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Dymm B, Goldstein LB, Unnithan S, Al-Khalidi HR, Koltai D, Bushnell C, Husseini NE. Depression following small vessel stroke is common and more prevalent in women. J Stroke Cerebrovasc Dis 2024; 33:107646. [PMID: 38395097 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107646] [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: 06/26/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES We sought to examine the frequency of depression after small vessel-type stroke (SVS) and associated risk factors. MATERIALS AND METHODS We conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which included 200 participants within 2-years of SVS and 79 controls without a history of stroke from 2007 to 2012 at four sites. The primary outcome was PHQ-8, with scores ≥10 consistent with post-stroke depression (PSD). A logistic regression adjusted for age, race, sex, history of diabetes and Short-Form Montreal Cognitive Assessment score (SF-MoCA) was used to compare the risk of having depression after SVS compared to controls. Another logistic regression, adjusted for age, sex, race, level of education, SF-MoCA, white matter disease (WMD) burden, stroke severity (NIHSS), time between stroke and depression screen, history of diabetes, and history of hypertension was used to identify factors independently associated with depression in participants with SVS. RESULTS The cohort included 161 participants with SVS (39 excluded due to missing data) and 79 controls. The mean interval between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n = 51) had PSD compared to 6.3% (n = 5) of controls (RR = 5.44, 95% CI = 2.21-13.38, p = 0.0002). The only two variables independently associated with PSD in participants with SVS were female sex (RR = 1.84, 95% CI = 1.09-3.09, p = 0.020) and diabetes (RR 1.69, 95% CI 1.03-2.79). CONCLUSIONS After adjusting for several demographic and clinical variables, having a SVS was associated with an approximate 5-fold increased risk of depression and was more frequent in women and in those with diabetes. The extent of WMD was not independently associated with PSD, suggesting that small vessel disease in the setting of an overt SVS may not account for the increased prevalence of depression.
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Affiliation(s)
- Braydon Dymm
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States.
| | | | - Shakthi Unnithan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, United States
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, United States
| | - Deborah Koltai
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States
| | - Cheryl Bushnell
- Wake Forest Atrium Health, Department of Neurology, United States
| | - Nada El Husseini
- Duke University Hospital, Department of Neurology, 2301 Erwin Rd, Durham, NC 27705, United States
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Cappato R, Mark DB, Silverstein AP, Noseworthy PA, Bonitta G, Poole JE, Piccini JP, Bahnson TD, Daniels MR, Al-Khalidi HR, Lee KL, Packer DL. Regional differences in outcomes with ablation versus drug therapy for atrial fibrillation: Results from the CABANA trial. Am Heart J 2024; 270:103-116. [PMID: 38307365 DOI: 10.1016/j.ahj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The finding of unexpected variations in treatment benefits by geographic region in international clinical trials raises complex questions about the interpretation and generalizability of trial findings. We observed such geographical variations in outcome and in the effectiveness of atrial fibrillation (AF) ablation versus drug therapy in the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial. This paper describes these differences and investigates potential causes. METHODS The examination of treatment effects by geographic region was a prespecified analysis. CABANA enrolled patients from 10 countries, with 1,285 patients at 85 North American (NA) sites and 919 at 41 non-NA sites. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Death and first atrial fibrillation recurrence were secondary endpoints. RESULTS At least 1 primary endpoint event occurred in 157 patients (12.2%) from NA and 33 (3.6%) from non-NA sites over a median 54.9 and 40.5 months of follow-up, respectively (NA/non-NA adjusted hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.48-3.21, P < .001). In NA patients, 78 events occurred in the ablation and 79 in the drug arm, (HR 0.91, 95% CI 0.66, 1.24) while 11 and 22 events occurred in non-NA patients (HR 0.51, 95% CI 0.25,1.05, interaction P = .154). Death occurred in 53 ablation and 51 drug therapy patients in the NA group (HR 0.96, 95% CI 0.65,1.42) and in 5 ablation and 16 drug therapy patients in the non-NA group (HR 0.32, 95% CI 0.12,0.86, interaction P = .044). Adjusting for baseline regional differences or prognostic risk variables did not account for the regional differences in treatment effects. Atrial fibrillation recurrence was reduced by ablation in both regions (NA: HR 0.54, 95% CI 0.46, 0.63; non-NA: HR 0.44, 95% CI 0.30, 0.64, interaction P = .322). CONCLUSIONS In CABANA, primary outcome events occurred significantly more often in the NA group but assignment to ablation significantly reduced all-cause mortality in the non-NA group only. These differences were not explained by regional variations in procedure effectiveness, safety, or patient characteristics. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0091150; https://clinicaltrials.gov/study/NCT00911508.
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Affiliation(s)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC.
| | | | | | - Gianluca Bonitta
- L'altra Statistica Consultancy and Training, Biostatistics Office, Roma, Italy
| | | | | | | | | | | | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC
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Lai HHH, Yang H, Tasian GE, Harper JD, Desai AC, McCune RD, Kirkali Z, Al-Khalidi HR, Scales CD, Curatolo M. Contribution of Hypersensitivity to Postureteroscopy Ureteral Stent Pain: Findings From Study to Enhance Understanding of Stent-associated Symptoms. Urology 2024; 184:32-39. [PMID: 38070834 DOI: 10.1016/j.urology.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/25/2023] [Accepted: 10/16/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To examine the relationships between preoperative hypersensitivity to pain and central sensitization, and postoperative ureteral stent pain after ureteroscopy (URS) for urinary stones. METHODS Adults enrolled in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) underwent quantitative sensory testing (QST) prior to URS and stent placement. Hypersensitivity to mechanical pain was assessed using a pressure algometer. Participants rated their pain intensity to pressure applied to the ipsilateral flank area and lower abdominal quadrant on the side of planned stent placement, and the contralateral forearm (control). Pressure pain thresholds were also assessed. Central sensitization was assessed by applying a pointed stimulator (pinprick) and calculating the temporal summation. Postoperative stent pain intensity and interference were assessed using PROMIS questionnaires. Data were analyzed using repeated-measures mixed-effects linear models. RESULTS Among the 412 participants, the median age was 54.0years, and 46% were female. Higher preoperative pain ratings to 2 kg and 4 kg mechanical pressure to the ipsilateral flank and abdominal areas were associated with higher postoperative stent pain intensity with the stent in situ. Greater degree of central sensitization preoperatively, manifesting as higher temporal summation, was associated with higher postoperative pain intensity. Factors associated with preoperative hypersensitivity on QST included female sex, presence of chronic pain conditions, widespread pain, and depression. CONCLUSION Hypersensitivity to pain and central sensitization preoperatively was associated with postoperative ureteral stent pain, suggesting a physiologic basis for stent symptom variation. QST may identify patients more likely to develop stent pain after URS and could inform selection for preventive and interventional strategies.
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Affiliation(s)
- Hing Hung Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis, MO.
| | - Hongqui Yang
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Gregory E Tasian
- Division of Urology and Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | | | - Alana C Desai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rebecca D McCune
- Division of Urology and Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Charles D Scales
- Departments of Surgery (Urology) and Population Health Science, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Michele Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA; Harborview Injury Preventions and Research Center, University of Washington, Seattle, WA; Center for Sensory-Motor Interaction, University of Aalborg, Aalborg, Denmark
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4
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Diamond JE, Kaltenbach LA, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Butler J, Allen LA, Lanfear DE, Thibodeau JT, Granger CB, Hernandez AF, Ariely D, DeVore AD. Access to Mobile Health Interventions Among Patients Hospitalized With Heart Failure: Insights Into the Digital Divide From the CONNECT-HF mHealth Substudy. Circ Heart Fail 2024; 17:e011140. [PMID: 38205653 DOI: 10.1161/circheartfailure.123.011140] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Affiliation(s)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.)
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics (H.R.A.-K.), Duke University, Durham, NC
| | - Nancy M Albert
- Office of Nursing Research and Innovation, Cleveland Clinic Health System, Clinical Nurse Specialist-Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular & Thoracic Institute, Clinic Main Campus, OH (N.M.A.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- University of Mississippi, Jackson (J.B.)
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora (L.A.A.)
| | - David E Lanfear
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, MI (D.E.L.)
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (J.T.T.)
| | - Christopher B Granger
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
| | - Adrian F Hernandez
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
| | - Dan Ariely
- Center for Advanced Hindsight (D.A.), Duke University, Durham, NC
| | - Adam D DeVore
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
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5
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Haeusler KG, Eichner FA, Heuschmann PU, Fiebach JB, Engelhorn T, Callans D, De Potter T, Debruyne P, Scherr D, Hindricks G, Al-Khalidi HR, Mont L, Kim WY, Piccini JP, Schotten U, Themistoclakis S, Di Biase L, Kirchhof P. Detection of brain lesions after catheter ablation depends on imaging criteria: insights from AXAFA-AFNET 5 trial. Europace 2023; 25:euad323. [PMID: 37897713 PMCID: PMC10963060 DOI: 10.1093/europace/euad323] [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: 08/29/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 10/30/2023] Open
Abstract
AIMS Left atrial catheter ablation is well established in patients with symptomatic atrial fibrillation (AF) but associated with risk of embolism to the brain. The present analysis aims to assess the impact of diffusion-weighted imaging (DWI) slice thickness on the rate of magnetic resonance imaging (MRI)-detected ischaemic brain lesions after ablation. METHODS AND RESULTS AXAFA-AFNET 5 trial (NCT02227550) participants underwent MRI using high-resolution (hr) DWI (slice thickness: 2.5-3 mm) and standard DWI (slice thickness: 5-6 mm) within 3-48 h after ablation. In 321 patients with analysable brain MRI (mean age 64 years, 33% female, median CHA2DS2-VASc 2), hrDWI detected at least one acute brain lesion in 84 (26.2%) patients and standard DWI in 60 (18.7%; P < 0.01) patients. High-resolution diffusion-weighted imaging detected more lesions compared to standard DWI (165 vs. 104; P < 0.01). The degree of agreement for lesion confirmation using hrDWI vs. standard DWI was substantial (κ = 0769). Comparing the proportion of DWI-detected lesions, lesion distribution, and total lesion volume per patient, there was no difference in the cohort of participants undergoing MRI at 1.5 T (n = 52) vs. 3 T (n = 269). CONCLUSION The pre-specified AXAFA-AFNET 5 sub-analysis revealed significantly increased rates of MRI-detected acute brain lesions using hrDWI instead of standard DWI in AF patients undergoing ablation. In comparison to DWI slice thickness, MRI field strength had a no significant impact in the trial. Comparing the varying rates of ablation-related MRI-detected brain lesions across previous studies has to consider these technical parameters. Future studies should use hrDWI, as feasibility was demonstrated in the multicentre AXAFA-AFNET 5 trial.
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Affiliation(s)
- Karl Georg Haeusler
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- Department of Neurology, Universitätsklinikum Würzburg Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Felizitas A Eichner
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
- Institute of Medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David Callans
- Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | | | - Daniel Scherr
- Division of Cardiology, Medical University Graz, Austria
| | | | - Hussein R Al-Khalidi
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathan P Piccini
- Duke Clinical Research Institute (DCRI), Durham, NC, USA
- Division of Cardiology Duke University Medical Center, Duke University, Durham NC, USA
| | - Ulrich Schotten
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- Departments of Cardiology and Physiology, University Maastricht, Maastricht, The Netherlands
| | | | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
- Texas Cardiac Arrhythmia Institute at St.David’s Medical Center, Austin, TX, USA
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
- Department of Cardiology, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research, Partner site Hamburg/Kiel/Lübeck, Germany
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6
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, and University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology and Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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7
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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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8
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Dombeck C, Scales CD, McKenna K, Swezey T, Harper JD, Antonelli JA, Desai AC, Lai HH, McCune R, Curatolo M, Al-Khalidi HR, Maalouf NM, Reese PP, Wessells H, Kirkali Z, Corneli A. Patients' Experiences With the Removal of a Ureteral Stent: Insights From In-depth Interviews With Participants in the USDRN STENTS Qualitative Cohort Study. Urology 2023; 178:26-36. [PMID: 37149059 PMCID: PMC10530092 DOI: 10.1016/j.urology.2023.04.018] [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: 01/31/2023] [Revised: 04/04/2023] [Accepted: 04/18/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To describe the experiences of patients undergoing stent removal in the USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS), a prospective, observational cohort study of patients with short-term ureteral stent placement post-ureteroscopy. METHODS We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) painful or bothersome aspects of stent removal, (2) symptoms immediately after removal, and (3) symptoms in the days following removal. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. RESULTS The 38 participants interviewed were aged 13-77 years, 55% female, and 95% White. Interviews were conducted 7-30 days after stent removal. Almost all participants (n = 31) described that they experienced either pain or discomfort during stent removal, but for most (n = 25) pain was of short duration. Many participants (n = 21) described anticipatory anxiety related to the procedure, and several (n = 11) discussed discomfort arising from lack of privacy or feeling exposed. Interactions with medical providers often helped put participants at ease, but also increased discomfort for some. Following stent removal, several participants described lingering pain and/or urinary symptoms, but these largely resolved within 24 hours. A few participants described symptoms persisting for more than a day post stent removal. CONCLUSION These findings on patients' experiences during and shortly after ureteral stent removal, particularly the psychological distress they experienced, identify opportunities for improvement in patient care. Clear communication from providers about what to expect with the removal procedure, and the possibility of delayed pain, may help patients adapt to discomfort.
