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Wang A, Spertus JA, Wojdyla DM, Abraham TP, Nilles EK, Owens AT, Saberi S, Cresci S, Sehnert A, Lakdawala NK. Mavacamten for Obstructive Hypertrophic Cardiomyopathy With or Without Hypertension: Post-Hoc Analysis of the EXPLORER-HCM Trial. JACC Heart Fail 2024; 12:567-579. [PMID: 37855754 DOI: 10.1016/j.jchf.2023.07.030] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Hypertension (HTN) is common in patients with hypertrophic cardiomyopathy (HCM), but its effect on the treatment of left ventricular outflow tract (LVOT) obstruction is undefined. Although elevated systolic blood pressure (SBP) may impact dynamic LVOT gradients, its response to cardiac myosin inhibition is unknown. OBJECTIVES In a post hoc exploratory analysis of the EXPLORER-HCM trial (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy), the authors examined the characteristics of patients with obstructive HCM and HTN and the associations between HTN, SBP, and the response to mavacamten treatment of LVOT obstruction. METHODS Patients were stratified by baseline history of HTN and mean SBP during 30-week treatment with mavacamten or placebo. The study estimated treatment differences and evaluated HTN and SBP groups by treatment interaction. Analysis of covariance was used to model changes in continuous endpoints, and a generalized linear model was used for binary endpoints. RESULTS HTN was present in 119 of 251 patients (47.4%), including 60 receiving mavacamten and 59 receiving placebo. Patients with HTN vs no HTN were older (63.4 vs 54.0 years; P < 0.001), had higher SBP (134 ± 15.1 mm Hg vs 123 ± 13.8 mm Hg; P < 0.001), more comorbidities, and lower peak oxygen consumption (19 ± 3 vs 20 ± 4 mL/kg/min; P = 0.021). Patients with HTN had similar NYHA functional class (NYHA functional class II, 72% vs 73%), Valsalva LVOT gradients (72 ± 34 mm Hg vs 74 ± 30 mm Hg), Kansas City Cardiomyopathy Questionnaire-Clinical Summary Scores (70.6 ± 18.8 vs 68.9 ± 23.1), and NT pro-B-type natriuretic peptide levels (geometric mean 632 ± 129 pg/mL vs 745 ± 130 pg/mL). Mavacamten-treated patients had improvement in all primary, secondary, and exploratory endpoints regardless of HTN status or mean SBP. CONCLUSIONS The clinical benefits of mavacamten in symptomatic, obstructive HCM were similar in patients with and without HTN, despite differences in baseline characteristics. (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy [EXPLORER-HCM]; NCT03470545).
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Affiliation(s)
- Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - John A Spertus
- Departments of Internal Medicine and Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Theodore P Abraham
- Division of Cardiology, Department of Medicine, University of San Francisco School of Medicine, San Francisco, California, USA
| | - Ester Kim Nilles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anjali Tiku Owens
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sara Saberi
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon Cresci
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amy Sehnert
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Neal K Lakdawala
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Price AL, Amin AP, Rogers S, Messenger JC, Moussa ID, Miller JM, Jennings J, Masoudi FA, Abbott JD, Young R, Wojdyla DM, Rao SV. Implementation of a Multidimensional Strategy to Reduce Post-PCI Bleeding Risk. Circ Cardiovasc Interv 2024; 17:e013003. [PMID: 38410946 PMCID: PMC10942247 DOI: 10.1161/circinterventions.123.013003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 12/14/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND The American College of Cardiology Reduce the Risk: PCI Bleed Campaign was a hospital-based quality improvement campaign designed to reduce post-percutaneous coronary intervention (PCI) bleeding events. The aim of the campaign was to provide actionable evidence-based tools for participants to review, adapt, and adopt, depending upon hospital resources and engagement. METHODS We used data from 8 757 737 procedures in the National Cardiovascular Data Registry between 2015 and 2021 to compare patient and hospital characteristics and bleeding outcomes among campaign participants (n=195 hospitals) and noncampaign participants (n=1384). Post-PCI bleeding risk was compared before and after campaign participation. Multivariable hierarchical logistic regression was used to determine the adjusted association between campaign participation and post-PCI bleeding events. Prespecified subgroups were examined. RESULTS Campaign hospitals were more often higher volume teaching facilities located in urban or suburban locations. After adjustment, campaign participation was associated with a significant reduction in the rate of bleeding (bleeding: adjusted odds ratio, 0.61 [95% CI, 0.53-0.71]). Campaign hospitals had a greater decrease in bleeding events than noncampaign hospitals. In a subgroup analysis, the reduction in bleeding was noted in non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction patients, but no significant reduction was seen in patients without acute coronary syndrome. CONCLUSIONS Participation in the American College of Cardiology Reduce the Risk: PCI Bleed Campaign was associated with a significant reduction in post-PCI bleeding. Our results underscore that national quality improvement efforts can be associated with a significant impact on PCI outcomes.
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Affiliation(s)
| | - Amit P. Amin
- Rush University Medical Center, Chicago, IL (A.P.A.)
| | - Susan Rogers
- American College of Cardiology, Washington DC (S.R.)
| | | | - Issam D. Moussa
- Carle Heart & Vascular Institute, Carle Illinois College of Medicine, Urbana (I.D.M.)
| | | | | | | | - J. Dawn Abbott
- Warren Alpert Medical School of Brown University, Brown University, Lifespan Cardiovascular Institute, Providence, RI (J.D.A.)
| | - Rebecca Young
- Duke Clinical Research Institute, Durham, NC (R.Y., D.M.W.)
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Cresci S, Bach RG, Saberi S, Owens AT, Spertus JA, Hegde SM, Lakdawala NK, Nilles EK, Wojdyla DM, Sehnert AJ, Wang A. Effect of Mavacamten in Women Compared With Men With Obstructive Hypertrophic Cardiomyopathy: Insights From EXPLORER-HCM. Circulation 2024; 149:498-509. [PMID: 37961906 PMCID: PMC11006596 DOI: 10.1161/circulationaha.123.065600] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Compared with men, women with hypertrophic cardiomyopathy (HCM) have a higher incidence of heart failure and worse outcomes. We investigated baseline clinical and echocardiographic characteristics and response to mavacamten among women compared with men in the EXPLORER-HCM study (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy). METHODS A prespecified post hoc analysis of sex from the blinded, randomized EXPLORER-HCM trial of mavacamten versus placebo in symptomatic patients with obstructive HCM was performed. Baseline characteristics were compared with t tests for continuous variables (expressed as mean values) and χ2 tests for categorical variables. Prespecified primary, secondary, and exploratory end points and echocardiographic measurements from baseline to end of treatment (week 30) were analyzed with ANCOVA for continuous end points and a generalized linear model with binomial distribution for binary end points, with adjustment for each outcome's baseline value, New York Heart Association class, β-blocker use, and ergometer type. RESULTS At baseline, women (n=102) were older (62 years versus 56 years; P<0.0001), had lower peak oxygen consumption (16.7 mL·kg-1·min-1 versus 21.3 mL·kg-1·min-1; P<0.0001), were more likely to be assigned New York Heart Association class III (42% versus 17%; P<0.0001), had worse health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 64 versus 75; P<0.0001), and had higher baseline plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels (1704 ng/L versus 990 ng/L; P=0.004) than men (n=149). After 30 weeks of mavacamten treatment, similar improvements were observed in women and men in the primary composite end point (percentage difference on mavacamten versus placebo, 22% versus 19%, respectively; P=0.759) and in the secondary end points of change in postexercise left ventricular outflow tract gradient (-42.4 mm Hg versus -33.6 mm Hg; P=0.348), change in peak oxygen consumption (1.2 mL·kg-1·min-1 versus 1.6 mL·kg-1·min-1; P=0.633), and percentage achieving ≥1 New York Heart Association class improvement (41% versus 28%; P=0.254). However, women had greater improvement in health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 14.8 versus 6.1; P=0.026) and in the exploratory end point of NT-proBNP levels (-1322 ng/L versus -649 ng/L; P=0.0008). CONCLUSIONS Although at baseline women with symptomatic obstructive HCM enrolled in EXPLORER-HCM were older and had worse heart failure and health status than men, treatment with mavacamten resulted in similar improvements in the primary and most secondary EXPLORER-HCM end points and greater improvements in health status and NT-proBNP. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Sharon Cresci
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Genetics, Washington University School of Medicine, St. Louis, MO
| | - Richard G. Bach
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali T. Owens
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John A. Spertus
- University of Missouri-Kansas City’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, USA
| | - Sheila M. Hegde
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Neal K. Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Hong C, Liu M, Wojdyla DM, Hickey J, Pencina M, Henao R. Trans-Balance: Reducing demographic disparity for prediction models in the presence of class imbalance. J Biomed Inform 2024; 149:104532. [PMID: 38070817 PMCID: PMC10850917 DOI: 10.1016/j.jbi.2023.104532] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Risk prediction, including early disease detection, prevention, and intervention, is essential to precision medicine. However, systematic bias in risk estimation caused by heterogeneity across different demographic groups can lead to inappropriate or misinformed treatment decisions. In addition, low incidence (class-imbalance) outcomes negatively impact the classification performance of many standard learning algorithms which further exacerbates the racial disparity issues. Therefore, it is crucial to improve the performance of statistical and machine learning models in underrepresented populations in the presence of heavy class imbalance. METHOD To address demographic disparity in the presence of class imbalance, we develop a novel framework, Trans-Balance, by leveraging recent advances in imbalance learning, transfer learning, and federated learning. We consider a practical setting where data from multiple sites are stored locally under privacy constraints. RESULTS We show that the proposed Trans-Balance framework improves upon existing approaches by explicitly accounting for heterogeneity across demographic subgroups and cohorts. We demonstrate the feasibility and validity of our methods through numerical experiments and a real application to a multi-cohort study with data from participants of four large, NIH-funded cohorts for stroke risk prediction. CONCLUSION Our findings indicate that the Trans-Balance approach significantly improves predictive performance, especially in scenarios marked by severe class imbalance and demographic disparity. Given its versatility and effectiveness, Trans-Balance offers a valuable contribution to enhancing risk prediction in biomedical research and related fields.
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Affiliation(s)
- Chuan Hong
- Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - Molei Liu
- Columbia University, Department of Biostatistics, New York, NY, USA
| | | | - Jimmy Hickey
- North Carolina State University, Department of Statistics, Raleigh, NC, USA
| | - Michael Pencina
- Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Ricardo Henao
- Duke University, Department of Biostatistics and Bioinformatics, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
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Goodwin NP, Clare RM, Harrington JL, Badjatiya A, Wojdyla DM, Udell JA, Butler J, Januzzi JL, Parikh PB, James S, Alexander JH, Lopes RD, Wallentin L, Ohman EM, Hernandez AF, Jones WS. Morbidity and Mortality Associated With Heart Failure in Acute Coronary Syndrome: A Pooled Analysis of 4 Clinical Trials. J Card Fail 2023; 29:1603-1614. [PMID: 37479054 DOI: 10.1016/j.cardfail.2023.07.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Heart failure (HF) may complicate acute coronary syndrome (ACS) and is associated with a high burden of short- and long-term morbidity and mortality. Only limited data regarding future ischemic events and rehospitalization are available for patients who suffer HF before or during ACS. METHODS A secondary analysis of 4 large ACS trials (PLATO, APPRAISE-2, TRACER, and TRILOGY ACS) using Cox proportional hazards models was performed to investigate the association of HF status (no HF, chronic HF, de novo HF) at presentation for ACS with all-cause and cardiovascular death, major adverse cardiovascular event (MACE ), myocardial infarction, stroke, and hospitalization for heart failure (HHF) by 1 year. Cumulative incidence plots are presented at 30 days and 1 year. RESULTS A total of 11.1% of the 47,474 patients presenting with ACS presented with evidence of acute HF, 55.0% of whom presented with de novo HF. Patients with chronic HF presented with evidence of acute HF at a higher rate than those with no previous HF (40.3% vs 6.9%). Compared to those without HF, those with chronic and de novo HF had higher rates of all-cause mortality (adjusted hazard ratio [aHR] 2.01, 95% confidence interval [CI] 1.72-2.34 and aHR 1.47, 95% CI1.15-1.88, respectively), MACE (aHR 1.47, 95% CI1.31-1-.66 and aHR 1.38, 95% CI1.12-1.69), and HHF (aHR 2.29, 95% CI2.02-2.61 and aHR 1.48, 95% CI 1.20-1.82) at 1 year. CONCLUSION In this large cohort of patients with ACS, both prior and de novo HF complicating ACS were associated with significantly higher risk-adjusted rates of death, ischemic events and HHF at 30 days and 1 year. Further studies examining the association between HF and outcomes in this high-risk population are warranted, especially given the advent of more contemporary HF therapies.
