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Sayed A, Brophy JM. Effect of bempedoic acid on mortality and cardiovascular events in primary and secondary prevention: A post-hoc analysis of the CLEAR-outcomes trial. Int J Cardiol 2024; 406:132074. [PMID: 38643794 DOI: 10.1016/j.ijcard.2024.132074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/06/2024] [Accepted: 04/17/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The effects of bempedoic acid on mortality in the secondary prevention setting have not been examined. METHODS We used data from the overall and primary prevention reports of CLEAR - Outcomes to reconstruct data for the secondary prevention population. A Bayesian analyses was employed to calculate the posterior probability of benefit or harm for the outcomes of all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE). Relative effect sizes are presented as risk ratios (RR) with 95% credible intervals (CrI), which represent the intervals that true effect sizes are expected to fall in with 95% probability, given the priors and model. RESULTS In primary prevention, the posterior probability of bempedoic acid decreasing all-cause and cardiovascular mortality was 99.4% (RR: 0.70; 95% CrI: 0.51 to 0.92) and 99.7% (RR: 0.58; 95% CrI: 0.38 to 0.86) respectively. In secondary prevention, the posterior probability of bempedoic acid increasing all-cause and cardiovascular mortality was 96.6% (RR: 1.15; 95% CrI: 0.99 to 1.33) and 97.2% (RR: 1.21; 95% CrI: 1.00 to 1.45) respectively. The probability of bemepdoic acid reducing MACE in the primary and secondary prevention settings was 99.9% (RR: 0.70; 95% CrI: 0.54 to 0.88) and 95.8% (RR: 0.92; 95% CrI: 0.84 to 1.01) respectively. CONCLUSION In contrast to its effect in the primary prevention subgroup of CLEAR - Outcomes, bempedoic acid resulted in a more modest MACE reduction and a potential increase in mortality in the secondary prevention subgroup. Whether these findings represent true treatment effect heterogeneity or the play of chance requires further evidence.
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Affiliation(s)
- Ahmed Sayed
- Ain Shams University, Faculty of Medicine, Cairo, Egypt
| | - James M Brophy
- McGill University Health Center Centre for Health Outcomes Research (CORE), Montréal, Québec, Canada.
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Ko DT, Brophy JM, Mamas MA, McCrindle BW, Wijeysundera HC. Social Determinants of Health in Cardiovascular Disease: A Call to Action. Can J Cardiol 2024:S0828-282X(24)00331-3. [PMID: 38663527 DOI: 10.1016/j.cjca.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Newcastle, United Kingdom
| | - Brian W McCrindle
- University of Toronto, Toronto, Ontario, Canada; Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
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Mésidor M, Sirois C, Guertin JR, Schnitzer ME, Candas B, Blais C, Cossette B, Poirier P, Brophy JM, Lix L, Tadrous M, Diop A, Hamel D, Talbot D. Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation. J Clin Epidemiol 2024; 168:111284. [PMID: 38367659 DOI: 10.1016/j.jclinepi.2024.111284] [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: 09/19/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVES Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year. STUDY DESIGN AND SETTING We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting. RESULTS A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously. CONCLUSION We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.
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Affiliation(s)
- Miceline Mésidor
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada.