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Affiliation(s)
- Carrie Dombeck
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Surgery (Urology), Duke Surgical Center for Outcomes Research & Equity in Surgery, Duke University School of Medicine, Durham, NC.
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Teresa Swezey
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Jodi A Antonelli
- Department of Surgery (Urology), Duke Surgical Center for Outcomes Research & Equity in Surgery, Duke University School of Medicine, Durham, NC
| | - Alana C Desai
- Department of Surgery (Urologic Surgery), Washington University in St. Louis, St. Louis, MO
| | - H Henry Lai
- Department of Surgery (Urologic Surgery), Washington University in St. Louis, St. Louis, MO; Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO
| | | | - Michele Curatolo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Naim M Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter P Reese
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hunter Wessells
- Department of Urology, University of Washington, Seattle, WA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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9
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O’Halloran JA, Ko ER, Anstrom KJ, Kedar E, McCarthy MW, Panettieri RA, Maillo M, Nunez PS, Lachiewicz AM, Gonzalez C, Smith PB, de Tai SMT, Khan A, Lora AJM, Salathe M, Capo G, Gonzalez DR, Patterson TF, Palma C, Ariza H, Lima MP, Blamoun J, Nannini EC, Sprinz E, Mykietiuk A, Alicic R, Rauseo AM, Wolfe CR, Witting B, Wang JP, Parra-Rodriguez L, Der T, Willsey K, Wen J, Silverstein A, O’Brien SM, Al-Khalidi HR, Maldonado MA, Melsheimer R, Ferguson WG, McNulty SE, Zakroysky P, Halabi S, Benjamin DK, Butler S, Atkinson JC, Adam SJ, Chang S, LaVange L, Proschan M, Bozzette SA, Powderly WG. Abatacept, Cenicriviroc, or Infliximab for Treatment of Adults Hospitalized With COVID-19 Pneumonia: A Randomized Clinical Trial. JAMA 2023; 330:328-339. [PMID: 37428480 PMCID: PMC10334296 DOI: 10.1001/jama.2023.11043] [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: 03/24/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023]
Abstract
Importance Immune dysregulation contributes to poorer outcomes in COVID-19. Objective To investigate whether abatacept, cenicriviroc, or infliximab provides benefit when added to standard care for COVID-19 pneumonia. Design, Setting, and Participants Randomized, double-masked, placebo-controlled clinical trial using a master protocol to investigate immunomodulators added to standard care for treatment of participants hospitalized with COVID-19 pneumonia. The results of 3 substudies are reported from 95 hospitals at 85 clinical research sites in the US and Latin America. Hospitalized patients 18 years or older with confirmed SARS-CoV-2 infection within 14 days and evidence of pulmonary involvement underwent randomization between October 2020 and December 2021. Interventions Single infusion of abatacept (10 mg/kg; maximum dose, 1000 mg) or infliximab (5 mg/kg) or a 28-day oral course of cenicriviroc (300-mg loading dose followed by 150 mg twice per day). Main Outcomes and Measures The primary outcome was time to recovery by day 28 evaluated using an 8-point ordinal scale (higher scores indicate better health). Recovery was defined as the first day the participant scored at least 6 on the ordinal scale. Results Of the 1971 participants randomized across the 3 substudies, the mean (SD) age was 54.8 (14.6) years and 1218 (61.8%) were men. The primary end point of time to recovery from COVID-19 pneumonia was not significantly different for abatacept (recovery rate ratio [RRR], 1.12 [95% CI, 0.98-1.28]; P = .09), cenicriviroc (RRR, 1.01 [95% CI, 0.86-1.18]; P = .94), or infliximab (RRR, 1.12 [95% CI, 0.99-1.28]; P = .08) compared with placebo. All-cause 28-day mortality was 11.0% for abatacept vs 15.1% for placebo (odds ratio [OR], 0.62 [95% CI, 0.41-0.94]), 13.8% for cenicriviroc vs 11.9% for placebo (OR, 1.18 [95% CI 0.72-1.94]), and 10.1% for infliximab vs 14.5% for placebo (OR, 0.59 [95% CI, 0.39-0.90]). Safety outcomes were comparable between active treatment and placebo, including secondary infections, in all 3 substudies. Conclusions and Relevance Time to recovery from COVID-19 pneumonia among hospitalized participants was not significantly different for abatacept, cenicriviroc, or infliximab vs placebo. Trial Registration ClinicalTrials.gov Identifier: NCT04593940.
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Affiliation(s)
| | - Emily R. Ko
- Duke University Health System, Durham, North Carolina
| | | | | | | | | | | | | | | | - Cynthia Gonzalez
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - P. Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Akram Khan
- Oregon Health and Science University, Portland
| | | | | | | | | | | | - Christopher Palma
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | | | | | | | - Eduardo Sprinz
- Hospital de Clinicas de Porto Alegre HCPA, Porto Alegre, Brazil
| | | | - Radica Alicic
- Providence Medical Research Center, Spokane, Washington
| | | | | | | | | | | | - Tatyana Der
- Duke University Health System, Durham, North Carolina
| | | | - Jun Wen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Adam Silverstein
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sean M. O’Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Steven E. McNulty
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Susan Halabi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sandra Butler
- Technical Resources International (TRI), Bethesda, Maryland
| | - Jane C. Atkinson
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Stacey J. Adam
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | - Soju Chang
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | | | - Michael Proschan
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Samuel A. Bozzette
- National Center for Advancing Translational Sciences, Bethesda, Maryland
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10
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Wang TY, Svensson LG, Wen J, Vekstein A, Gerdisch M, Rao VU, Moront M, Johnston D, Lopes RD, Chavez A, Ruel M, Blackstone EH, Becker RC, Thourani V, Puskas J, Al-Khalidi HR, Cable DG, Elefteriades JA, Pochettino A, Wolfe JA, Graeve A, Sultan I, Sabe AA, Michelena HI, Alexander JH. Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve. NEJM Evid 2023; 2:EVIDoa2300067. [PMID: 38320162 DOI: 10.1056/evidoa2300067] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Apixaban, Warfarin, and On-X Mechanical Aortic ValvesAlthough vitamin K antagonists are the only oral anticoagulants approved with mechanical heart valves, this trial examined whether apixaban could be safely used in patients with an On-X mechanical aortic valve. A total of 863 such patients were assigned apixaban 5 mg twice daily or warfarin (target international normalized ratio 2.0 to 3.0). A total of 20 thrombotic events occurred in the apixaban group (4.2%/patient-year) and 6 events in the warfarin group (1.3%/patient-year). Major bleeding rates were 3.6%/patient-year with apixaban and 4.5%/patient-year with warfarin.
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Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Jun Wen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Andrew Vekstein
- 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
| | - Alma Chavez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON
| | | | | | | | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - David G Cable
- OSF HealthCare Cardiovascular Institute, Rockford, IL
| | | | | | - J Alan Wolfe
- Northeast Georgia Medical Center, Gainesville, GA
| | - Allen Graeve
- MultiCare Institute for Research and Innovation, Tacoma, WA
| | | | - Ashraf A Sabe
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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11
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Nanna MG, Yow E, Vemulapalli S, Mark DB, Kelsey M, Patel MR, Al-Khalidi HR, Rogers C, Udelson JE, Douglas PS. Clinical and cost implications of deferred testing in low-risk patients with stable chest pain: a simulation using the PROMISE trial. Am Heart J 2023; 261:124-126. [PMID: 36828202 PMCID: PMC10903188 DOI: 10.1016/j.ahj.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 05/26/2023]
Abstract
Current guidelines recommend a deferred testing approach in low-risk patients presenting with stable chest pain. After simulating a deferred testing approach using the PROMISE Minimal Risk Score to identify 915 minimal risk participants with cost data from the PROMISE trial, a deferred testing strategy was associated with an adjusted cost savings of -$748.74 (95% CI: -1646.97, 158.06) per participant and 74.6% of samples had better clinical outcomes and lower mean cost. This supports the current guideline recommended deferred testing approach in low-risk patients with stable chest pain.
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Affiliation(s)
- Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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12
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Corneli A, Dombeck C, McKenna K, Harper JD, Antonelli JA, Desai AC, Lai HH, Tasian GE, Ziemba J, McCune R, Piskator B, Al-Khalidi HR, Maalouf NM, Reese PP, Wessells H, Kirkali Z, Scales CD. The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study. J Endourol 2023; 37:642-653. [PMID: 37021358 PMCID: PMC10280172 DOI: 10.1089/end.2022.0810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Indexed: 04/07/2023] Open
Abstract
Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.
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Affiliation(s)
- Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carrie Dombeck
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jonathan D. Harper
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Jodi A. Antonelli
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alana C. Desai
- Department of Surgery (Urologic Surgery) and Washington University in St. Louis, St. Louis, Missouri, USA
| | - H. Henry Lai
- Department of Surgery (Urologic Surgery) and Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Gregory E. Tasian
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justin Ziemba
- Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca McCune
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brooke Piskator
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Naim M. Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter P. Reese
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hunter Wessells
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Charles D. Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Surgery (Urology), Duke Surgical Center for Outcomes Research and Equity in Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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13
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Pagidipati NJ, Nelson AJ, Kaltenbach LA, Leyva M, McGuire DK, Pop-Busui R, Cavender MA, Aroda VR, Magwire ML, Richardson CR, Lingvay I, Kirk JK, Al-Khalidi HR, Webb L, Gaynor T, Pak J, Senyucel C, Lopes RD, Green JB, Granger CB. Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes: A Randomized Clinical Trial. JAMA 2023; 329:1261-1270. [PMID: 36877177 PMCID: PMC9989955 DOI: 10.1001/jama.2023.2854] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [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: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 03/07/2023]
Abstract
Importance Evidence-based therapies to reduce atherosclerotic cardiovascular disease risk in adults with type 2 diabetes are underused in clinical practice. Objective To assess the effect of a coordinated, multifaceted intervention of assessment, education, and feedback vs usual care on the proportion of adults with type 2 diabetes and atherosclerotic cardiovascular disease prescribed all 3 groups of recommended, evidence-based therapies (high-intensity statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and sodium-glucose cotransporter 2 [SGLT2] inhibitors and/or glucagon-like peptide 1 receptor agonists [GLP-1RAs]). Design, Setting, and Participants Cluster randomized clinical trial with 43 US cardiology clinics recruiting participants from July 2019 through May 2022 and follow-up through December 2022. The participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease not already taking all 3 groups of evidence-based therapies. Interventions Assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools for participants (n = 459) vs usual care per practice guidelines (n = 590). Main Outcomes and Measures The primary outcome was the proportion of participants prescribed all 3 groups of recommended therapies at 6 to 12 months after enrollment. The secondary outcomes included changes in atherosclerotic cardiovascular disease risk factors and a composite outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (the trial was not powered to show these differences). Results Of 1049 participants enrolled (459 at 20 intervention clinics and 590 at 23 usual care clinics), the median age was 70 years and there were 338 women (32.2%), 173 Black participants (16.5%), and 90 Hispanic participants (8.6%). At the last follow-up visit (12 months for 97.3% of participants), those in the intervention group were more likely to be prescribed all 3 therapies (173/457 [37.9%]) vs the usual care group (85/588 [14.5%]), which is a difference of 23.4% (adjusted odds ratio [OR], 4.38 [95% CI, 2.49 to 7.71]; P < .001) and were more likely to be prescribed each of the 3 therapies (change from baseline in high-intensity statins from 66.5% to 70.7% for intervention vs from 58.2% to 56.8% for usual care [adjusted OR, 1.73; 95% CI, 1.06-2.83]; ACEIs or ARBs: from 75.1% to 81.4% for intervention vs from 69.6% to 68.4% for usual care [adjusted OR, 1.82; 95% CI, 1.14-2.91]; SGLT2 inhibitors and/or GLP-1RAs: from 12.3% to 60.4% for intervention vs from 14.5% to 35.5% for usual care [adjusted OR, 3.11; 95% CI, 2.08-4.64]). The intervention was not associated with changes in atherosclerotic cardiovascular disease risk factors. The composite secondary outcome occurred in 23 of 457 participants (5%) in the intervention group vs 40 of 588 participants (6.8%) in the usual care group (adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]). Conclusions and Relevance A coordinated, multifaceted intervention increased prescription of 3 groups of evidence-based therapies in adults with type 2 diabetes and atherosclerotic cardiovascular disease. Trial Registration ClinicalTrials.gov Identifier: NCT03936660.
