfolk, NR4 7QN, UK.
| | - Linda D Sharples
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Sue Pavitt
- Centre for Health Sciences Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9LJ, UK.
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, LS7 4SA, UK.
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Greenwood JP, Motwani M, Maredia N, Brown JM, Everett CC, Nixon J, Bijsterveld P, Dickinson CJ, Ball SG, Plein S. Response to letter regarding article "comparison of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) trial". Circulation 2014; 130:e340. [PMID: 25602955 DOI: 10.1161/circulationaha.114.012784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
| | - Manish Motwani
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
| | - Neil Maredia
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Jane Nixon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Petra Bijsterveld
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
| | | | - Stephen G Ball
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre and, The Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics, University of Leeds, Leeds, UK
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Greenwood JP, Ripley DP, Motwani M, Brown J, Nixon J, Everett CC, Maredia N, Bijsterveld P, Plein S. Diagnostic accuracy of the core components of a multi-parametric cardiovascular magnetic resonance imaging protocol: a CE-MARC sub-study. J Cardiovasc Magn Reson 2014. [PMCID: PMC4045608 DOI: 10.1186/1532-429x-16-s1-o19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Greenwood JP, Herzog BA, Brown J, Everett CC, Nixon J, Bijsterveld P, Maredia N, Motwani M, Ball SG, Plein S. Prognostic value of CMR in suspected CHD: 3 year follow-up of the CE-MARC study. J Cardiovasc Magn Reson 2014. [PMCID: PMC4042271 DOI: 10.1186/1532-429x-16-s1-o36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Greenwood JP, Motwani M, Maredia N, Brown JM, Everett CC, Nixon J, Bijsterveld P, Dickinson CJ, Ball SG, Plein S. Comparison of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) Trial. Circulation 2013; 129:1129-38. [PMID: 24357404 DOI: 10.1161/circulationaha.112.000071] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Coronary artery disease is the leading cause of death in women, and underdiagnosis contributes to the high mortality. This study compared the sex-specific diagnostic performance of cardiovascular magnetic resonance (CMR) and single-photon emission computed tomography (SPECT). METHODS AND RESULTS A total of 235 women and 393 men with suspected angina underwent CMR, SPECT, and x-ray angiography as part of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) study. CMR comprised adenosine stress/rest perfusion, cine imaging, late gadolinium enhancement, and magnetic resonance coronary angiography. Gated adenosine stress/rest SPECT was performed with (99m)Tc-tetrofosmin. For CMR, the sensitivity in women and men was similar (88.7% versus 85.6%; P=0.57), as was the specificity (83.5% versus 82.8%; P=0.86). For SPECT, the sensitivity was significantly worse in women than in men (50.9% versus 70.8%; P=0.007), but the specificities were similar (84.1% versus 81.3%; P=0.48). The sensitivity in both the female and male groups was significantly higher with CMR than SPECT (P<0.0001 for both), but the specificity was similar (P=0.77 and P=1.00, respectively). For perfusion-only components, CMR outperformed SPECT in women (area under the curve, 0.90 versus 0.67; P<0.0001) and in men (area under the curve, 0.89 versus 0.74; P<0.0001). Diagnostic accuracy was similar in both sexes with perfusion CMR (P=1.00) but was significantly worse in women with SPECT (P<0.0001). CONCLUSIONS In both sexes, CMR has greater sensitivity than SPECT. Unlike SPECT, there are no significant sex differences in the diagnostic performance of CMR. These findings, plus an absence of ionizing radiation exposure, mean that CMR should be more widely adopted in women with suspected coronary artery disease. CLINICAL TRIAL REGISTRATION URL http://www.controlled-trials.com. Unique identifier: ISRCTN77246133.
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Affiliation(s)
- John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health & Therapeutics (J.P.G., M.M., N.M., P.B., S.G.B., S.P.) and Clinical Trials Research Unit (J.M.B., C.C.E., J.N.), University of Leeds, Leeds, UK; and Department of Nuclear Cardiology, Leeds General Infirmary, Leeds, UK (C.J.D.)