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Affiliation(s)
- Nathan P Goodwin
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Robert M Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Josephine L Harrington
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Anish Badjatiya
- Division of Cardiology, Department of Medicine, Texas Heart Institute/Baylor College of Medicine, Houston, TX, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jacob A Udell
- Cardiovascular Division, Department of Medicine, Women's College Hospital; and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital and Cardiac Trials, Baim Institute for Clinical Research, Boston, MA, USA
| | - Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Stefan James
- Department Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Renato D Lopes
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lars Wallentin
- Department Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - E Magnus Ohman
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - W Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Vinereanu D, Wojdyla DM, Alexander JH, Lopes RD, Al-Khatib SM, Gersh BJ, Bahit MC, Hohnloser SH, Flaker GC, Rosenquist M, Hijazi Z, Wallentin L, Granger CB. Heart rate and death and hospitalization for heart failure in patients with persistent or permanent atrial fibrillation: Insights from the ARISTOTLE trial. Am Heart J 2023; 265:132-136. [PMID: 37506747 DOI: 10.1016/j.ahj.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 04/10/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
Rate control is fundamental in the treatment of patients with atrial fibrillation (AF). The independent association of heart rate with outcomes and range of heart rate associated with best outcomes remains uncertain. We assessed the relationship between heart rate and clinical outcomes in patients with persistent or permanent AF enrolled in the randomized, double-blind ARISTOTLE trial. In patients with persistent or permanent AF, a faster heart rate is associated with a modest, but statistically significant increase in death and heart failure hospitalizations. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00412984).
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Affiliation(s)
- Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Bucharest, Romania.
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | | | | | | | - Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Mallya P, Stevens LM, Zhao J, Hong C, Henao R, Economou-Zavlanos N, Wojdyla DM, Schibler T, Manchanda V, Pencina MJ, Hall JL. Facilitating Harmonization of Variables in Framingham, MESA, ARIC, and REGARDS Studies Through a Metadata Repository. Circ Cardiovasc Qual Outcomes 2023; 16:e009938. [PMID: 37850400 PMCID: PMC10841164 DOI: 10.1161/circoutcomes.123.009938] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND High-quality research in cardiovascular prevention, as in other fields, requires inclusion of a broad range of data sets from different sources. Integrating and harmonizing different data sources are essential to increase generalizability, sample size, and representation of understudied populations-strengthening the evidence for the scientific questions being addressed. METHODS Here, we describe an effort to build an open-access repository and interactive online portal for researchers to access the metadata and code harmonizing data from 4 well-known cohort studies-the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, FHS (Framingham Heart Study), MESA (Multi-Ethnic Study of Atherosclerosis), and ARIC (Atherosclerosis Risk in Communities) study. We introduce a methodology and a framework used for preprocessing and harmonizing variables from multiple studies. RESULTS We provide a real-case study and step-by-step guidance to demonstrate the practical utility of our repository and interactive web page. In addition to our successful development of such an open-access repository and interactive web page, this exercise in harmonizing data from multiple cohort studies has revealed several key themes. These themes include the importance of careful preprocessing and harmonization of variables, the value of creating an open-access repository to facilitate collaboration and reproducibility, and the potential for using harmonized data to address important scientific questions and disparities in cardiovascular disease research. CONCLUSIONS By integrating and harmonizing these large-scale cohort studies, such a repository may improve the statistical power and representation of understudied cohorts, enabling development and validation of risk prediction models, identification and investigation of risk factors, and creating a platform for racial disparities research. REGISTRATION URL: https://precision.heart.org/duke-ninds.
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Affiliation(s)
- Pratheek Mallya
- American Heart Association, Dallas, TX (P.M., J.Z., V.M., J.L.H.)
| | - Laura M Stevens
- University of Colorado Anschutz Medical School, Aurora (L.M.S.)
| | - Juan Zhao
- American Heart Association, Dallas, TX (P.M., J.Z., V.M., J.L.H.)
| | - Chuan Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (C.H., R.H., M.P.)
- Duke Clinical Research Institute, Durham, NC (C.H., R.H., D.W., T.S.)
| | - Ricardo Henao
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (C.H., R.H., M.P.)
- Duke Clinical Research Institute, Durham, NC (C.H., R.H., D.W., T.S.)
| | | | - Daniel M Wojdyla
- Duke Clinical Research Institute, Durham, NC (C.H., R.H., D.W., T.S.)
| | - Tony Schibler
- Duke Clinical Research Institute, Durham, NC (C.H., R.H., D.W., T.S.)
| | - Vihaan Manchanda
- American Heart Association, Dallas, TX (P.M., J.Z., V.M., J.L.H.)
| | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (C.H., R.H., M.P.)
| | - Jennifer L Hall
- American Heart Association, Dallas, TX (P.M., J.Z., V.M., J.L.H.)
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Gaudino M, Sandner S, An KR, Dimagli A, Di Franco A, Audisio K, Harik L, Perezgrovas-Olaria R, Soletti G, Fremes SE, Hare DL, Kulik A, Lamy A, Peper J, Ruel M, Ten Berg JM, Willemsen LM, Zhao Q, Wojdyla DM, Bhatt DL, Alexander JH, Redfors B. Graft Failure After Coronary Artery Bypass Grafting and Its Association With Patient Characteristics and Clinical Events: A Pooled Individual Patient Data Analysis of Clinical Trials With Imaging Follow-Up. Circulation 2023; 148:1305-1315. [PMID: 37417248 DOI: 10.1161/circulationaha.123.064090] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 01/20/2023] [Accepted: 06/14/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Graft patency is the postulated mechanism for the benefits of coronary artery bypass grafting (CABG). However, systematic graft imaging assessment after CABG is rare, and there is a lack of contemporary data on the factors associated with graft failure and on the association between graft failure and clinical events after CABG. METHODS We pooled individual patient data from randomized clinical trials with systematic CABG graft imaging to assess the incidence of graft failure and its association with clinical risk factors. The primary outcome was the composite of myocardial infarction or repeat revascularization occurring after CABG and before imaging. A 2-stage meta-analytic approach was used to evaluate the association between graft failure and the primary outcome. We also assessed the association between graft failure and myocardial infarction, repeat revascularization, or all-cause death occurring after imaging. RESULTS Seven trials were included comprising 4413 patients (mean age, 64.4±9.1 years; 777 [17.6%] women; 3636 [82.4%] men) and 13 163 grafts (8740 saphenous vein grafts and 4423 arterial grafts). The median time to imaging was 1.02 years (interquartile range [IQR], 1.00-1.03). Graft failure occurred in 1487 (33.7%) patients and in 2190 (16.6%) grafts. Age (adjusted odds ratio [aOR], 1.08 [per 10-year increment] [95% CI, 1.01-1.15]; P=0.03), female sex (aOR, 1.27 [95% CI, 1.08-1.50]; P=0.004), and smoking (aOR, 1.20 [95% CI, 1.04-1.38]; P=0.01) were independently associated with graft failure, whereas statins were associated with a protective effect (aOR, 0.74 [95% CI, 0.63-0.88]; P<0.001). Graft failure was associated with an increased risk of myocardial infarction or repeat revascularization occurring between CABG and imaging assessment (8.0% in patients with graft failure versus 1.7% in patients without graft failure; aOR, 3.98 [95% CI, 3.54-4.47]; P<0.001). Graft failure was also associated with an increased risk of myocardial infarction or repeat revascularization occurring after imaging (7.8% versus 2.0%; aOR, 2.59 [95% CI, 1.86-3.62]; P<0.001). All-cause death after imaging occurred more frequently in patients with graft failure compared with patients without graft failure (11.0% versus 2.1%; aOR, 2.79 [95% CI, 2.01-3.89]; P<0.001). CONCLUSIONS In contemporary practice, graft failure remains common among patients undergoing CABG and is strongly associated with adverse cardiac events.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria (S.S.)
| | - Kevin R An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
- Division of Cardiac Surgery (K.R.A.), University of Toronto, Canada
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Roberto Perezgrovas-Olaria
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.)
| | - Stephen E Fremes
- Department of Cardiac Surgery, Schulich Heart Centre Sunnybrook Health Sciences Centre (S.E.F.), University of Toronto, Canada
| | - David L Hare
- Department of Cardiology, Austin Health, University of Melbourne, Australia (D.L.H.)
| | - Alexander Kulik
- Division of Cardiac Surgery, Boca Raton Regional Hospital and Florida Atlantic Hospital (A.K.)
| | - Andre Lamy
- Department of Surgery, McMaster University, Hamilton, Canada (A.L.)
| | - Joyce Peper
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands (J.P., J.M.t.B., L.M.W.)
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada (M.R.)
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands (J.P., J.M.t.B., L.M.W.)
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands (J.P., J.M.t.B., L.M.W.)
| | - Qiang Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China (Q.Z.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute (D.M.W.), Duke University Medical Center, Durham, NC
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY (D.L.B.)
| | - John H Alexander
- Division of Cardiology, Department of Medicine (J.H.A.), Duke University Medical Center, Durham, NC
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
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Wang A, Spertus JA, Wojdyla DM, Abraham TP, Nilles EK, Owens AT, Saberi S, Cresci S, Sehnert A, Lakdawala NK. THE EFFECT OF MAVACAMTEN TREATMENT FOR SYMPTOMATIC, OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY IN PATIENTS WITH OR WITHOUT HYPERTENSION: ANALYSIS OF THE EXPLORER-HCM TRIAL. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00769-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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10
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Cresci S, Bach RG, Saberi S, Owens AT, Lakdawala NK, Nilles EK, Wojdyla DM, Sehnert AJ, Wang A. WOMEN IN EXPLORER-HCM HAD MORE SEVERE HEART FAILURE AT BASELINE BUT SIMILAR, OR GREATER, RESPONSE TO MAVACAMTEN. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00788-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Wang A, Lakdawala NK, Abraham TP, Nilles EK, Wojdyla DM, Owens AT, Bach RG, Saberi S, Sehnert A, Cresci S. THE EFFECT OF MAVACAMTEN TREATMENT FOR SYMPTOMATIC, OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY IN PATIENTS OF OLDER AGE AND LONGER DURATION OF DIAGNOSIS: ANALYSIS OF THE EXPLORER-HCM TRIAL. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00771-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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12
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Hong C, Pencina MJ, Wojdyla DM, Hall JL, Judd SE, Cary M, Engelhard MM, Berchuck S, Xian Y, D’Agostino R, Howard G, Kissela B, Henao R. Predictive Accuracy of Stroke Risk Prediction Models Across Black and White Race, Sex, and Age Groups. JAMA 2023; 329:306-317. [PMID: 36692561 PMCID: PMC10408266 DOI: 10.1001/jama.2022.24683] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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] [Received: 07/25/2022] [Accepted: 12/26/2022] [Indexed: 01/25/2023]
Abstract
Importance Stroke is the fifth-highest cause of death in the US and a leading cause of serious long-term disability with particularly high risk in Black individuals. Quality risk prediction algorithms, free of bias, are key for comprehensive prevention strategies. Objective To compare the performance of stroke-specific algorithms with pooled cohort equations developed for atherosclerotic cardiovascular disease for the prediction of new-onset stroke across different subgroups (race, sex, and age) and to determine the added value of novel machine learning techniques. Design, Setting, and Participants Retrospective cohort study on combined and harmonized data from Black and White participants of the Framingham Offspring, Atherosclerosis Risk in Communities (ARIC), Multi-Ethnic Study for Atherosclerosis (MESA), and Reasons for Geographical and Racial Differences in Stroke (REGARDS) studies (1983-2019) conducted in the US. The 62 482 participants included at baseline were at least 45 years of age and free of stroke or transient ischemic attack. Exposures Published stroke-specific algorithms from Framingham and REGARDS (based on self-reported risk factors) as well as pooled cohort equations for atherosclerotic cardiovascular disease plus 2 newly developed machine learning algorithms. Main Outcomes and Measures Models were designed to estimate the 10-year risk of new-onset stroke (ischemic or hemorrhagic). Discrimination concordance index (C index) and calibration ratios of expected vs observed event rates were assessed at 10 years. Analyses were conducted by race, sex, and age groups. Results The combined study sample included 62 482 participants (median age, 61 years, 54% women, and 29% Black individuals). Discrimination C indexes were not significantly different for the 2 stroke-specific models (Framingham stroke, 0.72; 95% CI, 0.72-073; REGARDS self-report, 0.73; 95% CI, 0.72-0.74) vs the pooled cohort equations (0.72; 95% CI, 0.71-0.73): differences 0.01 or less (P values >.05) in the combined sample. Significant differences in discrimination were observed by race: the C indexes were 0.76 for all 3 models in White vs 0.69 in Black women (all P values <.001) and between 0.71 and 0.72 in White men and between 0.64 and 0.66 in Black men (all P values ≤.001). When stratified by age, model discrimination was better for younger (<60 years) vs older (≥60 years) adults for both Black and White individuals. The ratios of observed to expected 10-year stroke rates were closest to 1 for the REGARDS self-report model (1.05; 95% CI, 1.00-1.09) and indicated risk overestimation for Framingham stroke (0.86; 95% CI, 0.82-0.89) and pooled cohort equations (0.74; 95% CI, 0.71-0.77). Performance did not significantly improve when novel machine learning algorithms were applied. Conclusions and Relevance In this analysis of Black and White individuals without stroke or transient ischemic attack among 4 US cohorts, existing stroke-specific risk prediction models and novel machine learning techniques did not significantly improve discriminative accuracy for new-onset stroke compared with the pooled cohort equations, and the REGARDS self-report model had the best calibration. All algorithms exhibited worse discrimination in Black individuals than in White individuals, indicating the need to expand the pool of risk factors and improve modeling techniques to address observed racial disparities and improve model performance.