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Affiliation(s)
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
- Victorian Heart Institute, Monash University, Melbourne, Australia
| | | | - Monica Leyva
- Duke Clinical Research Institute, Durham, North Carolina
| | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | | | | | | | | | | | | | - Julienne K. Kirk
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | | | - Laura Webb
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
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14
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Lusk JB, Song A, Unnithan S, Al-Khalidi HR, Delic A, de Havenon A, Biousse V, Schrag M, Poli S, Piccini JP, Xian Y, O'Brien EC, Mac Grory B. Examining the Association Between Hospital-Documented Atrial Fibrillation and Central Retinal Artery Occlusion. Stroke 2023; 54:983-991. [PMID: 36729390 DOI: 10.1161/strokeaha.122.042292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Carotid stenosis is thought to be the primary risk factor for central retinal artery occlusion (CRAO); however, it is not known whether atrial fibrillation (AF), a cardiac arrhythmia that underlies over 25% of cerebral ischemic strokes, predisposes patients to CRAO. Methods: A retrospective, observational, cohort study was performed using data from the State Inpatient Databases and State Emergency Department Databases from New York (2006-2015), California (2003-2011), and Florida (2005-2015) to determine the association between AF and CRAO. The primary exposure was hospital-documented AF. The primary endpoint was hospital-documented CRAO, defined as having an ICD-9-CM code 362.31 in the primary diagnosis position. Cause-specific hazard models were used to model CRAO-free survival among patients according to hospital-documented AF status. Results: Of 39,834,885 patients included in the study, 2,723,842 (median age: 72.7 years, 48.5% female) had AF documented during the exposure window. Patients with AF were older, more likely to be of non-Hispanic White race/ethnicity and had a higher burden of cardiovascular comorbidities compared to patients without AF. The cumulative incidence of CRAO was 7.09 per 100,000 at risk in those with AF and 2.34 per 100,000 at risk in those without AF over the study period. Before adjustment, AF was associated with higher risk of CRAO (HR 2.55, 95% CI 2.15-3.03). However, after adjustment for demographics, state, and cardiovascular comorbidities, there was an inverse association between AF and risk of CRAO (aHR 0.72, 95% CI 0.60-0.87). These findings were robust in our pre-specified sensitivity analyses. By contrast, positive control outcomes of embolic and ischemic stroke showed an expected strong relationship between AF and risk of stroke. Conclusions: We found an inverse association between AF and CRAO in a large, representative study of hospitalized patients; however, this cohort did not ascertain AF or CRAO occurring outside of hospital or emergency department settings.
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Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine, Durham, NC (J.B.L., A.S.)
| | - Ailin Song
- Duke University School of Medicine, Durham, NC (J.B.L., A.S.)
| | - Shakthi Unnithan
- Department of Biostatistics and Bioinformatics (S.U., H.R.A.-K.), Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics (S.U., H.R.A.-K.), Duke University School of Medicine, Durham, NC
| | - Alen Delic
- Department of Neurology, University of Utah, Salt Lake City (A.D.)
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT (A.d.H.)
| | - Valérie Biousse
- Departments of Ophthalmology (V.B.), Emory University School of Medicine, Atlanta, GA
- Neurology (V.B.), Emory University School of Medicine, Atlanta, GA
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN (M.S.)
| | - Sven Poli
- Department of Neurology and Stroke (S.P.), University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research (S.P.), University of Tübingen, Germany
| | - Jonathan P Piccini
- Department of Medicine (J.P.P.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.P.P., E.C.O., B.M.G.)
| | - Ying Xian
- Department of Neurology, University of Texas-Southwestern Medical Center, Dallas (Y.X.)
| | - Emily C O'Brien
- Department of Neurology (E.C.O., B.M.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.P.P., E.C.O., B.M.G.)
- Department of Population Health Sciences, Duke University, Durham, NC (E.C.O.)
| | - Brian Mac Grory
- Department of Neurology (E.C.O., B.M.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.P.P., E.C.O., B.M.G.)
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15
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Nelson AJ, Pagidipati NJ, Kelsey MD, Ardissino M, Aroda VR, Cavender MA, Lopes RD, Al-Khalidi HR, Braceras R, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Levya M, Senyucel C, Webb L, McGuire DK, Green JB, Granger CB. Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design. Am Heart J 2023; 256:2-12. [PMID: 36279931 DOI: 10.1016/j.ahj.2022.10.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 06/04/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | - Julienne K Kirk
- Wake Forest University School of Medicine, Winston Salem, NC
| | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | | | | | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health and Hospital System, Dallas, TX
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16
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Lusk JB, Song A, Unnithan S, Al-Khalidi HR, Piccini JP, Xian Y, O'Brien EC, Mac Grory BC. Abstract 30: Association Between Hospital-ascertained Atrial Fibrillation And Central Retinal Artery Occlusion: A Study Of 12 Million Patients. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.30] [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] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Atrial fibrillation (AF) is a major risk factor for cerebral ischemic stroke. However, it is not known whether AF predicts the development of central retinal artery occlusion (CRAO), a form of ischemic stroke affecting the retina.
Methods:
A retrospective cohort study was undertaken using data from the California Healthcare Cost and Utilization Project (HCUP) State Inpatient and State Emergency Department Datasets (SID/SEDDs). Patients 18 years and older discharged from non-federal hospitals between 2005 and 2011 who did not have a history of CRAO were analyzed. The exposure variable was AF and the endpoint was CRAO, each identified using validated ICD-9-CM diagnosis codes. Association between AF and CRAO was modeled using a Fine-Gray method with death as a competing risk with adjustment for age, biological sex, race, and vascular co-morbidities.
Results:
A total of 12,181,778 patients were included, among these 806,397 with AF and 11,375,381 without AF. In total, 309 patients had CRAO. In an unadjusted analysis, there was a higher risk of CRAO in patients with versus without AF (HR 2.24 (95% CI: 1.51 to 3.32)). After adjustment for pre-specified covariates, there appeared to be a lower hazard of CRAO in patients with AF (aHR 0.61 (95% CI: 0.45 to 0.98)). Further analyses including cerebral ischemic stroke (aHR 1.16 (95% CI: 1.14 to 1.18)) and specifically embolic stroke (aHR 4.29 (95% CI 4.10-4.48)) as positive controls argued against overadjustment bias. We present sensitivity analyses including CRAO identified in any position of the discharge ICD list, using different ascertainment windows for AF and using broader categories of retinal ischemia.
Conclusion:
The incidence of CRAO was higher in patients with AF than those without AF, but the hazard of CRAO was not higher for patients with AF after adjustment for measured covariates. Endpoint and exposure ascertainment may have been limited by inclusion only of inpatient and emergency department encounters.
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Affiliation(s)
| | | | | | | | | | | | - Emily C O'Brien
- Neurology and Population Health Sciences, Duke Univ, Durham, NC
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17
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Bukhari-Parlakturk N, Lutz M, Al-Khalidi HR, Unnithan S, Wang JEH, Scott B, Termsarasab P, Appelbaum LG, Calakos N. Suitability of Automated Writing Measures for Clinical Trial Outcome in Writer's Cramp. Mov Disord 2023; 38:123-132. [PMID: 36226903 PMCID: PMC9851940 DOI: 10.1002/mds.29237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/01/2022] [Revised: 08/20/2022] [Accepted: 09/13/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Writer's cramp (WC) dystonia is a rare disease that causes abnormal postures during the writing task. Successful research studies for WC and other forms of dystonia are contingent on identifying sensitive and specific measures that relate to the clinical syndrome and achieve a realistic sample size to power research studies for a rare disease. Although prior studies have used writing kinematics, their diagnostic performance remains unclear. OBJECTIVE This study aimed to evaluate the diagnostic performance of automated measures that distinguish subjects with WC from healthy volunteers. METHODS A total of 21 subjects with WC and 22 healthy volunteers performed a sentence-copying assessment on a digital tablet using kinematic and hand recognition softwares. The sensitivity and specificity of automated measures were calculated using a logistic regression model. Power analysis was performed for two clinical research designs using these measures. The test and retest reliability of select automated measures was compared across repeat sentence-copying assessments. Lastly, a correlational analysis with subject- and clinician-rated outcomes was performed to understand the clinical meaning of automated measures. RESULTS Of the 23 measures analyzed, the measures of word legibility and peak accelerations distinguished subjects with WC from healthy volunteers with high sensitivity and specificity and demonstrated smaller sample sizes suitable for rare disease studies, and the kinematic measures showed high reliability across repeat visits, while both word legibility and peak accelerations measures showed significant correlations with the subject- and clinician-rated outcomes. CONCLUSIONS Novel automated measures that capture key aspects of the disease and are suitable for use in clinical research studies of WC dystonia were identified. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Noreen Bukhari-Parlakturk
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Institute for Brain Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Lutz
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shakthi Unnithan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Burton Scott
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pichet Termsarasab
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Nicole Calakos
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Institute for Brain Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Neurobiology, Duke University School of Medicine, Durham, North Carolina, USA
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18
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Pokorney SD, Chertow GM, Al-Khalidi HR, Gallup D, Dignacco P, Mussina K, Bansal N, Gadegbeku CA, Garcia DA, Garonzik S, Lopes RD, Mahaffey KW, Matsuda K, Middleton JP, Rymer JA, Sands GH, Thadhani R, Thomas KL, Washam JB, Winkelmayer WC, Granger CB. Apixaban for Patients With Atrial Fibrillation on Hemodialysis: A Multicenter Randomized Controlled Trial. Circulation 2022; 146:1735-1745. [PMID: 36335914 DOI: 10.1161/circulationaha.121.054990] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [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: 03/28/2021] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND There are no randomized data evaluating the safety or efficacy of apixaban for stroke prevention in patients with end-stage kidney disease on hemodialysis and with atrial fibrillation (AF). METHODS The RENAL-AF trial (Renal Hemodialysis Patients Allocated Apixaban Versus Warfarin in Atrial Fibrillation) was a prospective, randomized, open-label, blinded-outcome evaluation (PROBE) of apixaban versus warfarin in patients receiving hemodialysis with AF and a CHA2DS2-VASc score ≥2. Patients were randomly assigned 1:1 to 5 mg of apixaban twice daily (2.5 mg twice daily for patients ≥80 years of age, weight ≤60 kg, or both) or dose-adjusted warfarin. The primary outcome was time to major or clinically relevant nonmajor bleeding. Secondary outcomes included stroke, mortality, and apixaban pharmacokinetics. Pharmacokinetic sampling was day 1, day 3, and month 1. RESULTS From January 2017 through January 2019, 154 patients were randomly assigned to apixaban (n=82) or warfarin (n=72). The trial stopped prematurely because of enrollment challenges. Time in therapeutic range (international normalized ratio, 2.0-3.0) for warfarin-treated patients was 44% (interquartile range, 23%-59%). The 1-year rates for major or clinically relevant nonmajor bleeding were 32% and 26% in apixaban and warfarin groups, respectively (hazard ratio, 1.20 [95% CI, 0.63-2.30]), whereas 1-year rates for stroke or systemic embolism were 3.0% and 3.3% in apixaban and warfarin groups, respectively. Death was the most common major event in the apixaban (21 patients [26%]) and warfarin (13 patients [18%]) arms. The pharmacokinetic substudy enrolled the target 50 patients. Median steady-state 12-hour area under the curve was 2475 ng/mL×h (10th to 90th percentiles, 1342-3285) for 5 mg of apixaban twice daily and 1269 ng/mL×h (10th to 90th percentiles, 615-1946) for 2.5 mg of apixaban twice daily. There was substantial overlap between minimum apixaban blood concentration, 12-hour area under the curve, and maximum apixaban blood concentration for patients with and without a major or clinically relevant nonmajor bleeding event. CONCLUSIONS There was inadequate power to draw any conclusion regarding rates of major or clinically relevant nonmajor bleeding comparing apixaban and warfarin in patients with AF and end-stage kidney disease on hemodialysis. Clinically relevant bleeding events were ≈10-fold more frequent than stroke or systemic embolism among this population on anticoagulation, highlighting the need for future randomized studies evaluating the risks versus benefits of anticoagulation among patients with AF and end-stage kidney disease on hemodialysis. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02942407.
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Affiliation(s)
- Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Dianne Gallup
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Pat Dignacco
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Kurt Mussina
- Stanford University, Palo Alto, CA (G.M.C., K.W.M., K.M.)
| | - Nisha Bansal
- University of Washington, Seattle (N.B., D.A.G.)
| | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Kelly Matsuda
- Stanford University, Palo Alto, CA (G.M.C., K.W.M., K.M.)
- Frenova Renal Research, Waltham, MA (K.M.)
| | - John P Middleton
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Jennifer A Rymer
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Ravi Thadhani
- Massachussetts General and Brigham and Women's Hospitals, Boston (R.T.)
| | - Kevin L Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Jeffrey B Washam
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Christopher B Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
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19
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Farsky PS, White J, Al-Khalidi HR, Sueta CA, Rouleau JL, Panza JA, Velazquez EJ, O'Connor CM. Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2022; 164:1890-1899.e4. [PMID: 33610365 PMCID: PMC8260609 DOI: 10.1016/j.jtcvs.2020.12.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 07/26/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy. METHODS The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug. RESULTS At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation. CONCLUSIONS Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.