| | - Caroline Sirois
- Centre de recherche du CHU de Québec, Université Laval, Québec, Canada; Faculté de pharmacie, Université Laval, Québec, Canada; Institut national de santé publique du Québec, Québec, Canada
| | - Jason Robert Guertin
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Mireille E Schnitzer
- Faculté de pharmacie et Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Bernard Candas
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Claudia Blais
- Faculté de pharmacie, Université Laval, Québec, Canada; Institut national de santé publique du Québec, Québec, Canada
| | - Benoit Cossette
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Montréal, Canada
| | - Paul Poirier
- Faculté de pharmacie, Université Laval, Québec, Canada; Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada; McGill University Hospital Center, Centre for Health Outcomes Research, Montréal, Canada
| | - Lisa Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mina Tadrous
- University of Toronto, Leslie Dan Faculty of Pharmacy, Toronto, Canada
| | - Awa Diop
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Denis Hamel
- Institut national de santé publique du Québec, Québec, Canada
| | - Denis Talbot
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
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Rouette J, McDonald EG, Schuster T, Matok I, Brophy JM, Azoulay L. Thiazide Diuretics and Risk of Colorectal Cancer: A Population-Based Cohort Study. Am J Epidemiol 2024; 193:47-57. [PMID: 37579305 DOI: 10.1093/aje/kwad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 05/05/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
Evidence from clinical trials and observational studies on the association between thiazide diuretics and colorectal cancer risk is conflicting. We aimed to determine whether thiazide diuretics are associated with an increased colorectal cancer risk compared with dihydropyridine calcium channel blockers (dCCBs). A population-based, new-user cohort was assembled using the UK Clinical Practice Research Datalink. Between 1990-2018, we compared thiazide diuretic initiators with dCCB initiators and estimated hazard ratios (HR) with 95% confidence intervals (CIs) of colorectal cancer using Cox proportional hazard models. Models were weighted using standardized morbidity ratio weights generated from calendar time-specific propensity scores. The cohort included 377,760 thiazide diuretic initiators and 364,300 dCCB initiators, generating 3,619,883 person-years of follow-up. Compared with dCCBs, thiazide diuretics were not associated with colorectal cancer (weighted HR = 0.97, 95% CI: 0.90, 1.04). Secondary analyses yielded similar results, although an increased risk was observed among patients with inflammatory bowel disease (weighted HR = 2.45, 95% CI: 1.13, 5.35) and potentially polyps (weighted HR = 1.46, 95% CI: 0.93, 2.30). Compared with dCCBs, thiazide diuretics were not associated with an overall increased colorectal cancer risk. While these findings provide some reassurance, research is needed to corroborate the elevated risks observed among patients with inflammatory bowel disease and history of polyps.
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Brophy JM, Nadeau L. Beta-Blockers, Digoxin, or Both Following an Incident Diagnosis of Atrial Fibrillation: A Prospective Cohort Study. Can J Cardiol 2023; 39:1587-1593. [PMID: 37331622 DOI: 10.1016/j.cjca.2023.06.009] [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] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Atrial fibrillation is one of the most common arrhythmias, but the optimal drug choice for a rate control strategy remains uncertain. METHODS A retrospective cohort claims database study of patients with an incident hospital discharge diagnosis of atrial fibrillation between 2011 and 2015. The exposure variables were a discharge prescription for beta-blockers, digoxin, or both. The primary outcome was a composite of total in-hospital mortality or a repeat cardiovascular (CV) hospitalization. Baseline confounding was controlled with propensity score inverse probability weighting using a entropy balancing algorithm and the prespecified estimand was the average treatment effect among the treated. Treatment effects for the weighted samples were calculated from a Cox proportional hazards model. RESULTS A total of 12,723 patients were discharged on beta-blockers alone, 406 on digoxin alone, and 1499 discharged on combined beta-blocker and digoxin therapy with a median follow-up time of 356 days. After baseline covariate adjustment, the digoxin alone (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.85-1.81) and the combined group (HR, 1.09; 95% CI, 0.90-1.31) were not associated with increased risk for the composite endpoint compared with the beta- blocker-alone group. These results were robust to sensitivity analyses. CONCLUSIONS Patients hospitalized for incident atrial fibrillation and discharged on digoxin alone or the combination of digoxin and a beta-blocker were not associated with an increase in the composite outcome of recurrent CV hospitalizations and death compared with those discharged on isolated beta-blocker therapy. However, additional studies are required to refine the precision of these estimates.
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Affiliation(s)
- James M Brophy
- McGill University Health Center Centre for Health Outcomes Research (CORE), Montréal, Québec, Canada.