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Affiliation(s)
- Chuan Hong
- Duke AI Health, Durham, North Carolina
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Michael J. Pencina
- Duke AI Health, Durham, North Carolina
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Suzanne E. Judd
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Cary
- Duke AI Health, Durham, North Carolina
- Duke University School of Nursing, Durham, North Carolina
| | - Matthew M. Engelhard
- Duke AI Health, Durham, North Carolina
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Samuel Berchuck
- Department of Statistical Science, Duke University School of Medicine, Durham, North Carolina
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas
| | - Ralph D’Agostino
- Department of Mathematics & Statistics, Boston University Arts and Sciences, Boston, Massachusetts
| | - George Howard
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brett Kissela
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ricardo Henao
- Duke AI Health, Durham, North Carolina
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
- Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina
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13
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Guimaraes P, Wojdyla DM, Alexander JH, Goodman SG, Aronson R, Windecker S, Mehran R, Granger CB, Lopes RD. Causes of death in patients with atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention: insights from the AUGUSTUS trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/15/2022] Open
Abstract
Abstract
Background
Patients with atrial fibrillation (AF) and concomitant coronary artery disease are at increased risk for poor outcomes. Less is known about specific causes of death in this population.
Methods
We describe specific causes of death among patients with AF and acute coronary syndrome and/or percutaneous coronary intervention included in the AUGUSTUS trial and followed for 6 months. An independent clinical events committee, blinded to treatment assignment, adjudicated cause of death according to pre-defined criteria. The association between baseline factors and all-cause death was evaluated using Cox proportional hazards modeling.
Results
A total of 151 deaths occurred in 4614 patients and were adjudicated as follows: 111 (73.5%) deaths due to cardiovascular (CV) causes and 40 (26.5%) due to non-CV causes. The most common cause of CV death was sudden death (n=39 [35.1%]), followed by myocardial infarction (n=29 [26.1%]) and heart failure (n=24 [21.6%]). The most common causes of non-CV death were infection (n=11 [27.5%]), bleeding (n=8 [20.0%]), and malignancy (n=5 [12.5%]). Increasing age, African American race, history of heart failure, treatment with diuretics, and lower body weight were associated with an increased risk of all-cause death (Table).
Conclusions
Among patients with AF and coronary artery disease, cardiovascular causes were responsible for the majority of deaths within 6 months. Our findings provide relevant information to inform the design of future studies in this population.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): AUGUTUS was funded by Bristol Myers Squibb and Pfizer.
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Affiliation(s)
- P Guimaraes
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - D M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine , Durham , United States of America
| | - J H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine , Durham , United States of America
| | - S G Goodman
- St. Michael's Hospital, University of Toronto , Toronto , Canada
| | - R Aronson
- Bristol-Myers Squibb , Lawrenceville , United States of America
| | - S Windecker
- Bern University Hospital, Inselspital , Bern , Switzerland
| | - R Mehran
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - C B Granger
- Duke Clinical Research Institute, Duke University School of Medicine , Durham , United States of America
| | - R D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine , Durham , United States of America
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14
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Al-Khatib SM, Wojdyla DM, Granger CB, Wallentin L, Garcia DA, Hijazi Z, Held C, Alexander JH, Vinereanu D, Flaker GC, Hylek EM, Lopes RD. Duration of Anticoagulation Interruption Before Invasive Procedures and Outcomes in Patients With Atrial Fibrillation: Insights From the ARISTOTLE Trial. Circulation 2022; 146:958-960. [PMID: 36121911 DOI: 10.1161/circulationaha.122.059438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.Al-K., D.M.W., C.B.G., J.H.A., R.D.L.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.Al-K., D.M.W., C.B.G., J.H.A., R.D.L.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.Al-K., D.M.W., C.B.G., J.H.A., R.D.L.)
| | - Lars Wallentin
- Uppsala Clinical Research Center and the Department of Medical Sciences, Cardiology, Uppsala University, Sweden (L.W., Z.H., C.H.)
| | - David A Garcia
- Hematology Division, University of Washington, Seattle (D.A.G.)
| | - Ziad Hijazi
- Uppsala Clinical Research Center and the Department of Medical Sciences, Cardiology, Uppsala University, Sweden (L.W., Z.H., C.H.)
| | - Claes Held
- Uppsala Clinical Research Center and the Department of Medical Sciences, Cardiology, Uppsala University, Sweden (L.W., Z.H., C.H.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.Al-K., D.M.W., C.B.G., J.H.A., R.D.L.)
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania (D.V.)
| | - Gregory C Flaker
- Division of Cardiology, University of Missouri, Columbia, MO (G.C.F.)
| | - Elaine M Hylek
- Boston University School of Medicine, Boston, MA (E.M.H.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.Al-K., D.M.W., C.B.G., J.H.A., R.D.L.)
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15
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Khan SS, Page C, Wojdyla DM, Schwartz YY, Greenland P, Pencina MJ. Predictive Utility of a Validated Polygenic Risk Score for Long-Term Risk of Coronary Heart Disease in Young and Middle-Aged Adults. Circulation 2022; 146:587-596. [PMID: 35880530 PMCID: PMC9398962 DOI: 10.1161/circulationaha.121.058426] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Understanding the predictive utility of previously derived polygenic risk scores (PRSs) for long-term risk of coronary heart disease (CHD) and its additive value beyond traditional risk factors can inform prevention strategies. METHODS Data from adults 20 to 59 years of age who were free of CHD from the FOS (Framingham Offspring Study) and the ARIC (Atherosclerosis Risk in Communities) study were analyzed. Because the PRS was derived from samples of predominantly European ancestry, individuals who self-reported White race were included. The sample was stratified by age and cohort: young (FOS, 20-39 years [median, 30 years] of age), early midlife (FOS, 40-59 years [median, 43] years of age), and late midlife (ARIC, 45-59 years [median, 52 years] of age). Two previously derived and validated prediction tools were applied: (1) a 30-year traditional risk factor score and (2) a genome-wide PRS comprising >6 million genetic variants. Hazard ratios for the association between each risk estimate and incident CHD were calculated. Predicted and observed rates of CHD were compared to assess discrimination for each model individually and together with the optimism-corrected C index (95% CI). RESULTS Among 9757 participants, both the traditional risk factor score (hazard ratio per 1 SD, 2.60 [95% CI, 2.08-3.27], 2.09 [95% CI, 1.83-2.40], and 2.11 [95% CI, 1.96-2.28]) and the PRS (hazard ratio, 1.98 [95% CI, 1.70-2.30], 1.64 [95% CI, 1.47-1.84], and 1.22 [95% CI, 1.15-1.30]) were significantly associated with incident CHD in young, early midlife, and late midlife, respectively. Discrimination was similar or better for the traditional risk factor score (C index, 0.74 [95% CI, 0.70-0.78], 0.70 [95% CI, 0.67-0.72], and 0.72 [95% CI, 0.70-0.73]) compared with an age- and sex-adjusted PRS (0.73 [95% CI, 0.69-0.78], 0.66 [95% CI, 0.62-0.69], and 0.66 [95% CI, 0.64-0.67]) in young, early-midlife, and late-midlife participants, respectively. The ΔC index when PRS was added to the traditional risk factor score was 0.03 (95% CI, 0.001-0.05), 0.02 (95% CI, -0.002 to 0.037), and 0.002 (95% CI, -0.002 to 0.006) in young, early-midlife, and late-midlife participants, respectively. CONCLUSIONS Despite a statistically significant association between PRS and 30-year risk of CHD, the C statistic improved only marginally with the addition of PRS to the traditional risk factor model among young adults and did not improve among midlife adults. PRS, an immutable factor that cannot be directly intervened on, has minimal clinical utility for long-term CHD prediction when added to a traditional risk factor model.
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Affiliation(s)
- Sadiya S. Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Courtney Page
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel M. Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Yosef Y. Schwartz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip Greenland
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael J. Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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16
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Bahit MC, Vora AN, Li Z, Wojdyla DM, Thomas L, Goodman SG, Aronson R, Jordan JD, Kolls BJ, Dombrowski KE, Vinereanu D, Halvorsen S, Berwanger O, Windecker S, Mehran R, Granger CB, Alexander JH, Lopes RD. Apixaban or Warfarin and Aspirin or Placebo After Acute Coronary Syndrome or Percutaneous Coronary Intervention in Patients With Atrial Fibrillation and Prior Stroke: A Post Hoc Analysis From the AUGUSTUS Trial. JAMA Cardiol 2022; 7:682-689. [PMID: 35612866 DOI: 10.1001/jamacardio.2022.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022]
Abstract
Importance Data are limited regarding the risk of cerebrovascular ischemic events and major bleeding in patients with atrial fibrillation (AF) and recent acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI). Objective Determine the efficacy and safety of apixaban or vitamin K antagonists (VKA) and aspirin or placebo according to prior stroke, transient ischemic attack (TIA), or thromboembolism (TE). Design, Setting, and Participants In this prospective, multicenter, 2-by-2 factorial, randomized clinical trial, post hoc parallel analyses were performed to compare randomized treatment regimens according to presence or absence of prior stroke/TIA/TE using Cox proportional hazards models. Patients with AF, recent ACS or PCI, and planned use of P2Y12 inhibitors for 6 months or longer were included; 33 patients with missing data about prior stroke/TIA/TE were excluded. Interventions Apixaban (5 mg or 2.5 mg twice daily) or VKA and aspirin or placebo. Main Outcomes and Measures Major or clinically relevant nonmajor (CRNM) bleeding. Results Of 4581 patients included, 633 (13.8%) had prior stroke/TIA/TE. Patients with vs without prior stroke/TIA/TE were older; had higher CHA2DS2-VASC and HAS-BLED scores; and more frequently had prior bleeding, heart failure, diabetes, and prior oral anticoagulant use. Apixaban was associated with lower rates of major or CRNM bleeding and death or hospitalization than VKA in patients with (hazard ratio [HR], 0.69; 95% CI, 0.46-1.03) and without (HR, 0.68; 95% CI, 0.57-0.82) prior stroke/TIA/TE. Patients without prior stroke/TIA/TE receiving aspirin vs placebo had higher rates of bleeding; this difference appeared less substantial among patients with prior stroke/TIA/TE (P = .01 for interaction). Aspirin was associated with numerically lower rates of death or ischemic events than placebo in patients with (HR, 0.71; 95% CI, 0.42-1.20) and without (HR, 0.93; 95% CI, 0.72-1.21) prior stroke/TIA/TE (not statistically significant). Conclusions and Relevance The safety and efficacy of apixaban compared with VKA was consistent with the AUGUSTUS findings, irrespective of prior stroke/TIA/TE. Aspirin increased major or CRNM bleeding, particularly in patients without prior stroke/TIA/TE. Although aspirin may have some benefit in patients with prior stroke, our findings support the use of apixaban and a P2Y12 inhibitor without aspirin for the majority of patients with AF and ACS and/or PCI, regardless of prior stroke/TIA/TE status. Trial Registration ClinicalTrials.gov Identifier: NCT02415400.
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Affiliation(s)
- M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | - Amit N Vora
- UPMC Heart and Vascular Institute, Harrisburg, Pennsylvania.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Terrence Donnelly Heart Center, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - J Dedrick Jordan
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Brad J Kolls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Keith E Dombrowski
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa
| | - Dragos Vinereanu
- Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital, Bucharest, Romania
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | | | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Cardiovascular Research Foundation, New York, New York
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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17
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Zeitouni M, Marquis-Gravel G, Smilowitz NR, Zakroysky P, Wojdyla DM, Amit AP, Rao SV, Wang TY. Prophylactic Mechanical Circulatory Support Use in Elective Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease. Circ Cardiovasc Interv 2022; 15:e011534. [PMID: 35580202 DOI: 10.1161/circinterventions.121.011534] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices can be used in high-risk percutaneous coronary intervention (PCI). Our objective was to describe trends and outcomes of prophylactic MCS use in elective PCI for patients with stable coronary artery disease in the American College of Cardiology National Cardiovascular Data Registry's CathPCI registry. METHODS Among 2 108 715 consecutive patients with stable coronary artery disease undergoing elective PCI in the CathPCI registry between 2009 and 2018, we examined patterns of prophylactic use of MCS. Propensity score models with inverse probability of treatment weighting compared effectiveness (in-hospital death, cardiogenic shock, or new heart failure) and safety (stroke, tamponade, major bleeding, or vascular complication requiring treatment) between patients treated with intra-aortic balloon pump versus other MCS (Impella or extracorporeal membrane oxygenation). RESULTS Overall, 6905 (0.3%) patients underwent elective PCI with prophylactic MCS. MCS use trended up from 0.2% of elective PCIs in 2009 to 0.6% in 2018 (P<0.0001), driven by other MCS (P<0.0001), whereas intra-aortic balloon pump use remained low and constant (P=0.12). In-hospital major adverse cardiac events and cardiovascular complications occurred in 7.1% and 18.8% of elective PCI patients with prophylactic MCS use and 0.5% and 2.3% of patients without prophylactic MCS use. Intra-aortic balloon pump use was associated with a higher risk of major adverse cardiac events (9.6% versus 6.0%, adjusted odds ratio, 1.59 [95% CI, 1.32-1.91]) but lower risk of complications (18.2% versus 19.1%, adjusted odds ratio, 0.88 [95% CI, 0.77-0.99]) than use of other MCS. CONCLUSIONS The use of prophylactic MCS has increased over time for elective PCI in patients with stable coronary artery disease. Intra-aortic balloon pump was associated with higher major adverse cardiac events but lower risk of procedural complications compared with other MCS.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Guillaume Marquis-Gravel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Medical Center' New York (N.R.S.)