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Affiliation(s)
- Pedro S Farsky
- Instituto Dante Pazzanese de Cardiologia and Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Jennifer White
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Carla A Sueta
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jean L Rouleau
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Julio A Panza
- Westchester Medical Center and New York Medical College, Valhalla, NY
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20
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Ko ER, Anstrom KJ, Panettieri RA, Lachiewicz AM, Maillo M, O'Halloran JA, Boucher C, Smith PB, McCarthy MW, Segura Nunez P, Mendivil Tuchia de Tai S, Khan A, Mena Lora AJ, Salathe M, Kedar E, Capo G, Rodríguez Gonzalez D, Patterson TF, Palma C, Ariza H, Patelli Lima M, Blamoun J, Nannini EC, Sprinz E, Mykietiuk A, Wang JP, Parra-Rodriguez L, Der T, Willsey K, Benjamin DK, Wen J, Zakroysky P, Halabi S, Silverstein A, McNulty SE, O'Brien SM, Al-Khalidi HR, Butler S, Atkinson J, Adam SJ, Chang S, Maldonado MA, Proscham M, LaVange L, Bozzette SA, Powderly WG. Abatacept for Treatment of Adults Hospitalized with Moderate or Severe Covid-19. medRxiv 2022:2022.09.22.22280247. [PMID: 36203544 PMCID: PMC9536071 DOI: 10.1101/2022.09.22.22280247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND We investigated whether abatacept, a selective costimulation modulator, provides additional benefit when added to standard-of-care for patients hospitalized with Covid-19. METHODS We conducted a master protocol to investigate immunomodulators for potential benefit treating patients hospitalized with Covid-19 and report results for abatacept. Intravenous abatacept (one-time dose 10 mg/kg, maximum dose 1000 mg) plus standard of care (SOC) was compared with shared placebo plus SOC. Primary outcome was time-to-recovery by day 28. Key secondary endpoints included 28-day mortality. RESULTS Between October 16, 2020 and December 31, 2021, a total of 1019 participants received study treatment (509 abatacept; 510 shared placebo), constituting the modified intention-to-treat cohort. Participants had a mean age 54.8 (SD 14.6) years, 60.5% were male, 44.2% Hispanic/Latino and 13.7% Black. No statistically significant difference for the primary endpoint of time-to-recovery was found with a recovery-rate-ratio of 1.14 (95% CI 1.00-1.29; p=0.057) compared with placebo. We observed a substantial improvement in 28-day all-cause mortality with abatacept versus placebo (11.0% vs. 15.1%; odds ratio [OR] 0.62 [95% CI 0.41- 0.94]), leading to 38% lower odds of dying. Improvement in mortality occurred for participants requiring oxygen/noninvasive ventilation at randomization. Subgroup analysis identified the strongest effect in those with baseline C-reactive protein >75mg/L. We found no statistically significant differences in adverse events, with safety composite index slightly favoring abatacept. Rates of secondary infections were similar (16.1% for abatacept; 14.3% for placebo). CONCLUSIONS Addition of single-dose intravenous abatacept to standard-of-care demonstrated no statistically significant change in time-to-recovery, but improved 28-day mortality. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04593940 ).
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21
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Chew DS, Li Y, Cowper PA, Anstrom KJ, Piccini JP, Poole JE, Daniels MR, Monahan KH, Davidson-Ray L, Bahnson TD, Al-Khalidi HR, Lee KL, Packer DL, Mark DB. Cost-Effectiveness of Catheter Ablation Versus Antiarrhythmic Drug Therapy in Atrial Fibrillation: The CABANA Randomized Clinical Trial. Circulation 2022; 146:535-547. [PMID: 35726631 PMCID: PMC9378541 DOI: 10.1161/circulationaha.122.058575] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [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: 12/14/2022]
Abstract
BACKGROUND In the CABANA trial (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation), catheter ablation did not significantly reduce the primary end point of death, disabling stroke, serious bleeding, or cardiac arrest compared with drug therapy by intention-to-treat, but did improve the quality of life and freedom from atrial fibrillation recurrence. In the heart failure subgroup, ablation improved both survival and quality of life. Cost-effectiveness was a prespecified CABANA secondary end point. METHODS Medical resource use data were collected for all CABANA patients (N=2204). Costs for hospital-based care were assigned using prospectively collected bills from US patients (n=1171); physician and medication costs were assigned using the Medicare Fee Schedule and National Average Drug Acquisition Costs, respectively. Extrapolated life expectancies were estimated using age-based survival models. Quality-of-life adjustments were based on EQ-5D-based utilities measured during the trial. The primary outcome was the incremental cost-effectiveness ratio, comparing ablation with drug therapy on the basis of intention-to-treat, and assessed from the US health care sector perspective. RESULTS Costs in the first 3 months averaged $20 794±SD 1069 higher with ablation compared with drug therapy. The cumulative within-trial 5-year cost difference was $19 245 (95% CI, $11 360-$27 170) and the lifetime mean cost difference was $15 516 (95% CI, -$2963 to $35,512) higher with ablation than with drug therapy. The drug therapy arm accrued an average of 12.5 life-years (LYs) and 10.7 quality-adjusted life-years (QALYs). For the ablation arm, the corresponding estimates were 12.6 LYs and 11.0 QALYs. The incremental cost-effectiveness ratio was $57 893 per QALY gained, with 75% of bootstrap replications yielding an incremental cost-effectiveness ratio <$100 000 per QALY gained. With no quality-of-life/utility adjustments, the incremental cost-effectiveness ratio was $183 318 per LY gained. CONCLUSIONS Catheter ablation of atrial fibrillation was economically attractive compared with drug therapy in the CABANA Trial overall at present benchmarks for health care value in the United States on the basis of projected incremental QALYs but not LYs alone.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Alberta, Canada (D.S.C.)
| | - Yanhong Li
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Patricia A Cowper
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Kevin J Anstrom
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (K.J.A.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Melanie R Daniels
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | | | - Linda Davidson-Ray
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
| | - Tristram D Bahnson
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | - Kerry L Lee
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics (K.J.A., H.R.A.-K., K.L.L.), Duke University, Durham, NC
| | | | - Daniel B Mark
- Duke Clinical Research Institute (D.S.C., Y.L., P.A.C., K.J.A., J.P.P., M.R.D., L.D.-R., T.D.B., H.R.A.-K., K.L.L., D.B.M.), Duke University, Durham, NC
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.P., T.D.B., D.B.M.)
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22
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Rao VN, Kaltenbach LA, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Butler J, Allen LA, Lanfear DE, Ariely D, Miller JM, Brodsky MA, LaLonde TA, Lafferty JC, Granger CB, Hernandez AF, DeVore AD. The Association of Digital Health Application Use with Heart Failure Care and Outcomes: Insights from CONNECT-HF. J Card Fail 2022; 28:1487-1496. [PMID: 35905867 DOI: 10.1016/j.cardfail.2022.07.050] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unknown if digital applications may improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS CONNECT-HF included an optional, prospective ancillary study of a mobile health application among hospitalized patients for HFrEF. Digital users were matched to nonusers from the usual care group. Co-primary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2,431 patients offered digital applications across the United States, 1,526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs. 60 years, p=0.031). Digital users (N=368) versus matched nonusers (N=368) had improved composite HF quality scores (48.0% vs. 43.6%; +4.76% [3.27-6.24]; p=0.001) and composite clinical outcomes (33.0% vs. 39.6%; HR 0.76 [0.59-0.97]; p=0.027). CONCLUSIONS Among participants in CONNECT-HF, use of digital applications was modest, yet associated with higher HF quality of care scores, including use of GDMT, and better clinical outcomes. While cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.
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Affiliation(s)
- Vishal N Rao
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Larry A Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - David E Lanfear
- Department of Medicine, Cardiovascular Division, and Henry Ford Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, NC
| | - Julie M Miller
- Center for Advanced Hindsight, Duke University, Durham, NC
| | | | - Thomas A LaLonde
- Division of Cardiology, Department of Medicine, Ascension St. John Hospital, Detroit, MI
| | - James C Lafferty
- Department of Cardiology, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC.
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23
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Monahan KH, Bunch TJ, Mark DB, Poole JE, Bahnson TD, Al-Khalidi HR, Silverstein AP, Daniels MR, Lee KL, Packer DL. Influence of atrial fibrillation type on outcomes of ablation vs. drug therapy: results from CABANA. Europace 2022; 24:1430-1440. [PMID: 35640922 DOI: 10.1093/europace/euac055] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/10/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Influence of atrial fibrillation (AF) type on outcomes seen with catheter ablation vs. drug therapy is incompletely understood. This study assesses the impact of AF type on treatment outcomes in the Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA). METHODS AND RESULTS CABANA randomized 2204 patients ≥65 years old or <65 with at least one risk factor for stroke to catheter ablation or drug therapy. Of these, 946 (42.9%) had paroxysmal AF (PAF), 1042 (47.3%) had persistent AF (PersAF), and 215 (9.8%) had long-standing persistent AF (LSPAF) at baseline. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Symptoms were measured with the Mayo AF-Specific Symptom Inventory (MAFSI), and quality of life was measured with the Atrial Fibrillation Effect on Quality of Life (AFEQT). Comparisons are reported by intention to treat. Compared with drug therapy alone, catheter ablation produced a 19% relative risk reduction in the primary endpoint for PAF {adjusted hazard ratio [aHR]: 0.81 [95% confidence interval (CI): 0.50, 1.30]}, and a 17% relative reduction for PersAF (aHR: 0.83, 95% CI: 0.56, 1.22). For LSPAF, the ablation relative effect was a 7% reduction (aHR: 0.93, 95% CI: 0.36, 2.44). Ablation was more effective than drug therapy at reducing first AF recurrence in all AF types: by 51% for PAF (aHR: 0.49, 95% CI: 0.39, 0.62), by 47% for PersAF (aHR: 0.53, 95% CI: 0.43,0.65), and by 36% for LSPAF (aHR 0.64, 95% CI 0.41,1.00). Ablation was associated with greater improvement in symptoms, with the mean difference between groups in the MAFSI frequency score favouring ablation over 5 years of follow-up in all subgroups: PAF had a clinically significant -1.9-point difference (95% CI: -1.2 to -2.6); PersAF a -0.9 difference (95% CI: -0.2 to -1.6); LSPAF a clinically significant difference of -1.6 points (95% CI: -0.1 to -3.1). Ablation was also associated with greater improvement in quality of life in all subgroups, with the AFEQT overall score in PAF patients showing a clinically significant 5.3-point improvement (95% CI: 3.3 to 7.3) over drug therapy alone over 5 years of follow-up, PersAF a 1.7-point difference (95% CI: 0.0 to 3.7), and LSPAF a 3.1-point difference (95% CI: -1.6 to 7.8). CONCLUSION Prognostic treatment effects of catheter ablation compared with drug therapy on the primary and major secondary clinical endpoints did not differ consequentially by AF subtype. With regard to decreases in AF recurrence and improving quality of life, ablation was more effective than drug therapy in all three AF type subgroups. CLINICALTRIALS.GOV IDENTIFIER NCT00911508.
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Affiliation(s)
| | - T Jared Bunch
- Intermountain Health Care, University of Utah, Salt Lake City, UT 84132, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Jeanne E Poole
- University of Washington Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Melanie R Daniels
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC 27701, USA
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24
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Pokorney SD, Cocoros N, Al-Khalidi HR, Haynes K, Li S, Al-Khatib SM, Corrigan-Curay J, Driscoll MR, Garcia C, Calvert SB, Harkins T, Jin R, Knecht D, Levenson M, Lin ND, Martin D, McCall D, McMahill-Walraven C, Nair V, Parlett L, Petrone A, Temple R, Zhang R, Zhou Y, Platt R, Granger CB. Effect of Mailing Educational Material to Patients With Atrial Fibrillation and Their Clinicians on Use of Oral Anticoagulants: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2214321. [PMID: 35639381 PMCID: PMC9157265 DOI: 10.1001/jamanetworkopen.2022.14321] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Only about half of patients with atrial fibrillation (AF) who are at increased risk for stroke are treated with an oral anticoagulant (OAC), despite guideline recommendations for their use. Educating patients with AF about prevention of stroke with OACs may enable them as agents of change to initiate OAC treatment. OBJECTIVE To determine whether an educational intervention directed to patients and their clinicians stimulates the use of OACs in patients with AF who are not receiving OACs. DESIGN, SETTING, AND PARTICIPANTS The Implementation of a Randomized Controlled Trial to Improve Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation (IMPACT-AFib) trial was a prospective, multicenter, open-label, pragmatic randomized clinical trial conducted from September 25, 2017, to May 1, 2019, embedded in health plans that participate in the US Food and Drug Administration's Sentinel System. It used the distributed database comprising health plan members to identify eligible patients, their clinicians, and outcomes. IMPACT-AFib enrolled patients with AF, a CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score of 2 or more, no evidence of OAC prescription dispensing in the preceding 12 months, and no hospitalization-related bleeding event within the prior 6 months. INTERVENTIONS Randomization to a single mailing of patient and/or clinician educational materials vs control. MAIN OUTCOMES AND MEASURES Analysis was performed on a modified intention-to-treat basis. The primary end point was the proportion of patients with at least 1 OAC prescription dispensed or at least 4 international normalized ratio test results within 1 year of the intervention. RESULTS Among 47 333 patients, there were 24 909 men (52.6%), the mean (SD) age was 77.9 (9.7) years, mean (SD) CHA2DS2-VASc score was 4.5 (1.7), 22 404 patients (47.3%) had an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more, and 8890 patients (18.8%) had a history of hospitalization for bleeding. There were 2328 of 23 546 patients (9.9%) in the intervention group with initiation of OAC at 1 year compared with 2330 of 23 787 patients (9.8%) in the control group (adjusted OR, 1.01 [95% CI, 0.95-1.07]; P = .79). CONCLUSIONS AND RELEVANCE Among a large population with AF with a guideline indication for OACs for stroke prevention who were randomized to a mailed educational intervention or to usual care, there was no clinically meaningful, numerical, or statistically significant difference in rates of OAC initiation. More-intensive interventions are needed to try and address the public health issue of underuse of anticoagulation for stroke prevention among patients with AF. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03259373.