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Plein S, Kidambi A, Sourbron S, Maredia N, Uddin A, Motwani M, Ripley DP, Herzog B, Brown JMB, Nixon J, Everett CC, Greenwood JP. 097 FACTORS ASSOCIATED WITH FALSE NEGATIVE CARDIOVASCULAR MAGNETIC RESONANCE PERFUSION STUDIES: A CE-MARC SUBSTUDY. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Greenwood JP, Kidambi A, Zaman A, Maredia N, Motwani M, Dickinson CJ, Brown JM, Nixon J, Everett CC, Ball SG, Plein S. 088 Comparison of cardiovascular magnetic resonance stress perfusion with single photon emission CT (SPECT) in patients with left main stem disease: a CE-MARC substudy. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, Bijsterveld P, Ridgway JP, Radjenovic A, Dickinson CJ, Ball SG, Plein S. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet 2012; 379:453-60. [PMID: 22196944 PMCID: PMC3273722 DOI: 10.1016/s0140-6736(11)61335-4] [Citation(s) in RCA: 762] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND In patients with suspected coronary heart disease, single-photon emission computed tomography (SPECT) is the most widely used test for the assessment of myocardial ischaemia, but its diagnostic accuracy is reported to be variable and it exposes patients to ionising radiation. The aim of this study was to establish the diagnostic accuracy of a multiparametric cardiovascular magnetic resonance (CMR) protocol with x-ray coronary angiography as the reference standard, and to compare CMR with SPECT, in patients with suspected coronary heart disease. METHODS In this prospective trial patients with suspected angina pectoris and at least one cardiovascular risk factor were scheduled for CMR, SPECT, and invasive x-ray coronary angiography. CMR consisted of rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement, and MR coronary angiography. Gated adenosine stress and rest SPECT used (99m)Tc tetrofosmin. The primary outcome was diagnostic accuracy of CMR. This trial is registered at controlled-trials.com, number ISRCTN77246133. FINDINGS In the 752 recruited patients, 39% had significant CHD as identified by x-ray angiography. For multiparametric CMR the sensitivity was 86·5% (95% CI 81·8-90·1), specificity 83·4% (79·5-86·7), positive predictive value 77·2%, (72·1-81·6) and negative predictive value 90·5% (87·1-93·0). The sensitivity of SPECT was 66·5% (95% CI 60·4-72·1), specificity 82·6% (78·5-86·1), positive predictive value 71·4% (65·3-76·9), and negative predictive value 79·1% (74·8-82·8). The sensitivity and negative predictive value of CMR and SPECT differed significantly (p<0·0001 for both) but specificity and positive predictive value did not (p=0·916 and p=0·061, respectively). INTERPRETATION CE-MARC is the largest, prospective, real world evaluation of CMR and has established CMR's high diagnostic accuracy in coronary heart disease and CMR's superiority over SPECT. It should be adopted more widely than at present for the investigation of coronary heart disease. FUNDING British Heart Foundation.
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Affiliation(s)
- John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK.
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Zaman A, Buckley DL, Sourbron S, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, Ridgway JP, Radjenovic A, Dickinson CJ, Sculpher M, Ball SG, Greenwood JP, Plein S. Assessment of myocardial perfusion-CMR in left main stem disease (LMS) in the CEMARC study. J Cardiovasc Magn Reson 2011. [PMCID: PMC3106874 DOI: 10.1186/1532-429x-13-s1-p170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Maredia N, Plein S, Younger JF, Brown JM, Nixon J, Everett CC, Ridgway JP, Radjenovic A, Dickinson CJ, Biglands J, Larghat A, Ball SG, Greenwood JP. Detection of triple vessel coronary artery disease by visual and quantitative first pass CMR myocardial perfusion imaging in the CE-MARC study. J Cardiovasc Magn Reson 2011. [PMCID: PMC3106510 DOI: 10.1186/1532-429x-13-s1-o29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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