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Amin P Amit
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (A.P.A.)
| | - Sunil V Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
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Welsh RC, Dehghani P, Lopes R, Wojdyla DM, Aronson R, Granger CB, Windecker S, Vora AN, Vinereanu D, Halvorsen S, Parkhomenko A, Mehran R, Alexander JH, Goodman S. Impact of prior oral anticoagulant use and outcomes on patients from secondary analysis in the AUGUSTUS trial. Open Heart 2022; 9:openhrt-2021-001892. [PMID: 35172988 PMCID: PMC8852719 DOI: 10.1136/openhrt-2021-001892] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Managing antithrombotic therapy in patients with atrial fibrillation (AF) and an acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) is challenging and can be affected by prior oral anticoagulant (OAC) treatment. We examined the relationship between prior OAC use and outcomes in the AUGUSTUS trial. Methods This prespecified secondary analysis is from AUGUSTUS, an open-label, 2-by-2 factorial, RCT to evaluate the safety of apixaban versus vitamin K antagonist (VKA) and aspirin versus placebo in patients with AF and ACS and/or PCI. The primary endpoint, major or clinically relevant non-major bleeding and clinical outcomes were compared in patients receiving (n=2262) or not receiving (n=2352) an OAC prior to enrolment. Results Patients with prior OAC use had more comorbidities, higher CHA2DS2-VASC and HAS-BLED scores, and were more likely enrolled following elective PCI. There was no difference in major or clinically relevant non-major bleeding with or without prior OAC (30 days: 5.1% vs 5.9% (adjusted HR (aHR) 0.82, 95% CI 0.63 to 1.06); 180 days: 13.5% vs 13.5% (aHR 0.98, 95% CI 0.83 to 1.16)). Patients with prior OAC use had a lower risk of death or ischaemic events (30 days: 1.7% vs 2.8% (aHR 0.61, 95% CI 0.41 to 0.92); 180 days: 5.4% vs 7.6% (aHR 0.70, 95% CI 0.55 to 0.88)). No interactions between randomised treatment (apixaban vs VKA, aspirin vs placebo) and prior OAC status were observed for outcomes, apart from apixaban (vs VKA) being associated with a lower risk of myocardial infarction with prior OAC use (180 days: 2.0% vs 3.7% (aHR 0.56, 95% CI 0.33 to 0.91(). Conclusions In AUGUSTUS, prior OAC use was associated with fewer ischaemic events but not more bleeding. In patients with AF and ACS and/or undergoing PCI, clinicians can be assured that the trial results can be applied to patients regardless of their prior OAC status. Trial registration number NCT02415400.
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Affiliation(s)
- Robert C Welsh
- Cardiac Sciences, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Payam Dehghani
- Medicine, Regina Qu'Appelle Health Region, Regina, Saskatchewan, Canada
| | - Renato Lopes
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel M Wojdyla
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center, Bern, Switzerland
| | - Amit N Vora
- Cardiology, Pinnacle Heart and Vascular Institue, Harrisburg, Pennsylvania, USA
| | - Dragos Vinereanu
- Cardiology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Sigrun Halvorsen
- Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Alexander Parkhomenko
- Cardiology, National Scientific Center Academician M D Strazhesko Institute of Cardiology of the National Academy of Medical Sciences of Ukraine, Kiiv, Ukraine
| | - Roxana Mehran
- Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John H Alexander
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | - Shaun Goodman
- Canadian Heart Research Centre, Toronto, Ontario, Canada.,Terrence Donnelly Heart Centre, St Michael's Hospital, Toronto, Ontario, Canada
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19
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Harskamp RE, Fanaroff AC, Lopes RD, Wojdyla DM, Goodman SG, Thomas LE, Aronson R, Windecker S, Mehran R, Granger CB, Alexander JH. Antithrombotic Therapy in Patients With Atrial Fibrillation After Acute Coronary Syndromes or Percutaneous Intervention. J Am Coll Cardiol 2022; 79:417-427. [DOI: 10.1016/j.jacc.2021.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 12/30/2022]
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20
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Fudim M, Wojdyla DM, Alexander JH, Goodman SG, Mehran R, Windecker S, Aronson R, Vinereanu D, Halvorsen S, Bahit MC, Granger CB, Lopes RD. Efficacy and Safety of Antithrombotic Therapy in Patients With Atrial Fibrillation, Recent Acute Coronary Syndrome, or Percutaneous Coronary Intervention and a History of Heart Failure: Insights From the AUGUSTUS Trial. J Am Heart Assoc 2021; 10:e023143. [PMID: 34873913 PMCID: PMC9075233 DOI: 10.1161/jaha.121.023143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marat Fudim
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Daniel M. Wojdyla
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - John H. Alexander
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Shaun G. Goodman
- Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
- Terrence Donnelly Heart CentreSt Michael’s HospitalUniversity of TorontoOntarioCanada
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai, and Cardiovascular Research FoundationNew YorkNY
| | | | | | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol DavilaUniversity and Emergency Hospital of BucharestBucharestRomania
| | | | - M. Cecilia Bahit
- Fundación INECOINECO Neurociencias OroñoRosario, Santa FeArgentina
| | | | - Renato D. Lopes
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
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21
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White HD, Schwartz GG, Szarek M, Bhatt DL, Bittner VA, Chiang CE, Diaz R, Goodman SG, Jukema JW, Loy M, Pagidipati N, Pordy R, Ristić AD, Zeiher AM, Wojdyla DM, Steg PG. Alirocumab after acute coronary syndrome in patients with a history of heart failure. Eur Heart J 2021; 43:1554-1565. [PMID: 34922353 PMCID: PMC9020985 DOI: 10.1093/eurheartj/ehab804] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/16/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Patients with heart failure (HF) have not been shown to benefit from statins. In a post hoc analysis, we evaluated outcomes in ODYSSEY OUTCOMES in patients with vs. without a history of HF randomized to the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab or placebo. METHODS AND RESULTS Among 18 924 patients with recent acute coronary syndrome (ACS) receiving intensive or maximum-tolerated statin treatment, the primary outcome of major adverse cardiovascular events (MACE) was compared in patients with or without a history of HF. The pre-specified secondary outcome of hospitalization for HF was also analysed. Overall, 2815 (14.9%) patients had a history of HF. Alirocumab reduced low-density lipoprotein cholesterol and lipoprotein(a) similarly in patients with or without HF. Overall, alirocumab reduced MACE compared with placebo [hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.78-0.93; P = 0.0001]. This effect was observed among patients without a history of HF (HR: 0.78; 95% CI: 0.70-0.86; P < 0.0001), but not in those with a history of HF (HR: 1.17; 95% CI: 0.97-1.40; P = 0.10) (Pinteraction = 0.0001). Alirocumab did not reduce hospitalization for HF, overall or in patients with or without prior HF. CONCLUSION Alirocumab reduced MACE in patients without a history of HF but not in patients with a history of HF. Alirocumab did not reduce hospitalizations for HF in either group. Patients with a history of HF are a high-risk group that does not appear to benefit from PCSK9 inhibition after ACS. KEY QUESTION Patients with heart failure (HF) have not been shown to benefit from statins. In a post hoc analysis of the ODYSSEY OUTCOMES trial in patients with recent acute coronary syndrome (ACS), we evaluated major adverse cardiovascular events (MACE) in patients with or without a history of HF assigned to treatment with the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab or placebo. KEY FINDING Alirocumab reduced low-density lipoprotein cholesterol similarly in patients with or without HF. However, alirocumab reduced MACE among patients without a history of HF, but not in those with a history of HF. TAKE HOME MESSAGE The current hypothesis-generating analysis does not provide a basis to recommend PCSK9 inhibitors to patients with recent ACS and a history of HF. A prospective placebo-controlled evaluation of PCSK9 inhibition in this setting is warranted.
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Affiliation(s)
- Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital, 5 Park Road, Grafton, Auckland, New Zealand
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, B130, Aurora, CO 80045, USA
| | - Michael Szarek
- Department of Epidemiology and Biostatistics, State University of New York, Downstate School of Public Health, 450 Clarkson Avenue, MS 43, Brooklyn, NY 11203, USA.,CPC Clinical Research, 13199 E Montview Blvd Suite 200, Aurora, CO 80045, USA.,Division of Cardiology, University of Colorado School of Medicine, Fitzsimons Building - 13001 E. 17th Place, Campus Box C290, Aurora, CO 80045, USA
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 701 19th Street South-LHRB 310, Birmingham, AL 35294, USA
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital and Taiwan School of Medicine, National Yang-Ming University, 201, Sec. 2, Shih-Pai road, Taipei, Taiwan
| | - Rafael Diaz
- Estudios Clınicos Latino America, Instituto Cardiovascular de Rosario, Paraguay 160, Santa Fe, Rosario 2000, Argentina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, 87 Ave NW, Edmonton, Alberta T6G 2E1, Canada.,Division of Cardiology, St. Michael's Hospital, Room 6-034 Donnelly Wing, Toronto, Ontario M5B 1W8, Canada
| | - Johan Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands.,Netherlands Heart Institute, Moreelsepark 1, Utrecht 3511 EP, the Netherlands
| | - Megan Loy
- Sanofi, 55 Corporate Dr, Bridgewater, NJ 08807, USA
| | - Neha Pagidipati
- Duke Clinical Research Institute, Duke University, School of Medicine, 300 W. Morgan St., NC 27701, USA
| | - Robert Pordy
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Rd, Tarrytown, NY 10591, USA
| | - Arsen D Ristić
- Department of Cardiology, University Clinical Center of Serbia, Belgrade University School of Medicine, 8 Dr Subotića Street, Belgrade
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University, School of Medicine, 300 W. Morgan St., NC 27701, USA
| | - Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, 46 Rue Henri Huchard, Paris, 75018 France.,National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
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22
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Sinnaeve PR, Schwartz GG, Wojdyla DM, Alings M, Bhatt DL, Bittner VA, Chiang CE, Correa Flores RM, Diaz R, Dorobantu M, Goodman SG, Jukema JW, Kim YU, Pordy R, Roe MT, Sy RG, Szarek M, White HD, Zeiher AM, Steg PG. Effect of alirocumab on cardiovascular outcomes after acute coronary syndromes according to age: an ODYSSEY OUTCOMES trial analysis. Eur Heart J 2021; 41:2248-2258. [PMID: 31732742 PMCID: PMC7308542 DOI: 10.1093/eurheartj/ehz809] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
Aims Lowering low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular risk irrespective of age, but the evidence is less strong for older patients. Methods and results This prespecified analysis from ODYSSEY OUTCOMES compared the effect of alirocumab vs. placebo in 18 924 patients with recent acute coronary syndrome (ACS) according to age. We examined the effect of assigned treatment on occurrence of the primary study outcome, a composite of coronary heart disease death, myocardial infarction, ischaemic stroke, or unstable angina requiring hospitalization [major adverse cardiovascular event (MACE)] and all-cause death. Relative risk reductions were consistent for patients ≥65 vs. <65 years for MACE [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.68–0.91 vs. 0.89, 0.80–1.00; Pinteraction = 0.19] and all-cause death [HR 0.77, 0.62–0.95 vs. 0.94, 0.77–1.15; Pinteraction = 0.46], and consistent for MACE when dichotomizing at age 75 years (HR 0.85, 0.64–1.13 in ≥75 vs. 0.85, 0.78–0.93 in <75, Pinteraction = 0.19). When considering age as a continuous variable in regression models, advancing age increased risk of MACE, as well as the absolute reduction in MACE with alirocumab, with numbers-needed-to-treat for MACE at 3 years of 43 (25–186) at age 45 years, 26 (15–97) at age 75 years, and 12 (6–81) for those at age 85 years. Although adverse events were more frequent in older patients, there were no differences between alirocumab and placebo. Conclusion In patients with recent ACS, alirocumab improves outcomes irrespective of age. Increasing absolute benefit but not harm with advancing age suggests that LDL-C lowering is an important preventive intervention for older patients after ACS. ![]()
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Affiliation(s)
- Peter R Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Box B130, Aurora, CO 80045, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, 200 Morris Street, Durham, NC 27701, USA
| | - Marco Alings
- Department of Cardiology, Amphia Ziekenhuis Molengracht, 4818 CK Breda, Netherlands
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Shih-Pai Road, 11217 Taipei, Taiwan
| | - Roger M Correa Flores
- Department of Internal Medicine, Cardiology, Alberto Sabogal Sologuren, ESSALUD, Jirón Colina 1081, Bellavista - Callao, Lima CA01, Peru
| | - Rafael Diaz
- Cardiology Department, Instituto Cardiovascular de Rosario, Paraguay 160, Santa Fe, Rosario 2000, Argentina
| | - Maria Dorobantu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 8 Calea Floreasca, ET 6 014461 Bucharest, Romania
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, 87 Ave NW, Edmonton, Alberta T6G 2E1, Canada.,Division of Cardiology, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, Netherlands
| | - Yong-Un Kim
- R&D Clinical Development, Sanofi, 1 avenue Pierre Brossolette, 91380 Chilly-Mazarin, France
| | - Robert Pordy
- Clinical Sciences - Cardiovascular & Metabolism Therapeutics, Regeneron Pharmaceuticals Inc., 777 Old Saw Mill River Rd, Tarrytown, NY 10591, USA
| | - Matthew T Roe
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, 200 Morris Street, Durham, NC 27701, USA
| | - Rody G Sy
- Cardiovascular Institute, Cardinal Santos Medical Center, Wilson Street, San Juan, 1502 Metro Manila, Philippines
| | - Michael Szarek
- Downstate School of Public Health, State University of New York, 450 Clarkson Avenue, MS 43, Brooklyn, NY 11203 USA
| | - Harvey D White
- Green Lane Cardiovascular Services, Auckland 20 City Hospital, Auckland, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | - Ph Gabriel Steg
- Hopital Bichat, Universiteé de Paris, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Assistance Publique-Hopitaux de Paris, Paris, France.,National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK
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23
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Yang S, Lorenzi E, Papadogeorgou G, Wojdyla DM, Li F, Thomas LE. Propensity score weighting for causal subgroup analysis. Stat Med 2021; 40:4294-4309. [PMID: 33982316 PMCID: PMC8360075 DOI: 10.1002/sim.9029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 10/12/2020] [Revised: 03/20/2021] [Accepted: 04/25/2021] [Indexed: 01/08/2023]
Abstract
A common goal in comparative effectiveness research is to estimate treatment effects on prespecified subpopulations of patients. Though widely used in medical research, causal inference methods for such subgroup analysis (SGA) remain underdeveloped, particularly in observational studies. In this article, we develop a suite of analytical methods and visualization tools for causal SGA. First, we introduce the estimand of subgroup weighted average treatment effect and provide the corresponding propensity score weighting estimator. We show that balancing covariates within a subgroup bounds the bias of the estimator of subgroup causal effects. Second, we propose to use the overlap weighting (OW) method to achieve exact balance within subgroups. We further propose a method that combines OW and LASSO, to balance the bias‐variance tradeoff in SGA. Finally, we design a new diagnostic graph—the Connect‐S plot—for visualizing the subgroup covariate balance. Extensive simulation studies are presented to compare the proposed method with several existing methods. We apply the proposed methods to the patient‐centered results for uterine fibroids (COMPARE‐UF) registry data to evaluate alternative management options for uterine fibroids for relief of symptoms and quality of life.