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Affiliation(s)
- Sean D. Pokorney
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Noelle Cocoros
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | - Shuang Li
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Sana M. Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Meighan Rogers Driscoll
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Crystal Garcia
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Sara B. Calvert
- Clinical Trials Transformation Initiative, Durham, North Carolina
| | | | - Robert Jin
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | | | - Mark Levenson
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration
| | - Nancy D. Lin
- OptumInsight Life Sciences Inc, Boston, Massachusetts
| | | | - Debbe McCall
- Rowan Tree Perspectives Consulting, Murrieta, California
| | | | - Vinit Nair
- Humana Healthcare Research Inc, Louisville, Kentucky
| | | | - Andrew Petrone
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Robert Temple
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rongmei Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration
| | - Yunping Zhou
- Humana Healthcare Research Inc, Louisville, Kentucky
| | - Richard Platt
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Christopher B. Granger
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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25
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Granger BB, Kaltenbach LA, Fonarow GC, Allen LA, Lanfear DE, Albert NM, Al-Khalidi HR, Butler J, Cooper LB, DeWald T, Felker GM, Heidenreich P, Kottam A, Lewis EF, Piña IL, Yancy CW, Granger CB, Hernandez AF, DeVore AD. Health System-Level Performance in Prescribing Guideline-Directed Medical Therapy for Patients with HFrEF: Results from the CONNECT-HF Trial. J Card Fail 2022; 28:1355-1361. [PMID: 35462033 DOI: 10.1016/j.cardfail.2022.03.356] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Health system-level interventions to improve use of guideline-directed medical therapy (GDMT) often fail in the acute care setting. We sought to identify factors associated with high performance in adoption of GDMT among health systems in CONNECT-HF. METHODS AND RESULTS Site-level composite quality scores were calculated at discharge and last follow-up. Site performance was defined as the average change in score from baseline to last follow-up and analyzed by performance tertile using a mixed-effects model with baseline performance as a fixed effect and site as a random effect. Among 150 randomized sites, mean 12-month improvement in GDMT was 1.8% (-26.4% to 60.0%). Achievement of ≥50% target dose for angiotensin-converting enzymes/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors and beta blockers at 12 months was modest, even at the highest performing sites (median 29.6% [23%, 41%] and 41.2% [29%, 50%]). Sites achieving higher GDMT scores had care teams that included social workers and pharmacists and patients able to afford medications and access medication lists in the electronic health record. CONCLUSIONS Substantial gaps in site-level use of GDMT were found even among highest performing sites. Failure of hospital-level interventions to improve quality metrics suggests that a team-based approach to care and improved patient access to medications are needed for post-discharge success.
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Affiliation(s)
- Bradi B Granger
- Duke Clinical Research Institute; Duke University School of Nursing; Duke University School of Medicine, Durham, NC, USA.
| | | | | | - Larry A Allen
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Tracy DeWald
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - G Michael Felker
- Duke Clinical Research Institute; Duke University School of Medicine, Durham, NC, USA
| | | | - Anupama Kottam
- Wayne State University and Detroit Medical Center, Detroit, MI, USA
| | | | - Ileana L Piña
- Wayne State University and Detroit Medical Center, Detroit, MI, USA
| | | | - Christopher B Granger
- Duke Clinical Research Institute; Duke University School of Medicine, Durham, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute; Duke University School of Medicine, Durham, NC, USA
| | - Adam D DeVore
- Duke Clinical Research Institute; Duke University School of Medicine, Durham, NC, USA
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26
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Harper JD, Desai AC, Antonelli JA, Tasian GE, Ziemba JB, Al-Khalidi HR, Lai HH, Maalouf NM, Reese PP, Wessells HB, Kirkali Z, Scales CD. Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS. BMC Urol 2022; 22:53. [PMID: 35387623 PMCID: PMC8988384 DOI: 10.1186/s12894-022-01004-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/10/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains. METHODS In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30. RESULTS The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability. CONCLUSIONS This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.
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Affiliation(s)
- Jonathan D. Harper
- grid.34477.330000000122986657Department of Urology, University of Washington School of Medicine, Seattle, WA 98195 USA
| | - Alana C. Desai
- grid.4367.60000 0001 2355 7002Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO USA
| | - Jodi A. Antonelli
- grid.267313.20000 0000 9482 7121Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Gregory E. Tasian
- grid.239552.a0000 0001 0680 8770Division of Pediatric Urology, Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Justin B. Ziemba
- grid.411115.10000 0004 0435 0884Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Hussein R. Al-Khalidi
- grid.26009.3d0000 0004 1936 7961Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA
| | - H. Henry Lai
- grid.4367.60000 0001 2355 7002Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Anesthesiology, Washington University School of Medicine, St Louis, MO USA
| | - Naim M. Maalouf
- grid.267313.20000 0000 9482 7121Department of Internal Medicine, Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Peter P. Reese
- grid.25879.310000 0004 1936 8972Renal-Electrolyte and Hypertension Division, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA ,grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Hunter B. Wessells
- grid.34477.330000000122986657Department of Urology, University of Washington School of Medicine, Seattle, WA 98195 USA
| | - Ziya Kirkali
- grid.419635.c0000 0001 2203 7304National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD USA
| | - Charles D. Scales
- grid.26009.3d0000 0004 1936 7961Departments of Surgery and Population Health Science, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA
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27
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Bahnson TD, Giczewska A, Mark DB, Russo AM, Monahan KH, Al-Khalidi HR, Silverstein AP, Poole JE, Lee KL, Packer DL. Association Between Age and Outcomes of Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: Results From the CABANA Trial. Circulation 2022; 145:796-804. [PMID: 34933570 PMCID: PMC9003625 DOI: 10.1161/circulationaha.121.055297] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [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 Observational data suggest that catheter ablation may be safe and effective to treat younger and older patients with atrial fibrillation. No large, randomized trial has examined this issue. This report describes outcomes according to age at entry in the CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS Patients with atrial fibrillation ≥65 years of age, or <65 with ≥1 risk factor for stroke, were randomly assigned to catheter ablation versus drug therapy. The primary outcome was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Secondary outcomes included all-cause mortality, the composite of mortality or cardiovascular hospitalization, and recurrence of atrial fibrillation. Treatment effect estimates were adjusted for baseline covariables using proportional hazards regression models. RESULTS Of 2204 patients randomly assigned in CABANA, 766 (34.8%) were <65 years of age, 1130 (51.3%) were 65 to 74 years of age, and 308 (14.0%) were ≥75 years of age. Catheter ablation was associated with a 43% reduction in the primary outcome for patients <65 years of age (adjusted hazard ratio [aHR], 0.57 [95% CI, 0.30-1.09]), a 21% reduction for 65 to 74 years of age (aHR, 0.79 [95% CI, 0.54-1.16]), and an indeterminate effect for age ≥75 years of age (aHR, 1.39 [95% CI, 0.75-2.58]). Four-year event rates for ablation versus drug therapy across age groups, respectively, were 3.2% versus 7.8%, 7.8% versus 9.6%, and 14.8% versus 9.0%. For every 10-year increase in age, the primary outcome aHR increased (ie, less favorable to ablation) an average of 27% (interaction P value=0.215). A similar pattern was seen with all-cause mortality: for every 10-year increase in age, the aHR increased an average of 46% (interaction P value=0.111). Atrial fibrillation recurrence rates were lower with ablation than with drug therapy across age subgroups (aHR 0.47, 0.58, and 0.49, respectively). Treatment-related complications were infrequent for both arms (<3%) regardless of age. CONCLUSIONS We found age-based variations in clinical outcomes for catheter ablation compared with drug therapy, with the largest relative and absolute benefits of catheter ablation in younger patients. No prognostic benefits for ablation were seen in the oldest patients. No differences were found by age in treatment-related complications or in the relative effectiveness of catheter ablation in preventing recurrent atrial arrhythmias. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00911508.
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Affiliation(s)
- Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Duke Center for Atrial Fibrillation, Duke Health System, Durham, NC (T.D.B.)
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Andrea M Russo
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.).,Cooper University Health System, Camden, NJ (A.M.R.)
| | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., A.G., D.B.M., H.R.A.-K., A.P.S., K.L.L.)
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Nanna MG, Vemulapalli S, Fordyce CB, Mark DB, Patel MR, Al-Khalidi HR, Kelsey M, Martinez B, Yow E, Mullen S, Stone GW, Ben-Yehuda O, Udelson JE, Rogers C, Douglas PS. The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial. Am Heart J 2022; 245:136-148. [PMID: 34953768 PMCID: PMC8979644 DOI: 10.1016/j.ahj.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/10/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. METHODS The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). RESULTS PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. CONCLUSIONS PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.
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Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Christopher B. Fordyce
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart and the Cardiovascular Research Foundation, New York, NY
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, NY, NY and the University of California, San Diego
| | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Häusler KG, Eichner FA, Heuschmann PU, Fiebach JB, Engelhorn T, Blank B, Callans D, Elvan A, Grimaldi M, Hansen J, Hindricks G, Al-Khalidi HR, Mont L, Nielsen JC, Piccini JP, Schotten U, Themistoclakis S, Vijgen J, Di Biase L, Kirchhof P. MRI-Detected Brain Lesions and Cognitive Function in Atrial Fibrillation Patients Undergoing Left Atrial Catheter Ablation in the Randomized AXAFA-AFNET 5 Trial. Circulation 2022; 145:906-915. [PMID: 35135308 DOI: 10.1161/circulationaha.121.056320] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/16/2022]
Abstract
Background: To assess the prevalence of magnetic resonance imaging (MRI) detected ischemic brain lesions and their association with cognitive function 3-months after first-time ablation using continuous oral anticoagulation in patients with paroxysmal atrial fibrillation (AF). Methods: Pre-specified analysis of the Anticoagulation using the direct factor Xa inhibitor apixaban during Atrial Fibrillation catheter Ablation: Comparison to vitamin K antagonist therapy (AXAFA-AFNET 5) trial, randomizing 674 patients with AF 1:1 to uninterrupted apixaban or vitamin K-antagonist therapy prior to first-time ablation. Brain MRI using fluid-attenuated inversion recovery (FLAIR) and high-resolution diffusion weighted imaging (hrDWI) was obtained within 3-48 hours after AF ablation in all eligible patients enrolled in 25 study centers in Europe and the United States. Patients underwent cognitive assessment 3-6 weeks before ablation and 3 months after ablation using the Montreal Cognitive Assessment (MoCA). Results: In 84 (26.1%) of 321 patients with analyzable MRI, hrDWI detected at least one acute brain lesion, including 44 (27.2%) apixaban and 40 (24.8%) vitamin K antagonist treated patients (p=0.675). Median MoCA score was similar in patients with or without acute brain lesions at 3-months after ablation (28 (IQR 26-29) vs. 28 (IQR 26-29); p=0.948). FLAIR-detected cerebral chronic white matter damage (defined as Wahlund score ≥4 points) was present in 130 (40.5%) patients and associated with lower median MoCA scores before ablation (27 (24-28) vs. 27 (IQR 25-29); p=0.026) and 3-months after ablation (27 (IQR 25-29) vs. 28 (IQR 26-29); p=0.011). Adjusted for age and gender, this association was no longer significant. Age was associated with lower MoCA scores before ablation (RR 1.02 per 10 years (95%CI 1.01-1.03)) and 3-months after ablation (RR 1.02 per 10 years (95%CI 1.01-1.03)). Conclusions: Brain MRI-detected chronic white matter damage as well as acute ischemic lesions were frequently found after first-time ablation for paroxysmal AF using uninterrupted oral anticoagulation. hrDWI-detected acute ischemic brain lesions were not associated with cognitive function at 3-months after ablation. Lower MoCA scores before and after ablation were associated with old age only, highlighting the safety of AF ablation on uninterrupted oral anticoagulation.
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Affiliation(s)
- Karl Georg Häusler
- Atrial Fibrillation NETwork (AFNET), Münster, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Felizitas A Eichner
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany; Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - David Callans
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Arif Elvan
- Isala Heart Center, Zwolle, The Netherlands
| | - Massimo Grimaldi
- Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, Italy
| | | | | | - Hussein R Al-Khalidi
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Lluís Mont
- Hospital Clinic Barcelona, University of Barcelona, Barcelona, Spain; Institut de Recerca Biomèdica August Pi Sunyer (IDIBAPS), Barcelona, Spain; CIBER cardiovascular, Madrid, Spain
| | | | - Jonathan P Piccini
- Duke Clinical Research Institute (DCRI), Durham, NC; Duke University, Division of Cardiology Duke University Medical Center, Durham NC
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Münster, Germany; University Maastricht, Department of Physiology, Maastricht, Netherlands
| | | | - Johan Vijgen
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Luigi Di Biase
- Albert Einstein College of Medicine, at Montefiore Hospital, New York; Texas Cardiac Arrhythmia Institute at St. Davidâs Medical Center, Austin, Texas
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Münster, Germany; University of Birmingham Institute of Cardiovascular Sciences, Birmingham, United Kingdom; Department of Cardiology, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
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30
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Nelson AJ, O’Brien EC, Kaltenbach LA, Green JB, Lopes RD, Morse CG, Al-Khalidi HR, Aroda VR, Cavender MA, Gaynor T, Kirk JK, Lingvay I, Magwire ML, McGuire DK, Pak J, Pop-Busui R, Richardson CR, Senyucel C, Kelsey MD, Pagidipati NJ, Granger CB. Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2022; 5:e2148030. [PMID: 35175345 PMCID: PMC8855234 DOI: 10.1001/jamanetworkopen.2021.48030] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021. EXPOSURES One or more health care encounters in 2018. MAIN OUTCOMES AND MEASURES Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA). RESULTS The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients). CONCLUSIONS AND RELEVANCE In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Caryn G. Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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Doenst T, Haddad H, Stebbins A, Hill JA, Velazquez EJ, Lee KL, Rouleau JL, Sopko G, Farsky PS, Al-Khalidi HR. Renal function and coronary bypass surgery in patients with ischemic heart failure. J Thorac Cardiovasc Surg 2022; 163:663-672.e3. [PMID: 32386761 PMCID: PMC7541611 DOI: 10.1016/j.jtcvs.2020.02.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic kidney disease is a known risk factor in cardiovascular disease, but its influence on treatment effect of bypass surgery remains unclear. We assessed the influence of chronic kidney disease on 10-year mortality and cardiovascular outcomes in patients with ischemic heart failure treated with medical therapy (medical treatment) with or without coronary artery bypass grafting. METHODS We calculated the baseline estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula, chronic kidney disease stages 1-5) from 1209 patients randomized to medical treatment or coronary artery bypass grafting in the Surgical Treatment for IsChemic Heart failure trial and assessed its effect on outcome. RESULTS In the overall Surgical Treatment for IsChemic Heart failure cohort, patients with chronic kidney disease stages 3 to 5 were older than those with stages 1 and 2 (66-71 years vs 54-59 years) and had more comorbidities. Multivariable modeling revealed an inverse association between estimated glomerular filtration rate and risk of death, cardiovascular death, or cardiovascular rehospitalization (all P < .001, but not for stroke, P = .697). Baseline characteristics of the 2 treatment arms were equal for each chronic kidney disease stage. There were significant improvements in death or cardiovascular rehospitalization with coronary artery bypass grafting (stage 1: hazard ratio, 0.71; confidence interval, 0.53-0.96, P = .02; stage 2: hazard ratio, 0.71; confidence interval, 0.59-0.84, P < .0001; stage 3: hazard ratio, 0.76; confidence interval, 0.53-0.96, P = .03). These data were inconclusive in stages 4 and 5 for insufficient patient numbers (N = 28). There was no significant interaction of estimated glomerular filtration rate with the treatment effect of coronary artery bypass grafting (P = .25 for death and P = .54 for death or cardiovascular rehospitalization). CONCLUSIONS Chronic kidney disease is an independent risk factor for mortality in patients with ischemic heart failure with or without coronary artery bypass grafting. However, mild to moderate chronic kidney disease does not appear to influence long-term treatment effects of coronary artery bypass grafting.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany.