| | - Lyne Nadeau
- McGill University Health Center Centre for Health Outcomes Research (CORE), Montréal, Québec, Canada
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Mavrakanas TA, Tsoukas MA, Brophy JM, Sharma A, Gariani K. SGLT-2 inhibitors improve cardiovascular and renal outcomes in patients with CKD: a systematic review and meta-analysis. Sci Rep 2023; 13:15922. [PMID: 37741858 PMCID: PMC10517929 DOI: 10.1038/s41598-023-42989-z] [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: 05/10/2023] [Accepted: 09/17/2023] [Indexed: 09/25/2023] Open
Abstract
The effect of sodium-glucose co-transporter-2 (SGLT-2) inhibitors on cardiovascular and renal outcomes has not been systematically reviewed across baseline kidney function groups. We conducted a systematic review and meta-analysis of randomized control trials (RCTs) with SGLT-2 inhibitors in patients with and without CKD. We performed a PubMed/Medline search of randomized, placebo-controlled, event-driven outcome trials of SGLT-2 inhibitors versus active or placebo control in patients with and without diabetes from inception to November 2022. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2 (PROSPERO registration CRD4202016054). The primary outcome was cardiovascular death. Secondary outcomes included hospitalization for heart failure, major adverse cardiovascular events, CKD progression, all-cause mortality, treatment discontinuation, and acute kidney injury (AKI). The relative risk (RR) was estimated using a random-effects model. Twelve RCTs were included in this meta-analysis (89,191 patients, including 38,949 with eGFR < 60 ml/min/1.73m2). Use of an SGLT-2 inhibitor in patients with CKD was associated with a lower incidence of cardiovascular death (RR 0.87; 95% CI 0.79-0.95) and of heart failure (RR 0.67; 95% CI 0.61-0.75), compared with placebo. Heart failure risk reduction with SGLT-2 inhibitors was larger among patients with CKD compared with patients without CKD (RR for the interaction 0.87, 95% CI 0.75-1.02, and p-value for interaction 0.08). SGLT-2 inhibitors were associated with a lower incidence of CKD progression among patients with pre-existing CKD: RR 0.77 (95% CI 0.68-0.88), compared with placebo. Among patients with CKD, a lower risk of AKI (RR 0.82; 95% CI 0.72-0.93) and treatment discontinuation was seen with SGLT-2 inhibitors compared with placebo. SGLT-2 inhibitors offer substantial protection against cardiovascular and renal outcomes in patients with CKD. These results strongly advocate in favor of using them in patients with CKD and keeping them as kidney function declines.
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Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Center Research Institute|CORE|Office 2B.44, 5252 de Maisonneuve West, Montreal, QC, H4A 3S9, Canada.
| | - Michael A Tsoukas
- Division of Endocrinology, McGill University Health Centre, Montreal, QC, Canada
| | - James M Brophy
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Karim Gariani
- Division of Endocrinology, Diabetes, Nutrition and Patient Therapeutic Education, Geneva University Hospitals, Geneva, GE, Switzerland
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Gorelik N, Rula EY, Pelzl CE, Hemingway J, Christensen EW, Brophy JM, Gyftopoulos S. Imaging Utilization Patterns in the Follow-Up of Extremity Soft Tissue Sarcomas in the United States. Curr Probl Diagn Radiol 2023; 52:357-366. [PMID: 37236841 DOI: 10.1067/j.cpradiol.2023.05.002] [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: 09/30/2022] [Revised: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
This study aimed to describe patterns of imaging utilization after resection of extremity soft tissue sarcoma in the United States, assess for potential disparities, and evaluate temporal trends. A retrospective cohort study using a national database of private payer claims data was performed to determine the utilization rate of extremity and chest imaging in a 5-year postoperative follow-up period for patients with extremity soft tissue sarcoma treated between 2007 and 2019. Imaging utilization was assessed according to patient demographics (age, sex, race and ethnicity, and region of residency), calendar year of surgery, and postoperative year. Associations of demographic variables with imaging use were assessed using chi-square tests, trends in imaging use were analyzed using the Cochran-Armitage trend test or linear regression, and associations of postoperative year with imaging use were evaluated with the Pearson Correlation coefficient. A total of 3707 patients were included. Most patients received at least 1 chest (74%) and extremity (53%) imaging examination during their follow-up period. The presence of surveillance imaging was significantly associated with age (P < 0.0001) and region (P = 0.0029). Over the study period, there was an increase in use of extremity MRI (P < 0.05) and ultrasound (P < 0.01) and chest CT (P < 0.0001) and a decrease in use of chest radiographs (P < 0.0001). Imaging use declined over postoperative years (decrease by 85%-92% from year 1-5). In conclusion, the use of surveillance imaging varied according to patient demographics and has increased for extremity MRI and ultrasound and chest CT over the study period.