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Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Laine E Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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24
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Hijazi Z, Alexander JH, Li Z, Wojdyla DM, Mehran R, Granger CB, Parkhomenko A, Bahit MC, Windecker S, Aronson R, Berwanger O, Halvorsen S, de Waha-Thiele S, Sinnaeve P, Darius H, Storey RF, Lopes RD. Apixaban or Vitamin K Antagonists and Aspirin or Placebo According to Kidney Function in Patients With Atrial Fibrillation After Acute Coronary Syndrome or Percutaneous Coronary Intervention: Insights From the AUGUSTUS Trial. Circulation 2021; 143:1215-1223. [PMID: 33461308 DOI: 10.1161/circulationaha.120.051020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the AUGUSTUS trial (An Open-Label, 2×2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists, and aspirin caused more bleeding than placebo in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention treated with a P2Y12 inhibitor. We evaluated the risk-benefit balance of antithrombotic therapy according to kidney function. METHODS In 4456 patients, the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula was used to calculate baseline estimated glomerular filtration rate (eGFR). The effect of apixaban versus vitamin K antagonists and aspirin versus placebo was assessed across kidney function categories by using Cox models. The primary outcome was International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding. Secondary outcomes included death or hospitalization and ischemic events (death, stroke, myocardial infarction, stent thrombosis [definite or probable], or urgent revascularization). Creatinine clearance <30 mL/min was an exclusion criterion in the AUGUSTUS trial. RESULTS Overall, 30%, 52%, and 19% had an eGFR of >80, >50 to 80, and 30 to 50 mL·min-1·1.73 m-2, respectively. At the 6-month follow-up, a total of 543 primary outcomes of bleeding, 1125 death or hospitalizations, and 282 ischemic events occurred. Compared with vitamin K antagonists, patients assigned apixaban had lower rates for all 3 outcomes across most eGFR categories without significant interaction. The absolute risk reduction with apixaban was most pronounced in those with an eGFR of 30 to 50 mL·min-1·1.73 m-2 for bleeding events with rates of 13.1% versus 21.3% (hazard ratio, 0.59; 95% CI, 0.41-0.84). Patients assigned aspirin had a higher risk of bleeding in all eGFR categories with an even greater increase among those with eGFR >80 mL·min-1·1.73 m-2: 16.6% versus 5.6% (hazard ratio, 3.22; 95% CI, 2.19-4.74; P for interaction=0.007). The risk of death or hospitalization and ischemic events were comparable to aspirin and placebo across eGFR categories with hazard ratios ranging from 0.97 (95% CI, 0.76-1.23) to 1.28 (95% CI, 1.02-1.59) and from 0.75 (95% CI, 0.48-1.17) to 1.34 (95% CI, 0.81-2.22), respectively. CONCLUSIONS The safety and efficacy of apixaban was consistent irrespective of kidney function, compared with warfarin, and in accordance with the overall trial results. The risk of bleeding with aspirin was consistently higher across all kidney function categories. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02415400.
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (Z.H.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Roxana Mehran
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and Cardiovascular Research Foundation, New York, NY (R.M.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | | | - M Cecilia Bahit
- Instituto de Neurología Cognitiva (INECO) Neurociencias Oroño, Fundación INECO, Rosario, Argentina (M.C.B.)
| | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W.)
| | | | | | | | - Suzanne de Waha-Thiele
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany (S.dW.-T.).,German Center for Cardiovascular Research (DZHK), Lübeck (S.dW.-T.)
| | - Peter Sinnaeve
- University Hospitals Leuven, University of Leuven, Belgium (P.S.)
| | - Harald Darius
- Vivantes Neukoelln Medical Center, Berlin, Germany (H.D.)
| | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
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25
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Carnicelli AP, Al-Khatib SM, Xavier D, Dalgaard F, Merrill PD, Wojdyla DM, Lewis BS, Hanna M, Alexander JH, Lopes RD, Wallentin L, Granger CB. Premature permanent discontinuation of apixaban or warfarin in patients with atrial fibrillation. Heart 2020; 107:713-720. [PMID: 32938772 DOI: 10.1136/heartjnl-2020-317229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 04/29/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS The ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial randomised patients with atrial fibrillation at risk of stroke to apixaban or warfarin. We sought to describe patients from ARISTOTLE who prematurely permanently discontinued study drug. METHODS/RESULTS We performed a posthoc analysis of patients from ARISTOTLE who prematurely permanently discontinued study drug during the study or follow-up period. Discontinuation rates and reasons for discontinuation were described. Death, thromboembolism (stroke, transient ischaemic attack, systemic embolism), myocardial infarction and major bleeding rates were stratified by ≤30 days or >30 days after discontinuation. A total of 4063/18 140 (22.4%) patients discontinued study drug at a median of 7.3 (2.2, 15.2) months after randomisation. Patients with discontinuation were more likely to be female and had a higher prevalence of cardiovascular disease, diabetes, renal impairment and anaemia. Premature permanent discontinuation was more common in those randomised to warfarin than apixaban (23.4% vs 21.4%; p=0.002). The most common reasons for discontinuation were patient request (46.1%) and adverse event (34.9%), with no significant difference between treatment groups. The cumulative incidence of clinical events ≤30 days after premature permanent discontinuation for all-cause death, thromboembolism, myocardial infarction, and major bleeding was 5.8%, 2.6%, 0.9%, and 3.0%, respectively. No significant difference was seen between treatment groups with respect to clinical outcomes after discontinuation. CONCLUSION Premature permanent discontinuation of study drug in ARISTOTLE was common, less frequent in patients receiving apixaban than warfarin and was followed by high 30-day rates of death, thromboembolism and major bleeding. Initiatives are needed to reduce discontinuation of oral anticoagulation.
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Affiliation(s)
| | | | - Denis Xavier
- St John's Medical College, Bangalore, Karnataka, India
| | | | - Peter D Merrill
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Michael Hanna
- Bristol-Myers Squibb Pharmaceutical Research and Development, Princeton, New Jersey, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Lars Wallentin
- Uppsala Clinical Research Center, University of Uppsala, Uppsala, Sweden
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26
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Rymer JA, Kaltenbach LA, Kochar A, Hess CN, Gilchrist IC, Messenger JC, Harrington RA, Jolly SS, Jacobs AK, Abbott JD, Wojdyla DM, Krucoff MW, Rao SV. Comparison of Rates of Bleeding and Vascular Complications Before, During, and After Trial Enrollment in the SAFE-PCI Trial for Women. Circ Cardiovasc Interv 2020; 12:e007086. [PMID: 31014090 DOI: 10.1161/circinterventions.118.007086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 11/16/2022]
Abstract
BACKGROUND SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women), a randomized controlled trial comparing radial and femoral access in women undergoing cardiac catheterization or percutaneous coronary intervention (PCI), was terminated early for lower than expected event rates. Whether this was because of patient selection or better access site practice among trial patients is unknown. METHODS AND RESULTS SAFE-PCI was conducted within the National Cardiovascular Data Registry CathPCI registry. Using the National Cardiovascular Research Infrastructure Identification, PCI date, and age, patients enrolled in SAFE-PCI were compared with trial-eligible female CathPCI registry patients 1 year before, during, and 1 year after SAFE-PCI enrollment. Patient and procedure characteristics, predicted bleeding and mortality, and post-PCI bleeding were compared between groups. Enrolled SAFE-PCI patients and registry patients from the 3 time periods were linked to Centers for Medicare and Medicaid Services data to compare 30-day death and unplanned revascularization rates. At 54 SAFE-PCI sites, there were 496 SAFE-PCI trial patients with a PCI visit within the CathPCI registry. There were 24 958 registry patients from 1 year before and 1 year after SAFE-PCI enrollment and 15 904 trial-eligible registry patients during trial enrollment. Trial patients were younger, had lower predicted bleeding and mortality, and had lower rates of post-PCI bleeding within 72 hours compared with registry patients. Among 12 212 Centers for Medicare and Medicaid Services-linked patients, there were no significant differences in 30-day death and unplanned revascularization among the 4 groups. CONCLUSIONS Lower predicted risk of bleeding and mortality among SAFE-PCI trial patients compared with registry patients suggests that lower-risk patients were selectively enrolled for the trial. These data demonstrate how registry-based randomized trials may offer methods for enrollment feedback to curb selection bias in recruitment. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01406236.
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Affiliation(s)
- Jennifer A Rymer
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Lisa A Kaltenbach
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W.)
| | - Ajar Kochar
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Connie N Hess
- Division of Cardiology, University of Colorado School of Medicine, Aurora (C.N.H., J.C.M.)
| | - Ian C Gilchrist
- Department of Medicine, Penn State University, Hershey, PA (I.C.G.)