| | - Haissam Haddad
- Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - James A Hill
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Malcom Randal VAMC, Gainesville, Fla
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jean L Rouleau
- Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Pedro S Farsky
- Department of Cardiology, Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Department of Cardiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
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Zeitler EP, Russo AM, Silverstein A, Al-Khalidi HR, Monahan KH, Packer DL, Mark DB. B-PO05-069 SEX-SPECIFIC QUALITY OF LIFE OUTCOMES OF ABLATION VERSUS DRUG THERAPY FOR AF: INSIGHTS FROM CABANA. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Raja SM, Guptill JT, McConnell A, Al-Khalidi HR, Hartwig MG, Klapper JA. Perioperative Outcomes of Thymectomy in Myasthenia Gravis: A Thoracic Surgery Database Analysis. Ann Thorac Surg 2021; 113:904-910. [PMID: 34339670 DOI: 10.1016/j.athoracsur.2021.06.071] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/22/2021] [Accepted: 06/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is clinical equipoise regarding the perioperative and long-term outcomes of autoimmune myasthenia gravis (MG) patients undergoing open vs minimally invasive thymectomy, particularly for non-thymomatous MG. This analysis utilizes multicenter, real-world clinical evidence to assess perioperative complications of open and minimally invasive thymectomy techniques in MG patients. METHODS Thymectomy cases 2009-2019 in MG patients were identified in the Society of Thoracic Surgeons General Thoracic Surgery Database. Thymectomies were grouped by surgical technique: transthoracic (TT), transcervical (TC), video-assisted thoracoscopic surgery (VATS), or Robotic VATS (RVATS). Multivariable logistic regression models assessed the association between surgical technique and perioperative complications. RESULTS Analysis of non-thymomatous cases (n=1,725) revealed VATS (OR 0.44, CI 0.23-0.83), RVATS (0.73, 0.48-1.26) and TC (0.19, 0.06-0.62) had lower odds of perioperative complications than TT thymectomies. VATS (2.29, 0.63-8.30) and RVATS (4.08, 1.21-3.78) thymectomies had higher odds of perioperative complications than TC. Analysis of thymomatous cases (n=311) found no significant difference in the odds of perioperative complications in TT vs minimally invasive (VATS/RVATS) procedures. The proportion of RVATS procedures increased from 6.43% to 44.27% while TT (56.43% to 34.35%) and TC (19.29% to 6.87%) thymectomies decreased. CONCLUSIONS Minimally invasive and TC thymectomies have fewer perioperative complications than TT when performed for non-thymomatous MG. Minimally invasive procedures are increasingly performed for both non-thymomatous and thymomatous disease. There is a nationwide shift towards minimally invasive procedures, even for thymoma resections. Long-term neurological outcome data are needed to determine whether a reduced perioperative risk for minimally invasive thymectomies translates to improved MG outcomes.
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Affiliation(s)
- Shruti M Raja
- Department of Neurology, Division of Neuromuscular Medicine, Duke University Medical Center.
| | - Jeffrey T Guptill
- Department of Neurology, Division of Neuromuscular Medicine, Duke University Medical Center
| | - Alec McConnell
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | - Matthew G Hartwig
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center
| | - Jacob A Klapper
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center
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DeVore AD, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Lewis EF, Butler J, Piña IL, Allen LA, Yancy CW, Cooper LB, Felker GM, Kaltenbach LA, McRae AT, Lanfear DE, Harrison RW, Disch M, Ariely D, Miller JM, Granger CB, Hernandez AF. Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial. JAMA 2021; 326:314-323. [PMID: 34313687 PMCID: PMC8317015 DOI: 10.1001/jama.2021.8844] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [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] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care. OBJECTIVE To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020. INTERVENTIONS Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website. MAIN OUTCOMES AND MEASURES The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed). RESULTS Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]). CONCLUSIONS AND RELEVANCE Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03035474.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
- Associate Section Editor, JAMA Cardiology
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M. Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Eldrin F. Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Ileana L. Piña
- Wayne State University and Detroit Medical Center, Detroit, Michigan
| | - Larry A. Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Clyde W. Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lauren B. Cooper
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - G. Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa A. Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - David E. Lanfear
- Henry Ford Heart and Vascular Institute, Department of Medicine, Cardiovascular Division, Henry Ford Hospital, Detroit, Michigan
| | - Robert W. Harrison
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Julie M. Miller
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Thomas KL, Al-Khalidi HR, Silverstein AP, Monahan KH, Bahnson TD, Poole JE, Mark DB, Packer DL. Ablation Versus Drug Therapy for Atrial Fibrillation in Racial and Ethnic Minorities. J Am Coll Cardiol 2021; 78:126-138. [PMID: 34238436 DOI: 10.1016/j.jacc.2021.04.092] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 02/01/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Rhythm control strategies for atrial fibrillation (AF), including catheter ablation, are substantially underused in racial/ethnic minorities in North America. OBJECTIVES This study sought to describe outcomes in the CABANA trial as a function of race/ethnicity. METHODS CABANA randomized 2,204 symptomatic participants with AF to ablation or drug therapy including rate and/or rhythm control drugs. Only participants in North America were included in the present analysis, and participants were subgrouped as racial/ethnic minority or nonminority with the use of National Institutes of Health definitions. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. RESULTS Of 1,280 participants enrolled in CABANA in North America, 127 (9.9%) were racial and ethnic minorities. Compared with nonminorities, racial and ethnic minorities were younger with median age 65.6 versus 68.5 years, respectively, and had more symptomatic heart failure (37.0% vs 22.0%), hypertension (92.1% vs 76.8%, respectively), and ejection fraction <40% (20.8% vs 7.1%). Racial/ethnic minorities treated with ablation had a 68% relative reduction in the primary endpoint (adjusted hazard ratio [aHR]: 0.32; 95% confidence interval [CI]: 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR: 0.28; 95% CI: 0.10-0.79). Primary event rates in racial/ethnic minority and nonminority participants were similar in the ablation arm (4-year Kaplan-Meier event rates 12.3% vs 9.9%); however, racial and ethnic minorities randomized to drug therapy had a much higher event rate than nonminority participants (27.4% vs. 9.4%). CONCLUSION Among racial or ethnic minorities enrolled in the North American CABANA cohort, catheter ablation significantly improved major clinical outcomes compared with drug therapy. These benefits, which were not seen in nonminority participants, appear to be due to worse outcomes with drug therapy. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Kevin L Thomas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Zink MD, Chua W, Zeemering S, di Biase L, Antoni BDL, David C, Hindricks G, Haeusler KG, Al-Khalidi HR, Piccini JP, Mont L, Nielsen JC, Escobar LA, de Bono J, Van Gelder IC, de Potter T, Scherr D, Themistoclakis S, Todd D, Kirchhof P, Schotten U. Predictors of recurrence of atrial fibrillation within the first 3 months after ablation. Europace 2021; 22:1337-1344. [PMID: 32725107 PMCID: PMC7478316 DOI: 10.1093/europace/euaa132] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 09/29/2019] [Revised: 01/19/2020] [Indexed: 11/23/2022] Open
Abstract
Aims Freedom from atrial fibrillation (AF) at 1 year can be achieved in 50–70% of patients undergoing catheter ablation. Recurrent AF early after ablation most commonly terminates spontaneously without further interventional treatment but is associated with later recurrent AF. The aim of this investigation is to identify clinical and procedural factors associated with recurrence of AF early after ablation. Methods and results We retrospectively analysed data for recurrence of AF within the first 3 months after catheter ablation from the randomized controlled AXAFA–AFNET 5 trial, which demonstrated that continuous anticoagulation with apixaban is as safe and as effective compared to vitamin K antagonists in 678 patients undergoing first AF ablation. The primary outcome of first recurrent AF within 90 days was observed in 163 (28%) patients, in which 78 (48%) patients experienced an event within the first 14 days post-ablation. After multivariable adjustment, a history of stroke/transient ischaemic attack [hazard ratio (HR) 1.54, 95% confidence interval (CI) 0.93–2.6; P = 0.11], coronary artery disease (HR 1.85, 95% CI 1.20–2.86; P = 0.005), cardioversion during ablation (HR 1.78, 95% CI 1.26–2.49; P = 0.001), and an age:sex interaction for older women (HR 1.01, 95% CI 1.00–1.01; P = 0.04) were associated with recurrent AF. The P-wave duration at follow-up was significantly longer for patients with AF recurrence (129 ± 31 ms vs. 122 ± 22 ms in patients without AF, P = 0.03). Conclusion Half of all early AF recurrences within the first 3 months post-ablation occurred within the first 14 days post-ablation. Vascular disease and cardioversion during the procedure are strong predictors of recurrent AF. P-wave duration at follow-up was longer in patients with recurrent AF. Trial registration Clinicaltrials.gov identifier NCT02227550
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Affiliation(s)
- Matthias Daniel Zink
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany.,Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Universiteitsingel 50, 6229 ER Maastricht, Netherlands
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Universiteitsingel 50, 6229 ER Maastricht, Netherlands
| | - Luigi di Biase
- Department of Medicine (Cardiology), Albert Einstein College of Medicine at Montefiore Hospital, Montefiore-Einstein Center for Heart & Vascular Care New York, NY, USA
| | - Bayes de Luna Antoni
- Autonomous University of Barcelona and Institut Català Ciències Cardiovasculars (ICCC)-St. Pau Hospital, Barcelona, Spain
| | - Callans David
- Cardiology Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Hussein R Al-Khalidi
- Department of Cardiac Electrophysiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Jonathan P Piccini
- Department of Cardiac Electrophysiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Lluís Mont
- Arrhythmia Section, Universitat de Barcelona, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Luis Alberto Escobar
- Autonomous University of Barcelona and Institut Català Ciències Cardiovasculars (ICCC)-St. Pau Hospital, Barcelona, Spain
| | - Joseph de Bono
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Isabelle C Van Gelder
- Department of Cardiology and Thorax Surgery, UMCG Thorax Center, University of Groningen, Groningen, The Netherlands
| | - Tom de Potter
- Department of Cardiology, Electrophysiology section, Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | - Daniel Scherr
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Universiteitsingel 50, 6229 ER Maastricht, Netherlands.,Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Dell'Angelo Hospital, Mestre-Venice, Italy
| | - Derick Todd
- Department of EP, Devices and ICC, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Universiteitsingel 50, 6229 ER Maastricht, Netherlands
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Affiliation(s)
- Khaled F. Bedair
- Faculty of Commerce, Tanta University, Tanta, Egypt
- School of Medicine, University of Dundee, Dundee, UK
| | - Yili Hong
- Department of Statistics, Virginia Tech, Blacksburg, VA, USA
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Rettmann ME, Holmes DR, Monahan KH, Breen JF, Bahnson TD, Mark DB, Poole JE, Ellis AM, Silverstein AP, Al-Khalidi HR, Lee KL, Robb RA, Packer DL. Treatment-Related Changes in Left Atrial Structure in Atrial Fibrillation: Findings From the CABANA Imaging Substudy. Circ Arrhythm Electrophysiol 2021; 14:e008540. [PMID: 33848199 DOI: 10.1161/circep.120.008540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Maryam E Rettmann
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - David R Holmes
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Kristi H Monahan
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Jerome F Breen
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle, WA (J.E.P.)
| | - Alicia M Ellis
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (T.D.B., D.B.M., A.M.E., A.P.S., H.R.A.-K., K.L.L.)
| | - Richard A Robb
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
| | - Douglas L Packer
- Mayo Clinic, Rochester, MN (M.E.R., D.R.H., K.H.M., J.F.B., R.A.R., D.L.P.)
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Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB. Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial. Circulation 2021; 143:1377-1390. [PMID: 33554614 DOI: 10.1161/circulationaha.120.050991] [Citation(s) in RCA: 202] [Impact Index Per Article: 67.3] [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] [Indexed: 01/04/2023]
Abstract
BACKGROUND In patients with heart failure and atrial fibrillation (AF), several clinical trials have reported improved outcomes, including freedom from AF recurrence, quality of life, and survival, with catheter ablation. This article describes the treatment-related outcomes of the AF patients with heart failure enrolled in the CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS The CABANA trial randomized 2204 patients with AF who were ≥65 years old or <65 years old with ≥1 risk factor for stroke at 126 sites to ablation with pulmonary vein isolation or drug therapy including rate or rhythm control drugs. Of these, 778 (35%) had New York Heart Association class >II at baseline and form the subject of this article. The CABANA trial's primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. RESULTS Of the 778 patients with heart failure enrolled in CABANA, 378 were assigned to ablation and 400 to drug therapy. Ejection fraction at baseline was available for 571 patients (73.0%), and 9.3% of these had an ejection fraction <40%, whereas 11.7% had ejection fractions between 40% and 50%. In the intention-to-treat analysis, the ablation arm had a 36% relative reduction in the primary composite end point (hazard ratio, 0.64 [95% CI, 0.41-0.99]) and a 43% relative reduction in all-cause mortality (hazard ratio, 0.57 [95% CI, 0.33-0.96]) compared with drug therapy alone over a median follow-up of 48.5 months. AF recurrence was decreased with ablation (hazard ratio, 0.56 [95% CI, 0.42-0.74]). The adjusted mean difference for the AFEQT (Atrial Fibrillation Effect on Quality of Life) summary score averaged over the entire 60-month follow-up was 5.0 points, favoring the ablation arm (95% CI, 2.5-7.4 points), and the MAFSI (Mayo Atrial Fibrillation-Specific Symptom Inventory) frequency score difference was -2.0 points, favoring ablation (95% CI, -2.9 to -1.2). CONCLUSIONS In patients with AF enrolled in the CABANA trial who had clinically diagnosed stable heart failure at trial entry, catheter ablation produced clinically important improvements in survival, freedom from AF recurrence, and quality of life relative to drug therapy. These results, obtained in a cohort most of whom had preserved left ventricular function, require independent trial verification. Registration: URL: https://www.clinicaltrials.gov/ct2/show/NCT00911508; Unique identifier: NCT0091150.
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Affiliation(s)
- Douglas L Packer
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Kristi H Monahan
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Peter A Noseworthy
- Mayo Clinic Hospital, St. Marys Campus, Rochester, MN (D.L.P., K.H.M., P.A.N.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (J.P.P., H.R.A.-K., A.P.S., T.D.B., K.L.L., D.B.M.)
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40
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Russo AM, Zeitler EP, Giczewska A, Silverstein AP, Al-Khalidi HR, Cha YM, Monahan KH, Bahnson TD, Mark DB, Packer DL, Poole JE. Association Between Sex and Treatment Outcomes of Atrial Fibrillation Ablation Versus Drug Therapy: Results From the CABANA Trial. Circulation 2021; 143:661-672. [PMID: 33499668 DOI: 10.1161/circulationaha.120.051558] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among patients with atrial fibrillation (AF), women are less likely to receive catheter ablation and may have more complications and less durable results. Most information about sex-specific differences after ablation comes from observational data. We prespecified an examination of outcomes by sex in the 2204-patient CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation). METHODS CABANA randomized patients with AF age ≥65 years or <65 years with ≥1 risk factor for stroke to a strategy of catheter ablation with pulmonary vein isolation versus drug therapy with rate/rhythm control agents. The primary composite outcome was death, disabling stroke, serious bleeding, or cardiac arrest, and key secondary outcomes included AF recurrence. RESULTS CABANA randomized 819 (37%) women (ablation 413, drug 406) and 1385 men (ablation 695, drug 690). Compared with men, women were older (median age, 69 years versus 67 years for men), were more symptomatic (48% Canadian Cardiovascular Society AF Severity Class 3 or 4 versus 39% for men), had more symptomatic heart failure (42% with New York Heart Association Class ≥II versus 32% for men), and more often had a paroxysmal AF pattern at enrollment (50% versus 39% for men) (P<0.0001 for all). Women were less likely to have ancillary (nonpulmonary vein) ablation procedures performed during the index procedure (55.7% versus 62.2% in men, P=0.043), and complications from treatment were infrequent in both sexes. For the primary outcome, the hazard ratio for those who underwent ablation versus drug therapy was 1.01 (95% CI, 0.62-1.65) in women and 0.73 (95% CI, 0.51-1.05) in men (interaction P value=0.299). The risk of recurrent AF was significantly reduced in patients undergoing ablation compared with those receiving drug therapy regardless of sex, but the effect was greater in men (hazard ratio, 0.64 [95% CI, 0.51-0.82] for women versus hazard ratio, 0.48 [95% CI, 0.40-0.58] for men; interaction P value=0.060). CONCLUSIONS Clinically relevant treatment-related strategy differences in the primary and secondary clinical outcomes of CABANA were not seen between men and women, and there were no sex differences in adverse events. The CABANA trial results support catheter ablation as an effective treatment strategy for both women and men. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00911508.
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Affiliation(s)
- Andrea M Russo
- Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - Emily P Zeitler
- The Geisel School of Medicine at Dartmouth, Hanover, NH, Division of Cardiology, Dartmouth-Hitchcock Medical Center, and The Dartmouth Institute, Lebanon, NH (E.P.Z.)
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Yong-Mei Cha
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Kristi H Monahan
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (A.G., A.P.S., H.R.A.-K., T.D.B., D.B.M.)
| | - Douglas L Packer
- Mayo Clinic, St Mary's Campus, Rochester, MN (Y.-M.C., K.H.M., D.L.P.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
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Scales CD, Lai HH, Desai AC, Antonelli JA, Maalouf NM, Tasian GE, Reese PP, Curatolo M, Weinfurt K, Al-Khalidi HR, Wessells H, Kirkali Z, Harper JD. Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design. J Endourol 2020; 35:761-768. [PMID: 33081503 DOI: 10.1089/end.2020.0776] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. Materials and Methods: We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. Results: The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. Conclusion: STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.
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Affiliation(s)
- Charles D Scales
- Departments of Surgery and Population Health Sciences, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alana C Desai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jodi A Antonelli
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Naim M Maalouf
- Department of Internal Medicine and Charles, Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregory E Tasian
- Department of Surgery, Division of Pediatric Urology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Renal-Electrolyte and Hypertension Division, Department of Medicine, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michele Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kevin Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hunter Wessells
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Jonathan D Harper
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
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Scales CD, Desai AC, Harper JD, Lai HH, Maalouf NM, Reese PP, Tasian GE, Al-Khalidi HR, Kirkali Z, Wessells H. Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial. Am J Kidney Dis 2020; 77:898-906.e1. [PMID: 33212205 DOI: 10.1053/j.ajkd.2020.09.016] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 09/15/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake. STUDY DESIGN We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants. SETTING & PARTICIPANTS Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake. INTERVENTIONS All participants receive usual care and a smart water bottle with smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions. OUTCOMES The primary end point is recurrence of a symptomatic stone during 24 months of follow-up. Secondary end points include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms. LIMITATIONS Periodic 24-hour urine volumes may not fully reflect daily behavior. CONCLUSIONS With its highly novel features, the PUSH Study will address an important health care problem. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT03244189.
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Affiliation(s)
- Charles D Scales
- Urologic Surgery and Population Health Science, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Alana C Desai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Jonathan D Harper
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Naim M Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Gregory E Tasian
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Urology, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Hunter Wessells
- Department of Urology, University of Washington School of Medicine, Seattle, WA
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Kochar A, Mulder H, Rockhold FW, Baumgartner I, Berger JS, Blomster JI, Fowkes FGR, Katona BG, Lopes RD, Al-Khalidi HR, Mahaffey KW, Norgren L, Hiatt WR, Patel MR, Jones WS. Cause of Death Among Patients With Peripheral Artery Disease. Circ Cardiovasc Qual Outcomes 2020; 13:e006550. [DOI: 10.1161/circoutcomes.120.006550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 11/16/2022]
Abstract
Background:
Peripheral artery disease is common and associated with high mortality. There are limited data detailing causes of death among patients with peripheral artery disease.
Methods:
EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) was a randomized clinical trial that assigned patients with peripheral artery disease to clopidogrel or ticagrelor. We describe the causes of death in EUCLID using mortality end points adjudicated through a clinical events classification process. The association between baseline factors and cardiovascular death was evaluated by Cox proportional hazards modeling. The competing risk of noncardiovascular death was assessed by the cumulative incidence function for cardiovascular death and the Fine and Gray method to ascertain the association between baseline characteristics and cardiovascular mortality.
Results:
A total of 1263 out of 13 885 (9.1%) patients died (median follow-up: 30 months). There were 706 patients (55.9%) with a cardiovascular cause of death and 522 (41.3%) with a noncardiovascular cause of death. The most common cause of cardiovascular death was sudden cardiac death (20.1%); while myocardial infarction (5.2%) and ischemic stroke (3.2%) were uncommon. The most common causes of noncardiovascular death were malignancies (17.9%) and infections (11.9%). The factor most associated with a higher risk of cardiovascular death was age per 5 year increase (HR, 1.26 [95% CI, 1.20–1.32]). Female sex was associated with a lower risk of cardiovascular death (HR, 0.68 [95% CI, 0.56–0.82]). To evaluate the effect of noncardiovascular death as a competing risk, we superimposed the cumulative incidence function curve with the Kaplan-Meier curve. These curves closely approximated each other. After accounting for the competing risk of noncardiovascular death, the magnitude and direction of the factors associated with cardiovascular death were minimally changed.
Conclusions:
Among patients with symptomatic peripheral artery disease, noncardiovascular causes of death reflected a high proportion (40%) of deaths. Accounting for noncardiovascular deaths as a competing risk, there was not a significant change in the risk estimation for cardiovascular death.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01732822.
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Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (A.K.)
| | - Hillary Mulder
- Duke Clinical Research Institute (H.M., F.W.R., R.D.L., H.R.A.-K., M.R.P.), Duke University, Durham, NC
| | - Frank W. Rockhold
- Duke Clinical Research Institute (H.M., F.W.R., R.D.L., H.R.A.-K., M.R.P.), Duke University, Durham, NC
| | - Iris Baumgartner
- Swiss Cardiovascular Centre, Inselspital, Bern University Hospital, University of Switzerland (I.B.)
| | - Jeffrey S. Berger
- Departments of Medicine and Surgery, New York University School of Medicine (J.S.B.)
| | | | - F. Gerry R. Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (F.G.R.F.)
| | | | - Renato D. Lopes
- Duke Heart Center, Division of Cardiology, School of Medicine (R.D.L., M.R.P., W.S.J.), Duke University, Durham, NC
- Duke Clinical Research Institute (H.M., F.W.R., R.D.L., H.R.A.-K., M.R.P.), Duke University, Durham, NC
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute (H.M., F.W.R., R.D.L., H.R.A.-K., M.R.P.), Duke University, Durham, NC
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Sweden (L.N.)
| | - William R. Hiatt
- University of Colorado School of Medicine and CPC Clinical Research, Aurora (W.R.H.)
| | - Manesh R. Patel
- Duke Heart Center, Division of Cardiology, School of Medicine (R.D.L., M.R.P., W.S.J.), Duke University, Durham, NC
- Duke Clinical Research Institute (H.M., F.W.R., R.D.L., H.R.A.-K., M.R.P.), Duke University, Durham, NC
| | - W. Schuyler Jones
- Duke Heart Center, Division of Cardiology, School of Medicine (R.D.L., M.R.P., W.S.J.), Duke University, Durham, NC
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Al-Khatib SM, Pokorney SD, Al-Khalidi HR, Haynes K, Garcia C, Martin D, Goldsack JC, Harkins T, Cocoros NM, Lin ND, Lipowicz H, McCall D, Nair V, Parlett L, McMahill-Walraven CN, Platt R, Granger CB. Underuse of oral anticoagulants in privately insured patients with atrial fibrillation: A population being targeted by the IMplementation of a randomized controlled trial to imProve treatment with oral AntiCoagulanTs in patients with Atrial Fibrillation (IMPACT-AFib). Am Heart J 2020; 229:110-117. [PMID: 32949986 DOI: 10.1016/j.ahj.2020.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many studies showing underuse of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) predated the advent of the non-vitamin K antagonist OACs. We retrospectively examined use of OACs in a large commercially insured population. METHODS Administrative claims data from 4 research partners participating in FDA-Catalyst, a program of the Sentinel Initiative, were queried in September 2017. Patients were included if they were ≥30 years old with ≥365 days of medical/pharmacy coverage, and had ≥2 diagnosis codes for AF, a CHA2DS2-VASc score ≥2, absence of contraindications to OAC use, and no evidence of OAC use in the 365 days before the index AF diagnosis. The main outcome measures of the current analysis were rates of OAC use in the prior 12 months of cohort identification and factors associated with non-use. RESULTS A total of 197,806 AF patients met the eligibility criteria prior to assessment of OAC treatment. Of these, 179,580 (91%) patients were ≥65 years old and 73,286 (37%) patients were ≥80 years old. Half of the patients (98,903) were randomized to the early intervention arm in the IMPACT-AFib trial and constitute the cohort for this analysis. Of these, 32,295 (33%) had no evidence of OAC use in the prior 12 months. Compared with patients with evidence of OAC use in the prior 12 months, patients without OAC use were more likely to be ≥80 years old, women, and have a history of anemia (51% vs 47%) and less likely to have diabetes (41% vs 44%), history of stroke or TIA (15% vs 19%), and history of heart failure (39% vs 48%). CONCLUSIONS Despite a high risk of stroke, one-third of privately insured patients with AF and no obvious contraindications to an OAC were not treated with an OAC. There is an unmet need for evidence-based interventions that could lead to greater use of OACs in patients with AF at risk for stroke.