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora (C.N.H., J.C.M.)
| | | | - Sanjit S Jolly
- Department of Medicine, McMaster University, Hamilton, ON (S.S.J.)
| | | | - J Dawn Abbott
- Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (J.D.A.)
| | - Daniel M Wojdyla
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W.)
| | - Mitchell W Krucoff
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Sunil V Rao
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
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27
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Aberra T, Peterson ED, Pagidipati NJ, Mulder H, Wojdyla DM, Philip S, Granowitz C, Navar AM. The association between triglycerides and incident cardiovascular disease: What is "optimal"? J Clin Lipidol 2020; 14:438-447.e3. [PMID: 32571728 DOI: 10.1016/j.jacl.2020.04.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elevated triglycerides (TGs) are associated with increased risk of cardiovascular disease (CVD), but the best way to both measure TGs and assess TG-related risk remains unknown. OBJECTIVE The objective of the study was to evaluate the association between TGs and CVD and determine whether the average of a series of TG measurements is more predictive of CVD risk than a single TG measurement. METHODS We examined 15,792 study participants, aged 40-65 years, free of CVD from the Atherosclerosis Risk in Communities and Framingham Offspring studies, using fasting TG measurements across multiple examinations over time. With up to 10 years of follow-up, we assessed time-to-first CVD event, as well as a composite of myocardial infarction, stroke, or cardiovascular death. RESULTS Compared with a single TG measurement, average TGs over time had greater discrimination for CVD risk (C-statistic, 0.60 vs 0.57). Risk for CVD increased as average TGs rose until an inflection point of ~100 mg/dL in men and ~200 mg/dL in women, above which this risk association plateaued. The relationship between average TGs and CVD remained statistically significant in multivariable modeling adjusting for low-density lipoprotein cholesterol, and interactions were found by sex and high-density lipoprotein cholesterol level. CONCLUSIONS The average of several TG readings provides incremental improvements for the prediction of CVD relative to a single TG measurement. Regardless of the method of measurement, higher TGs were associated with increased CVD risk, even at levels previously considered "optimal" (<150 mg/dL).
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Affiliation(s)
- Tsion Aberra
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Sephy Philip
- Department of Medical Affairs, Amarin Pharma, Inc., Bedminster, NJ, USA
| | - Craig Granowitz
- Department of Medical Affairs, Amarin Pharma, Inc., Bedminster, NJ, USA
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28
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Stanifer JW, Pokorney SD, Chertow GM, Hohnloser SH, Wojdyla DM, Garonzik S, Byon W, Hijazi Z, Lopes RD, Alexander JH, Wallentin L, Granger CB. Apixaban Versus Warfarin in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease. Circulation 2020; 141:1384-1392. [DOI: 10.1161/circulationaha.119.044059] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [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: 12/12/2022]
Abstract
Background:
Compared with the general population, patients with advanced chronic kidney disease have a >10-fold higher burden of atrial fibrillation. Limited data are available guiding the use of nonvitamin K antagonist oral anticoagulants in this population.
Methods:
We compared the safety of apixaban with warfarin in 269 patients with atrial fibrillation and advanced chronic kidney disease (defined as creatinine clearance [CrCl] 25 to 30 mL/min) enrolled in the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation). Cox proportional models were used to estimate hazard ratios for major bleeding and major or clinically relevant nonmajor bleeding. We characterized the pharmacokinetic profile of apixaban by assessing differences in exposure using nonlinear mixed effects models.
Results:
Among patients with CrCl 25 to 30 mL/min, apixaban caused less major bleeding (hazard ratio, 0.34 [95% CI, 0.14–0.80]) and major or clinically relevant nonmajor bleeding (hazard ratio, 0.35 [95% CI, 0.17–0.72]) compared with warfarin. Patients with CrCl 25 to 30 mL/min randomized to apixaban demonstrated a trend toward lower rates of major bleeding when compared with those with CrCl >30 mL/min (
P
interaction=0.08) and major or clinically relevant nonmajor bleeding (
P
interaction=0.05). Median daily steady-state areas under the curve for apixaban 5 mg twice daily were 5512 ng/(mL·h) and 3406 ng/(mL·h) for patients with CrCl 25 to 30 mL/min or >30 mL/min, respectively. For apixaban 2.5 mg twice daily, the median exposure was 2780 ng/(mL·h) for patients with CrCl 25 to 30 mL/min. The area under the curve values for patients with CrCl 25 to 30 mL/min fell within the ranges demonstrated for patients with CrCl >30 mL/min.
Conclusions:
Among patients with atrial fibrillation and CrCl 25 to 30 mL/min, apixaban caused less bleeding than warfarin, with even greater reductions in bleeding than in patients with CrCl >30 mL/min. We observed substantial overlap in the range of exposure to apixaban 5 mg twice daily for patients with or without advanced chronic kidney disease, supporting conventional dosing in patients with CrCl 25 to 30 mL/min. Randomized, controlled studies evaluating the safety and efficacy of apixaban are urgently needed in patients with advanced chronic kidney disease, including those receiving dialysis.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT00412984.
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Affiliation(s)
- John W. Stanifer
- Munson Nephrology, Munson Healthcare, Traverse City, MI (J.W.S.)
| | - Sean D. Pokorney
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, CA (G.M.C.)
| | | | - Daniel M. Wojdyla
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Samira Garonzik
- Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb Company, Princeton, NJ (S.G.)
| | - Wonkyung Byon
- Global Product Development Clinical Pharmacology, Pfizer, Inc, Groton, CT (W.B.)
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center (Z.H., L.W.), Uppsala University, Sweden
| | - Renato D. Lopes
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - John H. Alexander
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center (Z.H., L.W.), Uppsala University, Sweden
| | - Christopher B. Granger
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
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29
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Lopes RD, Leonardi S, Wojdyla DM, Vora AN, Thomas L, Storey RF, Vinereanu D, Granger CB, Goodman SG, Aronson R, Windecker S, Thiele H, Valgimigli M, Mehran R, Alexander JH. Stent Thrombosis in Patients With Atrial Fibrillation Undergoing Coronary Stenting in the AUGUSTUS Trial. Circulation 2020; 141:781-783. [DOI: 10.1161/circulationaha.119.044584] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [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)
- Renato D. Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.D.L., D.M.W., L.T., C.B.G., J.H.A.)
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Italy (S.L.)
| | - Daniel M. Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.D.L., D.M.W., L.T., C.B.G., J.H.A.)
| | | | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.D.L., D.M.W., L.T., C.B.G., J.H.A.)
| | | | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Romania (D.V.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.D.L., D.M.W., L.T., C.B.G., J.H.A.)
| | - Shaun G. Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
- Terrence Donnelly Heart Centre, St Michael’s Hospital, University of Toronto, ON, Canada (S.G.G.)
| | | | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W., M.V.)
| | - Holger Thiele
- Heart Center Leipzig at the University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Germany (H.T.)
| | - Marco Valgimigli
- Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W., M.V.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and Cardiovascular Research Foundation, New York (R.M.)
| | - John H. Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.D.L., D.M.W., L.T., C.B.G., J.H.A.)
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30
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Zeitouni M, Giczewska A, Lopes RD, Wojdyla DM, Christersson C, Siegbahn A, De Caterina R, Steg PG, Granger CB, Wallentin L, Alexander JH. Clinical and Pharmacological Effects of Apixaban Dose Adjustment in the ARISTOTLE Trial. J Am Coll Cardiol 2020; 75:1145-1155. [DOI: 10.1016/j.jacc.2019.12.060] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 01/15/2023]
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31
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Navar AM, Peterson ED, Steen DL, Wojdyla DM, Sanchez RJ, Khan I, Song X, Gold ME, Pencina MJ. Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research. JAMA Cardiol 2020; 4:375-379. [PMID: 30840023 DOI: 10.1001/jamacardio.2019.0198] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 01/04/2023]
Abstract
Importance Despite its documented undercapture of mortality data, the US Social Security Administration Death Master File (SSDMF) is still often used to provide mortality end points in retrospective clinical studies. Changes in death data reporting to SSDMF in 2011 may have further affected the reliability of mortality end points, with varying consequences over time and by state. Objective To evaluate the reliability of mortality rates in the SSDMF in a cohort of patients with atherosclerotic cardiovascular disease (ASCVD). Design, Setting, and Participants This observational analysis used the IBM MarketScan Medicare and commercial insurance databases linked to mortality information from the SSDMF. Adults with ASCVD who had a clinical encounter between January 1, 2012, and December 31, 2013, at least 2 years of follow-up, and from states with 1000 or more eligible adults with ASCVD were included in the study. Data analysis was conducted between April 18 and May 21, 2018. Main Outcomes and Measures Kaplan-Meier analyses were conducted to estimate state-level mortality rates for adults with ASCVD, stratified by database (commercial or Medicare). Constant hazards of mortality by state were tested, and individual state Kaplan-Meier curves for temporal changes were evaluated. For states in which the hazard of death was constant over time, mortality rates for adults with ASCVD were compared with state-level, age group-specific overall mortality rates in 2012, as reported by the National Center for Health Statistics (NCHS). Results This study of mortality data of 667 516 adults with ASCVD included 274 005 adults in the commercial insurance database cohort (171 959 male [62.8%] and median [interquartile range (IQR)] age of 58 [52-62] years) and 393 511 in the Medicare database cohort (245 366 male [62.4%] and median [IQR] age of 76 [70-83] years). Of the 41 states included, 11 states (26.8%) in the commercial cohort and 18 states (43.9%) in the Medicare cohort had a change in the hazard of death after 2012. Among states with constant hazard, state-level mortality rates using the SSDMF ranged widely, from 0.06 to 1.30 per 100 person-years (commercial cohort) and from 0.83 to 6.07 per 100 person-years (Medicare cohort). Variability between states in mortality estimates for adults with ASCVD using SSDMF data greatly exceeded variability in overall mortality from the NCHS. No correlation was found between NCHS mortality estimates and those from the SSDMF (ρ = 0.29 [P = .06] for age 55-64 years; ρ = 0.18 [P = .27] for age 65-74 years). Conclusions and Relevance The SSDMF appeared to markedly underestimate mortality rates, with variable undercapture among states and over time; this finding suggests that SSDMF data are not reliable and should not be used alone by researchers to estimate mortality rates.
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Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Associate Editor
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Dylan L Steen
- Associate Editor.,Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Xue Song
- IBM Watson Health, Cambridge, Massachusetts
| | - Matthew E Gold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Deputy Editor for Statistics
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32
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Navar AM, Mulder HM, Wojdyla DM, Peterson ED. Have the Major Cardiovascular Outcomes Trials Impacted Payer Approval Rates for PCSK9 Inhibitors? Circ Cardiovasc Qual Outcomes 2020; 13:e006019. [PMID: 31918581 DOI: 10.1161/circoutcomes.119.006019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Hillary M Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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33
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Pagidipati N, Wojdyla DM, Robinson J, Navar AM, Peterson ED, Pencina M. P3822Risk prediction for ASCVD in primary prevention patients on statin therapy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/14/2022] Open
Abstract
Abstract
Background
Statins are now widely used for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, existing risk prediction models were developed primarily on patients not on statins. We developed a novel model to estimate the risk of ASCVD among contemporary patients taking statins.
Methods
Using combined data from 3 large NIH-sponsored cohort studies: Atherosclerosis Risk in Communities, Framingham Offspring Study, and Multi-ethnic Study of Atherosclerosis we examined adults aged 40–79 years without prior ASCVD who were on statin therapy at the baseline exam. A Cox proportional hazards model was used to identify factors associated with a 10-year risk of CV death, MI, or stroke. Age, sex, and race were forced into the model while other potential candidate predictors were retained if statistically significant at the 0.05 level. Interaction terms with age, sex, and race were retained if significant at the 0.01 level. The model was assessed with c-statistic and calibration plots of observed events versus model-based risks after cross-validation and contrasted with the Pooled Cohorts Equations (PCE) recommended by the current U.S. guidelines.
Results
Among 2333 primary prevention patients on statins at baseline, a total of 220 events occurred over a median 8.8 years of follow-up. Most risk factors retained in our final model overlapped with those included in the PCE (age, sex, race, systolic blood pressure [sBP], diabetes, smoking, high-density lipoprotein cholesterol, total cholesterol). Our model also included creatinine clearance, aspirin use, and the interaction between age and sBP. Optimism-corrected discrimination of the new model was marginally higher than PCE: 0.69 (95% CI 0.66–0.72) versus 0.68 (95% CI 0.65–0.72). Cross-validated calibration was superior on our contemporary sample, especially at the higher levels of risk (Figure), where PCE over-estimated risk.
Calibration plots
Conclusion
Accurate estimation of 10-year ASCVD risk among patients currently on statins necessitates recalibration of the current PCE model or application of our algorithm developed specifically for this cohort. This might help avoid over-estimation of risk and reduce the need for unnecessary additional lipid-lowering therapy.
Acknowledgement/Funding
Regeneron Pharmaceuticals
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Affiliation(s)
- N Pagidipati
- Duke Clinical Research Institute, Cardiology, Durham, United States of America
| | - D M Wojdyla
- Duke Clinical Research Institute, Durham, United States of America
| | - J Robinson
- University of Iowa, Iowa City, United States of America
| | - A M Navar
- Duke Clinical Research Institute, Cardiology, Durham, United States of America
| | - E D Peterson
- Duke Clinical Research Institute, Cardiology, Durham, United States of America
| | - M Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
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34
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Vora AN, Alexander JH, Wojdyla DM, Aronson R, Granger CB, Darius H, Windecker S, Mehran R, Averkov O, Budaj A, Kong DF, Kobalava Z, Mehta RH, Mirza Z, Guimaraes PO, Parkhomenko A, Quadros A, Thiele H, Goodman SG, Lopes RD. Hospitalization Among Patients With Atrial Fibrillation and a Recent Acute Coronary Syndrome or Percutaneous Coronary Intervention Treated With Apixaban or Aspirin: Insights From the AUGUSTUS Trial. Circulation 2019; 140:1960-1963. [PMID: 31553201 DOI: 10.1161/circulationaha.119.043754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amit N Vora
- UPMC Pinnacle, Harrisburg, PA (A.N.V.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | | | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | - Harald Darius
- Vivantes Neukoelln Medical Center, Berlin, Germany (H.D.)