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Zeitouni M, Al-Khalidi HR, Roettig ML, Bolles MM, Doerfler SM, Fordyce CB, Hellkamp AS, Henry TD, Magdon-Ismail Z, Monk L, Nelson RD, O’Brien PK, Wilson BH, Ziada KM, Granger CB, Jollis JG. Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes 2020; 13:e006204. [DOI: 10.1161/circoutcomes.119.006204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/16/2022]
Abstract
Background:
Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.
Methods and Results:
From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.
Conclusions:
Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Anne S. Hellkamp
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (B.H.W.)
| | - Khaled M. Ziada
- Gill Heart & Vascular Institute University of Kentucky, Lexington (K.M.Z.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
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Kloosterman M, Chua W, Fabritz L, Al-Khalidi HR, Schotten U, Nielsen JC, Piccini JP, Di Biase L, Häusler KG, Todd D, Mont L, Van Gelder IC, Kirchhof P. Sex differences in catheter ablation of atrial fibrillation: results from AXAFA-AFNET 5. Europace 2020; 22:1026-1035. [PMID: 32142113 PMCID: PMC7336181 DOI: 10.1093/europace/euaa015] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/07/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Study sex-differences in efficacy and safety of atrial fibrillation (AF) ablation. METHODS AND RESULTS We assessed first AF ablation outcomes on continuous anticoagulation in 633 patients [209 (33%) women and 424 (67%) men] in a pre-specified subgroup analysis of the AXAFA-AFNET 5 trial. We compared the primary outcome (death, stroke or transient ischaemic attack, or major bleeding) and secondary outcomes [change in quality of life (QoL) and cognitive function] 3 months after ablation. Women were older (66 vs. 63 years, P < 0.001), more often symptomatic, had lower QoL and a longer history of AF. No sex differences in ablation procedure were found. Women stayed in hospital longer than men (2.1 ± 2.3 vs. 1.6 ± 1.3 days, P = 0.004). The primary outcome occurred in 19 (9.1%) women and 26 (6.1%) men, P = 0.19. Women experienced more bleeding events requiring medical attention (5.7% vs. 2.1%, P = 0.03), while rates of tamponade (1.0% vs. 1.2%) or intracranial haemorrhage (0.5% vs. 0%) did not differ. Improvement in QoL after ablation was similar between the sexes [12-item Short Form Health Survey (SF-12) physical 5.1% and 5.9%, P = 0.26; and SF-12 mental 3.7% and 1.6%, P = 0.17]. At baseline, mild cognitive impairment according to the Montreal Cognitive Assessment (MoCA) was present in 65 (32%) women and 123 (30%) men and declined to 23% for both sexes at end of follow-up. CONCLUSION Women and men experience similar improvement in QoL and MoCA score after AF ablation on continuous anticoagulation. Longer hospital stay, a trend towards more nuisance bleeds, and a lower overall QoL in women were the main differences observed.
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Affiliation(s)
- Mariëlle Kloosterman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | - Ulrich Schotten
- University of Maastricht, Maastricht Medical Center, Maastricht, the Netherlands
| | | | | | | | | | - Derick Todd
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Lluis Mont
- Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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47
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Poole JE, Bahnson TD, Monahan KH, Johnson G, Rostami H, Silverstein AP, Al-Khalidi HR, Rosenberg Y, Mark DB, Lee KL, Packer DL. Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial. J Am Coll Cardiol 2020; 75:3105-3118. [PMID: 32586583 PMCID: PMC8064404 DOI: 10.1016/j.jacc.2020.04.065] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [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: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/21/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized 2,204 patients with atrial fibrillation (AF) to catheter ablation or drug therapy. Analysis by intention-to-treat showed a nonsignificant 14% relative reduction in the primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest. OBJECTIVES The purpose of this study was to assess recurrence of AF in the CABANA trial. METHODS The authors prospectively studied CABANA patients using a proprietary electrocardiogram recording monitor for symptom-activated and 24-h AF auto detection. The AF recurrence endpoint was any post-90-day blanking atrial tachyarrhythmias lasting 30 s or longer. Biannual 96-h Holter monitoring was used to assess AF burden. Patients who used the CABANA monitors and provided 90-day post-blanking recordings qualified for this analysis (n = 1,240; 56% of CABANA population). Treatment comparisons were performed using a modified intention-to-treat approach. RESULTS Median age of the 1,240 patients was 68 years, 34.4% were women, and AF was paroxysmal in 43.0%. Over 60 months of follow-up, first recurrence of any symptomatic or asymptomatic AF (hazard ratio: 0.52; 95% confidence interval: 0.45 to 0.60; p < 0.001) or first symptomatic-only AF (hazard ratio: 0.49; 95% confidence interval: 0.39 to 0.61; p < 0.001) were both significantly reduced in the catheter ablation group. Baseline Holter AF burden in both treatment groups was 48%. At 12 months, AF burden in ablation patients averaged 6.3%, and in drug-therapy patients, 14.4%. AF burden was significantly less in catheter ablation compared with drug-therapy patients across the 5-year follow-up (p < 0.001). These findings were not sensitive to the baseline pattern of AF. CONCLUSIONS Catheter ablation was effective in reducing recurrence of any AF by 48% and symptomatic AF by 51% compared with drug therapy over 5 years of follow-up. Furthermore, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington.
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - George Johnson
- Seattle Institute of Cardiac Research, Seattle, Washington
| | - Hoss Rostami
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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48
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Garcia CJ, Haynes K, Pokorney SD, Lin ND, McMahill-Walraven C, Nair V, Parlett L, Martin D, Al-Khalidi HR, McCall D, Granger CB, Platt R, Cocoros NM. Practical challenges in the conduct of pragmatic trials embedded in health plans: Lessons of IMPACT-AFib, an FDA-Catalyst trial. Clin Trials 2020; 17:360-367. [PMID: 32589056 DOI: 10.1177/1740774520928426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
IMPACT-AFib was an 80,000-patient randomized clinical trial implemented by five US insurance companies (health plans) aimed at increasing the use of oral anticoagulants by individuals with atrial fibrillation who were at high risk of stroke and not on treatment. The underlying thesis was that patients could be change agents to initiate prescribing discussions with their providers. We tested the effect of mailing information to both patients and their providers. We used administrative medical claims and pharmacy dispensing data to identify eligible patients, to randomize them to an early or delayed intervention, and to assess clinical outcomes. The core data were analysis-ready datasets each site had created and curated for the FDA's Sentinel System, supplemented by updated "fresh" pharmacy and enrollment data to ensure eligibility at the time of intervention. Following mutually agreed upon procedures, sites linked to additional internal source data to implement the intervention-educational information mailed to patients and their providers in the early intervention arm, and to providers of patients in the delayed intervention arm approximately 12 months later. The primary analysis compares the early intervention arm to the delayed intervention arm, prior to the delayed intervention being conducted (i.e. compares intervention to non-intervention). The endpoints of interest were evidence of initiation of anticoagulation (primary) as well as clinical endpoints, including stroke and hospitalization for bleeding. Major challenges, some unanticipated, identified during the planning phase include convening multi-stakeholder investigator teams and advisors, addressing ethical concerns about not intervening in a usual care comparison group, and identifying and avoiding interference with sites' routine programs that were similar to the intervention. Needs and challenges during the implementation phase included the fact that even limited site-specific programming greatly increased time and effort, the need to refresh research data extracts immediately before outreach to patients and providers, potential difficulty identifying low-cost medications such as warfarin that may not be reimbursed by health plans and so not discoverable in dispensing data, the need to develop workarounds when "providers" in claims data were facilities, difficulty addressing clustering of patients by provider because providers can have multiple identifiers within and between health plans, and the need to anticipate loss to follow up because of health plan disenrollment or change in benefits. As pragmatic trials begin to shape evidence generation within clinical practice, investigators should anticipate issues inherent to claims data and working with multiple large sites. In IMPACT-AFib, we found that investing in collaboration and communication among all parties throughout all phases of the study helped ensure common understanding, early identification of challenges, and streamlined actual implementation.
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Affiliation(s)
- Crystal J Garcia
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Sean D Pokorney
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Nancy D Lin
- OptumInsight Life Sciences, Inc., Boston, MA, USA
| | | | - Vinit Nair
- Humana Healthcare Research, Humana Inc., Louisville, KY, USA
| | | | - David Martin
- U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Debbe McCall
- Rowan Tree Perspectives Consulting, Murrieta, CA, USA
| | - Christopher B Granger
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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49
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DeVore AD, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Lewis EF, Butler J, Piña IL, Heidenreich PA, Allen LA, Yancy CW, Cooper LB, Felker GM, Kaltenbach LA, McRae AT, Lanfear DE, Harrison RW, Kociol RD, Disch M, Ariely D, Miller JM, Granger CB, Hernandez AF. Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure: Rationale and design of CONNECT-HF. Am Heart J 2020; 220:41-50. [PMID: 31770656 DOI: 10.1016/j.ahj.2019.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 05/06/2019] [Accepted: 09/18/2019] [Indexed: 11/29/2022]
Abstract
Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Ileana L Piña
- Wayne State University and Detroit Medical Center, Detroit, MI
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Larry A Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Cyde W Yancy
- Division of Cardiology, Northwestern University, Chicago, IL
| | - Lauren B Cooper
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - David E Lanfear
- Department of Medicine, Cardiovascular Division, and Henry Ford Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Robert W Harrison
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | | | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, NC
| | - Julie M Miller
- Center for Advanced Hindsight, Duke University, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
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Saito S, Krucoff MW, Nakamura S, Mehran R, Maehara A, Al-Khalidi HR, Rowland SM, Tasissa G, Morrell D, Joseph D, Okaniwa Y, Shibata Y, Bertolet BD, Rothenberg MD, Généreux P, Bezerra H, Kong DF. Japan-United States of America Harmonized Assessment by Randomized Multicentre Study of OrbusNEich's Combo StEnt (Japan-USA HARMONEE) study: primary results of the pivotal registration study of combined endothelial progenitor cell capture and drug-eluting stent in patients with ischaemic coronary disease and non-ST-elevation acute coronary syndrome. Eur Heart J 2019; 39:2460-2468. [PMID: 29931092 PMCID: PMC6037087 DOI: 10.1093/eurheartj/ehy275] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 06/13/2018] [Indexed: 01/07/2023] Open
Abstract
Aims Harmonized Assessment by Randomized Multicentre Study of OrbusNEich’s Combo StEnt (HARMONEE) (NCT02073565) was a randomized pivotal registration trial of the Combo stent, which combined sirolimus and an abluminal bioabsorbable polymer with a novel endoluminal anti-CD34+ antibody coating designed to capture endothelial progenitor cells (EPC) and promote percutaneous coronary intervention (PCI) site healing. Methods and results Clinically stabilized PCI subjects were randomized 1:1 to receive Combo or everolimus-eluting stents (EES). Between February 2014 and June 2016, 572 subjects with 675 coronary lesions underwent 1-year angiography and fractional flow reserve, with optical coherence tomography (OCT) in the first 140 patients. The primary clinical endpoint was non-inferior 1-year target vessel failure (TVF). The primary mechanistic endpoint of EPC capture activity was superior strut coverage by OCT. Target vessel failure occurred in 7.0% Combo (20/287) vs. 4.2% EES (12/285), a 2.8% [95% confidence interval (95% CI) −1.0%, 6.5%] difference, meeting the non-inferiority hypothesis (P = 0.02). There were no cardiac deaths, with one stent thrombosis observed in the EES group. Quantitative coronary angiography late loss with Combo was equivalent to EES. Optical coherence tomography strut coverage at 1 year was superior with Combo vs. EES [91.3% (95% CI 88.7%, 93.8%) vs. 74.8% (95% CI 70.0%, 79.6%), P < 0.001], with homogeneous tissue in 81.2% vs. 68.8%, respectively. Conclusion Combo stent demonstrated non-inferior 1-year TVF and late loss in a randomized comparison to EES, with superior strut-based tissue coverage by OCT as a surrogate of EPC capture technology activity. ![]()
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Affiliation(s)
- Shigeru Saito
- Shonan Kamakura General Hospital, Kamakura, Japan, and Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Mitchell W Krucoff
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Akiko Maehara
- Cardiovascular Research Foundation and Columbia University, New York, NY, USA
| | - Hussein R Al-Khalidi
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | | | - Gudaye Tasissa
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | | | - Diane Joseph
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Mark D Rothenberg
- Atlantic Clinical Research Collaborative - Cardiology, Atlantis, FL, USA
| | | | - Hiram Bezerra
- University Hospitals of Cleveland, Cleveland, OH, USA
| | - David F Kong
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
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