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (S.W.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and Cardiovascular Research Foundation, New York (R.M.)
| | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow (O.A.)
| | - Andrzej Budaj
- Department of Cardiology, Grochowski Hospital, Warsaw, Poland (A.B.)
| | - David F Kong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | | | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
| | | | | | | | - Alexandre Quadros
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, Brazil (A.Q.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
| | - Shaun G Goodman
- Canadian VIGOUR Center, University of Alberta, Edmonton (S.G.G.).,Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, ON, Canada (S.G.G.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.N.V., J.H.A., D.M.W., C.B.G., D.F.K., R.H.M., R.D.L.)
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35
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Sharma A, Hagström E, Wojdyla DM, Neely ML, Harrington RA, Wallentin L, Alexander JH, Goodman SG, Lopes RD. Clinical consequences of bleeding among individuals with a recent acute coronary syndrome: Insights from the APPRAISE-2 trial. Am Heart J 2019; 215:106-113. [PMID: 31310855 DOI: 10.1016/j.ahj.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/06/2019] [Indexed: 11/25/2022]
Abstract
Patients with a recent acute coronary syndrome (ACS) receiving oral antiplatelets and anticoagulants are at risk for bleeding and subsequent adverse non-bleeding-related events. METHODS In this post hoc analysis, we evaluated 7,392 high-risk patients (median follow-up 241 days) with a recent ACS randomized to apixaban or placebo in APPRAISE-2. Clinical events during a 30-day period after Thrombolysis in Myocardial Infarction (TIMI) major/minor bleeding were analyzed using unadjusted and adjusted Cox proportional-hazards models. RESULTS In total, 153 (2.1%) patients experienced TIMI major/minor bleeding during follow-up. Bleeding risk for patients on triple therapy (apixaban, thienopyridine, and aspirin) was increased compared with those on dual therapy (apixaban plus aspirin: hazard ratio [HR] 2.02, 95% CI 1.08-3.79; thienopyridine plus aspirin: HR 1.99, 95% CI 1.41-2.83). Those receiving apixaban/aspirin had similar bleeding risk compared with those receiving thienopyridine/aspirin (HR 1.01, 95% CI 0.53-1.95). Patients who experienced TIMI major/minor bleeding had an increased risk of 30-day all-cause mortality (HR 24.7, 95% CI 15.34-39.66) and ischemic events (HR 6.7, 95% CI 3.14-14.14). CONCLUSIONS In a contemporary cohort of high-risk patients after ACS, bleeding was associated with a significantly increased risk of subsequent ischemic events and mortality regardless of antithrombotic or anticoagulant strategy. Patients receiving apixaban plus aspirin had a similar bleeding risk compared with those receiving thienopyridine plus aspirin. Interventions to improve outcomes in patients after ACS should include strategies to optimize the reduction in ischemic events while minimizing the risk of bleeding.
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Åkerblom A, Wojdyla DM, Wallentin L, James SK, de Souza Brito F, Steg PG, Cannon CP, Katus HA, Himmelmann A, Storey RF, Becker RC, Lopes RD. Ticagrelor in patients with heart failure after acute coronary syndromes-Insights from the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2019; 213:57-65. [PMID: 31108273 DOI: 10.1016/j.ahj.2019.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 04/10/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure (HF) following acute coronary syndromes (ACS) is associated with worse prognosis; however, the efficacy and safety of ticagrelor in patients with HF and if ticagrelor influences the risk of new-onset HF are unknown. METHODS We examined the efficacy and safety of ticagrelor compared to clopidogrel in patients with ACS in the randomized PLATelet inhibition and patient Outcomes (PLATO) trial subdivided by strata: (1) previous HF and/or clinical signs of HF on admission or (2) no HF on admission. The primary outcome was the combination of cardiovascular death, myocardial infarction, or stroke evaluated by multivariable Cox regression models. The safety outcome was major bleeding. New-onset HF was defined as an HF event after discharge in patients without previous HF. RESULTS Data were available in 18,556 patients, whom 2,862 (15.4%) patients had HF, including 1,584 (8.5%) patients with previous HF. Patients randomized to ticagrelor had lower risk of the composite end point regardless of HF status: hazard ratio (HR) 0.87 (95% CI: 0.73-1.03) in patients with HF and HR 0.84 (95% CI: 0.75-0.93) in patients with no HF (P = .76). Corresponding HR for major bleeding were HR 1.08 (95% CI: 0.87-1.34) and HR 1.03 (95% CI: 0.94-1.14) (P = .71). There was no difference in new-onset HF at 12 months between patients randomized to ticagrelor (4.1%, n = 278) or clopidogrel (4.0%, n = 276). CONCLUSIONS In patients with ACS, ticagrelor is more efficacious in protecting against new ischemic events and mortality than clopidogrel irrespective of the presence of HF. There is no difference between ticagrelor or clopidogrel treatment in new-onset HF post-ACS.
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Affiliation(s)
- Axel Åkerblom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Philippe Gabriel Steg
- Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Paris, France; Paris Diderot University, Sorbonne Paris Cité, Paris, France; NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK; FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, INSERM U1148, Paris, France
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA and Baim Institute, Boston, MA
| | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, Academic Health Center, Cincinnati, OH
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
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Guimarães PO, Pokorney SD, Lopes RD, Wojdyla DM, Gersh BJ, Giczewska A, Carnicelli A, Lewis BS, Hanna M, Wallentin L, Vinereanu D, Alexander JH, Granger CB. Efficacy and safety of apixaban vs warfarin in patients with atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol 2019; 42:568-571. [PMID: 30907005 PMCID: PMC6522998 DOI: 10.1002/clc.23178] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/22/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain. HYPOTHESIS We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair. METHODS Using data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model. RESULTS In ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes. CONCLUSIONS In patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. CLINICALTRIALS.GOV: NCT00412984.
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Affiliation(s)
- Patricia O Guimarães
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Department of Biomedical Engineering, Faculty of Electronics, Telecommunications and Informatics, Gdansk University of Technology, Poland
| | - Anthony Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Basil S Lewis
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | | | - Lars Wallentin
- Uppsala Clinical Research Center, Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Dragos Vinereanu
- Department of Cardiology, University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Ezekowitz JA, Lewis BS, Lopes RD, Wojdyla DM, McMurray JJV, Hanna M, Atar D, Cecilia Bahit M, Keltai M, Lopez-Sendon JL, Pais P, Ruzyllo W, Wallentin L, Granger CB, Alexander JH. Clinical outcomes of patients with diabetes and atrial fibrillation treated with apixaban: results from the ARISTOTLE trial. Eur Heart J Cardiovasc Pharmacother 2018; 1:86-94. [PMID: 27533976 DOI: 10.1093/ehjcvp/pvu024] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 11/14/2022]
Abstract
AIMS We compared clinical outcomes in patients with AF with and without diabetes in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial. METHODS AND RESULTS The main efficacy endpoints were SSE and mortality; safety endpoints were major and major/clinically relevant non-major bleeding. A total of 4547/18 201 (24.9%) patients had diabetes who were younger (69 vs. 70 years), more had coronary artery disease (39 vs. 31%), and higher mean CHADS2 (2.9 vs. 1.9) and HAS-BLED scores (1.9 vs. 1.7) (all P < 0.0001) than patients without diabetes. Patients with diabetes receiving apixaban had lower rates of SSE [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.53-1.05), all-cause mortality (HR 0.83, 95% CI 0.67-1.02), cardiovascular mortality (HR 0.89, 95% CI 0.66-1.20), intra-cranial haemorrhage (HR 0.49, 95% CI 0.25-0.95), and a similar rate of myocardial infarction (HR 1.02, 95% CI 0.62-1.67) compared with warfarin. For major bleeding, a quantitative interaction was seen (P-interaction = 0.003) with a greater reduction in major bleeding in patients without diabetes even after multivariable adjustment. Other measures of bleeding showed a consistent reduction with apixaban compared with warfarin without a significant interaction based on diabetes status. CONCLUSION Apixaban has similar benefits on reducing stroke, decreasing mortality, and causing less intra-cranial bleeding than warfarin in patients with and without diabetes.
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Affiliation(s)
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | | | | | - Dan Atar
- Oslo University Hospital, Oslo, Norway
| | | | - Matyas Keltai
- Semmelweis University, Hungarian Institute of Cardiology, Budapest, Hungary
| | | | - Prem Pais
- St. John's Medical College, Bangalore, India
| | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
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Navar AM, Wojdyla DM, Sanchez RJ, Steen DL, Khan I, Peterson ED, Pencina MJ. P291Predicting recurrent CVD events among adults with stable CVD: a new risk model based on pooled NIH cohorts. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/12/2022] Open
Affiliation(s)
- A M Navar
- Duke Clinical Research Institute, Durham, United States of America
| | - D M Wojdyla
- Duke Clinical Research Institute, Durham, United States of America
| | - R J Sanchez
- Regeneron Pharmaceuticals, Tarrytown, New York, United States of America
| | - D L Steen
- University of Cincinnati, Cincinnati, United States of America
| | - I Khan
- Sanofi, Bridgewater, New Jersey, United States of America
| | - E D Peterson
- Duke Clinical Research Institute, Durham, United States of America
| | - M J Pencina
- Duke Clinical Research Institute, Durham, United States of America
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Vinereanu D, Wojdyla DM, Alexander JH, Lopes RD, Gersh BJ, Al-Khatib SM, Hijazi Z, Siegbahn A, Wallentin L, Granger CB. P5793Faster heart rate is associated with significantly higher risk of death and hospitalization due to heart failure in patients with persistent or permanent atrial fibrillation: insights from ARISTOTLE. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5793] [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: 11/14/2022] Open
Affiliation(s)
- D Vinereanu
- University Emergency Hospital, Bucharest, Romania
| | - D M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
| | - J H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
| | - R D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
| | - B J Gersh
- Mayo Clinic College of Medicine, Rochester, United States of America
| | - S M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
| | - Z Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - A Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - L Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - C B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, United States of America
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Inohara T, Pieper K, Wojdyla DM, Patel MR, Jones WS, Tricoci P, Mahaffey KW, James SK, Alexander JH, Lopes RD, Wallentin L, Ohman EM, Roe MT, Vemulapalli S. Incidence, timing, and type of first and recurrent ischemic events in patients with and without peripheral artery disease after an acute coronary syndrome. Am Heart J 2018; 201:25-32. [PMID: 29910052 DOI: 10.1016/j.ahj.2018.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/21/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) are known to have an increased risk of ischemic cardiovascular events. However, the influence of concomitant PAD on first and subsequent recurrent ischemic events after an acute coronary syndrome (ACS) remains poorly characterized. METHODS We analyzed the combined data set from 4 randomized trials (PLATO, APPRAISE-2, TRA-CER, and TRILOGY ACS) in ACS for a follow-up length of 1 year. Using multivariable regression, we examined the association between PAD and major adverse cardiovascular events, a composite of cardiovascular death, myocardial infarction, and stroke. Among patients with a nonfatal first event, we evaluated the incidence and type of a second recurrent event. RESULTS A total of 4,098 of 48,094 (8.5%) post-ACS patients had a history of PAD. The unadjusted frequency of major adverse cardiovascular events was 2-fold higher in patients with PAD (14.3% vs 7.5%) over a median (25th-75th) follow-up of 353 (223-365) days with an adjusted hazard ratio of 1.63 (95% CI: 1.48-1.78; P < .001). The frequency of recurrent ischemic events among those patients with a first, nonfatal event was higher among those with PAD (40.0% vs 27.7%). The relative frequency of each event type (cardiovascular death, noncardiovascular death, myocardial infarction, or stroke) within first and subsequent ischemic events was similar regardless of PAD status at baseline. CONCLUSIONS Patients with PAD have a significantly higher risk of first and recurrent ischemic events in the post-ACS setting. These findings highlight the opportunity for improved treatments in patients with PAD who experience an ACS.
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Affiliation(s)
- Taku Inohara
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University, Stanford, CA; Stanford Center for Clinical Research, Stanford, CA
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Erik Magnus Ohman
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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Kopin D, Jones WS, Sherwood MW, Wojdyla DM, Wallentin L, Lewis BS, Verheugt FW, Vinereanu D, Bahit MC, Halvorsen S, Huber K, Parkhomenko A, Granger CB, Lopes RD, Alexander JH. Percutaneous coronary intervention and antiplatelet therapy in patients with atrial fibrillation receiving apixaban or warfarin: Insights from the ARISTOTLE trial. Am Heart J 2018; 197:133-141. [PMID: 29447773 DOI: 10.1016/j.ahj.2017.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/03/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND We assessed antiplatelet therapy use and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ARISTOTLE trial. METHODS Patients were categorized based on the occurrence of PCI during follow-up (median 1.8 years); PCI details and outcomes post-PCI are reported. Of the 18,201 trial participants, 316 (1.7%) underwent PCI (152 in apixaban group, 164 in warfarin group). RESULTS At the time of PCI, 84% (267) were on study drug (either apixaban or warfarin). Of these, 19% did not stop study drug during PCI, 49% stopped and restarted <5 days post-PCI, and 30% stopped and restarted >5 days post-PCI. At 30 days post-PCI, 35% of patients received dual -antiplatelet therapy (DAPT), 23% received aspirin only, and 13% received a P2Y12 inhibitor only; 29% received no antiplatelet therapy. Triple therapy (DAPT + oral anticoagulant [OAC]) was used in 21% of patients, 23% received OAC only, 15% received OAC plus aspirin, and 9% received OAC plus a P2Y12 inhibitor; 32% received antiplatelet agents without OAC. Post-PCI, patients assigned to apixaban versus warfarin had numerically similar rates of major bleeding (5.93 vs 6.73 events/100 patient-years; P = .95) and stroke (2.74 vs 1.84 events/100 patient-years; P = .62). CONCLUSIONS PCI occurred infrequently during follow-up. Most patients on study drug at the time of PCI remained on study drug in the peri-PCI period; 19% continued the study drug without interruption. Antiplatelet therapy use post-PCI was variable, although most patients received DAPT. Additional data are needed to guide the use of antithrombotics in patients undergoing PCI.
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Lopes RD, Rordorf R, De Ferrari GM, Leonardi S, Thomas L, Wojdyla DM, Ridefelt P, Lawrence JH, De Caterina R, Vinereanu D, Hanna M, Flaker G, Al-Khatib SM, Hohnloser SH, Alexander JH, Granger CB, Wallentin L. Digoxin and Mortality in Patients With Atrial Fibrillation. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2017.12.060] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rao MP, Vinereanu D, Wojdyla DM, Alexander JH, Atar D, Hylek EM, Hanna M, Wallentin L, Lopes RD, Gersh BJ, Granger CB. Clinical Outcomes and History of Fall in Patients with Atrial Fibrillation Treated with Oral Anticoagulation: Insights From the ARISTOTLE Trial. Am J Med 2018; 131:269-275.e2. [PMID: 29122636 DOI: 10.1016/j.amjmed.2017.10.036] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [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: 05/24/2017] [Revised: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE We assessed outcomes among anticoagulated patients with atrial fibrillation and a history of falling, and whether the benefits of apixaban vs warfarin are consistent in this population. METHODS Of the 18,201 patients in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, 16,491 had information about history of falling-753 with history of falling and 15,738 without history of falling. The primary efficacy outcome was stroke or systemic embolism; the primary safety outcome was major bleeding. RESULTS When compared with patients without a history of falling, patients with a history of falling were older, more likely to be female and to have dementia, cerebrovascular disease, depression, diabetes, heart failure, osteoporosis, fractures, and higher CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism, Vascular disease, Age 65-74 years, Sex category female) and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol) scores. Patients with a history of falling had higher rates of major bleeding (adjusted hazard ratio [HR] 1.39; 95% confidence interval [CI], 1.05-1.84; P = .020), including intracranial bleeding (adjusted HR 1.87; 95% CI, 1.02-3.43; P = .044) and death (adjusted HR 1.70; 95% CI, 1.36-2.14; P < .0001), but similar rates of stroke or systemic embolism and hemorrhagic stroke. There was no evidence of a differential effect of apixaban compared with warfarin on any outcome, regardless of history of falling. Among those with a history of falling, subdural bleeding occurred in 5 of 367 patients treated with warfarin and 0 of 386 treated with apixaban. CONCLUSIONS Patients with atrial fibrillation and a history of falling receiving anticoagulation have a higher risk of major bleeding, including intracranial, and death. The efficacy and safety of apixaban compared with warfarin were consistent, irrespective of history of falling.
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Affiliation(s)
- Meena P Rao
- Cape Fear Heart Associates, New Hanover Regional Medical Center, Wilmington, NC
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Romania.
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Washam JB, Kaltenbach LA, Wojdyla DM, Patel MR, Klein AJ, Abbott JD, Rao SV. Anticoagulant Use Among Patients With End-Stage Renal Disease Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2018; 11:e005628. [DOI: 10.1161/circinterventions.117.005628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/05/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey B. Washam
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - Lisa A. Kaltenbach
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - Daniel M. Wojdyla
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - Manesh R. Patel
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - Andrew J. Klein
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - J. Dawn Abbott
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
| | - Sunil V. Rao
- From the Duke University Medical Center, Durham, NC (J.B.W., M.R.P., S.V.R.); Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W., M.R.P., S.V.R.); Piedmont Heart Institute, Atlanta, GA (A.J.K.); and Brown Medical School, Providence, RI (J.D.A.)
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46
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Goto S, Merrill P, Wallentin L, Wojdyla DM, Hanna M, Avezum A, Easton JD, Harjola VP, Huber K, Lewis BS, Parkhomenko A, Zhu J, Granger CB, Lopes RD, Alexander JH. Antithrombotic therapy use and clinical outcomes following thrombo-embolic events in patients with atrial fibrillation: insights from ARISTOTLE. European Heart Journal - Cardiovascular Pharmacotherapy 2018; 4:75-81. [DOI: 10.1093/ehjcvp/pvy002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/23/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
| | - Peter Merrill
- Department of Statistics, Duke Clinical Research Institute, Duke Health, 2400 Pratt Street, Durham, NC 27705, USA
| | - Lars Wallentin
- Division of Cardiology, Department of Medical Sciences, Uppsala Clinical Research Center, Dag Hammarskjöldsv 38, Uppsala Science Park, Uppsala University, 751 85 Uppsala, Sweden
| | - Daniel M Wojdyla
- Department of Statistics, Duke Clinical Research Institute, Duke Health, 2400 Pratt Street, Durham, NC 27705, USA
| | - Michael Hanna
- Bristol-Myers Squibb, 3551 Lawrenceville Princeton, Lawrence Township, NJ 08648, USA
| | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, Av. Dante Pazzanese, 500 - Vila Mariana, São Paulo - SP, 04012-909, Brazil
| | - J Donald Easton
- Department of Neurology, University of California San Francisco, Box 0663, 675 Nelson Rising Lane, 412 San Francisco, CA 94158, USA
| | - Veli-Pekka Harjola
- Division of Emergency Care, Department of Medicine, Helsinki University Central Hospital, PO Box 340, Helsinki 00029 HUS, Finland
| | - Kurt Huber
- Department of Cardiology, Wilhelminenspital, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Basil S Lewis
- Department of Cardiology, Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine of the Technion, Mikhal St 7, Haifa 3436212, Israel
| | - Alexander Parkhomenko
- Department of Cardiology, Institute of Cardiology, Narodnoho Opolchennya St, 5, Kiev, Ukraine 02000
| | - Jun Zhu
- Fuwai Hospital, Beijing, China
| | - Christopher B Granger
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke Health, 2400 Pratt Street, Durham, NC 27705, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, 2400 Pratt Street, Durham, NC 27705, USA
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke Health, 2400 Pratt Street, Durham, NC 27705, USA
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47
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Norgren L, Patel MR, Hiatt WR, Wojdyla DM, Fowkes FGR, Baumgartner I, Mahaffey KW, Berger JS, Jones WS, Katona BG, Held P, Blomster JI, Rockhold FW, Björck M. Outcomes of Patients with Critical Limb Ischaemia in the EUCLID Trial. Eur J Vasc Endovasc Surg 2018; 55:109-117. [DOI: 10.1016/j.ejvs.2017.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/07/2017] [Indexed: 11/16/2022]
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48
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Posenau JT, Wojdyla DM, Shaw LK, Alexander KP, Ohman EM, Patel MR, Smith PK, Rao SV. Revascularization Strategies and Outcomes in Elderly Patients With Multivessel Coronary Disease. Ann Thorac Surg 2017; 104:107-115. [DOI: 10.1016/j.athoracsur.2016.10.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/09/2016] [Accepted: 10/23/2016] [Indexed: 10/20/2022]
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49
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Westenbrink BD, Alings M, Granger CB, Alexander JH, Lopes RD, Hylek EM, Thomas L, Wojdyla DM, Hanna M, Keltai M, Steg PG, De Caterina R, Wallentin L, van Gilst WH. Anemia is associated with bleeding and mortality, but not stroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J 2017; 185:140-149. [PMID: 28267467 DOI: 10.1016/j.ahj.2016.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) are prone to cardiovascular events and anticoagulation-related bleeding complications. We hypothesized that patients with anemia are at increased risk for these outcomes. METHODS We performed a post hoc analysis of the ARISTOTLE trial, which included >18,000 patients with AF randomized to warfarin (target international normalized ratio, 2.0-3.0) or apixaban 5 mg twice daily. Multivariable Cox regression analysis was used to determine if anemia (defined as hemoglobin <13.0 in men and <12.0 g/dL in women) was associated with future stroke, major bleeding, or mortality. RESULTS Anemia was present at baseline in 12.6% of the ARISTOTLE population. Patients with anemia were older, had higher mean CHADS2 and HAS-BLED scores, and were more likely to have experienced previous bleeding events. Anemia was associated with major bleeding (adjusted hazard ratio [HR], 1.92; 95% CI, 1.62-2.28; P<.0001) and all-cause mortality (adjusted HR, 1.68; 95% CI, 1.46-1.93; P<.0001) but not stroke or systemic embolism (adjusted HR, 0.92; 95% CI, 0.70-1.21). The benefits of apixaban compared with warfarin on the rates of stroke, mortality, and bleeding events were consistent in patients with and without anemia. CONCLUSIONS Chronic anemia is associated with a higher incidence of bleeding complications and mortality, but not of stroke, in anticoagulated patients with AF. Apixaban is an attractive anticoagulant for stroke prevention in patients with AF with or without anemia.
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Affiliation(s)
- B Daan Westenbrink
- University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Marco Alings
- Working Group on Cardiovascular Research, Utrecht, Netherlands
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Matyas Keltai
- Hungarian Institute of Cardiology, Budapest, Hungary
| | - P Gabriel Steg
- DHU FIRE, Université Paris-Diderot, Hôpital Bichat, AP-HP, INSERM, Paris, France
| | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Wiek H van Gilst
- University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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50
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Guimarães PO, Wojdyla DM, Alexander JH, Thomas L, Alings M, Flaker GC, Al-Khatib SM, Hanna M, Horowitz JD, Wallentin L, Granger CB, Lopes RD. Anticoagulation therapy and clinical outcomes in patients with recently diagnosed atrial fibrillation: Insights from the ARISTOTLE trial. Int J Cardiol 2017; 227:443-449. [PMID: 27852444 DOI: 10.1016/j.ijcard.2016.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 05/10/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence supporting use of antithrombotic therapy in atrial fibrillation (AF) is based mainly on data from patients with permanent, persistent, or paroxysmal AF. Less is known about the risk following a new diagnosis of AF and the efficacy and safety of apixaban in these patients. METHODS Using data from ARISTOTLE, we assessed the relationship between timing of AF diagnosis and clinical outcomes and the efficacy and safety of apixaban versus warfarin in these patients. Recently diagnosed AF was defined as a new diagnosis of AF within 30days prior to enrollment. Cox proportional hazards models were used to determine the association between recently diagnosed AF and clinical outcomes. We also assessed the efficacy and safety of apixaban versus warfarin according to time since AF diagnosis. RESULTS In ARISTOTLE, 1899 (10.5%) patients had recently diagnosed AF. After adjustment, patients with recently versus remotely diagnosed AF had a similar risk of stroke/systemic embolism (HR=1.07, 95% CI=0.80-1.42; p=0.67), but higher mortality was seen in patients with recently diagnosed AF (adjusted HR=1.21, 95% CI=1.02-1.43; p=0.03). The beneficial effects of apixaban, compared with warfarin, on clinical outcomes were consistent, irrespective of timing of AF diagnosis (all interaction p-values >0.12). CONCLUSION Patients with recently diagnosed AF had a similar risk of stroke but higher mortality than patients with remotely diagnosed AF, suggesting that they are not at "low risk" and warrant stroke prevention strategies. The benefits of apixaban over warfarin were preserved, irrespective of timing of AF diagnosis.
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Affiliation(s)
| | | | | | - Laine Thomas
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - Marco Alings
- Working Group on Cardiovascular Research, Utrecht, Netherlands; Julius Clinical, Zeist, Netherlands
| | - Greg C Flaker
- University of Missouri School of Medicine, Columbia, MO, USA
| | | | | | - John D Horowitz
- Cardiology Unit, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, NC, USA.
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