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Affiliation(s)
- Natalia Gorelik
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec, Canada.
| | | | - Casey E Pelzl
- Harvey L. Neiman Health Policy Institute, Reston, VA
| | | | | | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Centre for Health Outcomes Research (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Soterios Gyftopoulos
- Departments of Radiology and Orthopedic Surgery, NYU Langone Medical Center, New York, NY
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Azoulay L, St-Jean A, Dahl M, Quail J, Aibibula W, Brophy JM, Chan AW, Bresee L, Carney G, Eltonsy S, Tamim H, Paterson JM, Platt RW. Hydrochlorothiazide use and risk of keratinocyte carcinoma and melanoma: A multi-site population-based cohort study. J Am Acad Dermatol 2023:S0190-9622(23)00735-1. [PMID: 37105517 DOI: 10.1016/j.jaad.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The association between hydrochlorothiazide (HCTZ) and skin cancer remains controversial. OBJECTIVE To determine whether HCTZ is associated with an increased risk of skin cancer compared with angiotensin-converting enzyme inhibitors (ACEIs) and calcium channel blockers (CCBs). METHODS Two new-user, active comparator cohorts were assembled using six Canadian databases. Site-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using standardized morbidity ratio weighted Cox proportional hazard models and pooled using random-effects meta-analysis. RESULTS HCTZ was not associated with an overall increased risk of keratinocyte carcinoma compared with ACEIs or CCBs, although increased risks were observed with longer durations (≥10 years; HR: 1.12; 95% CI: 1.03-1.21) and higher cumulative doses (≥100,000 mg; HR: 1.49; 95% CI: 1.27-1.76). For melanoma, there was no association with ACEIs, but a 32% increased risk with CCBs (crude incidence rates: 64.2 vs. 58.4 per 100,000 person-years; HR: 1.32; 95% CI: 1.19-1.46; estimated number needed to harm at 5 years of follow-up: 1,627 patients), with increased risks with longer durations and cumulative doses. LIMITATIONS Residual confounding due to the observational design. CONCLUSIONS Increased risks of keratinocyte carcinoma and melanoma were observed with longer durations of use and higher cumulative doses of HCTZ.
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Affiliation(s)
- Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Audray St-Jean
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Matthew Dahl
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - An-Wen Chan
- Division of Dermatology, Department of Medicine, Women's College Research Institute, University of Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Lauren Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Greg Carney
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sherif Eltonsy
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hala Tamim
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Robert W Platt
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Rahman AA, Michaud J, Dell'Aniello S, Moodie EEM, Brophy JM, Durand M, Guertin JR, Boivin JF, Renoux C. Oral Anticoagulants and the Risk of Dementia in Patients With Nonvalvular Atrial Fibrillation: A Population-Based Cohort Study. Neurology 2023; 100:e1309-e1320. [PMID: 36581462 PMCID: PMC10033170 DOI: 10.1212/wnl.0000000000206748] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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] [Received: 03/23/2022] [Accepted: 11/15/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nonvalvular atrial fibrillation (NVAF) is associated with an increased risk of dementia. Oral anticoagulants (OACs) are essential for stroke prevention in NVAF, and studies have shown a possible protective effect on dementia. However, findings have been inconsistent and hampered by methodological limitations. Thus, we assessed whether the use of OACs is associated with a decreased incidence of dementia in patients with NVAF. In addition, we explored the impact of the cumulative duration of OAC use on the incidence of dementia. METHODS Using the UK Clinical Practice Research Datalink, we formed a cohort of all patients aged 50 years or older with an incident diagnosis of NVAF between 1988 and 2017 and no prior OAC use, with a follow-up until 2019. Patients were considered unexposed until 6 months after their first OAC prescription for latency considerations and exposed thereafter until the end of follow-up. We used time-dependent Cox regression models to estimate hazard ratios (HRs), adjusted for 54 covariates, with 95% CIs for dementia associated with OAC use, compared with nonuse. We also assessed whether the risk varied with the cumulative duration of OAC use, compared with nonuse, by comparing prespecified exposure categories defined in a time-varying manner and by modeling the HR using a restricted cubic spline. RESULTS The cohort included 142,227 patients with NVAF, with 8,023 cases of dementia over 662,667 person-years of follow-up (incidence rate 12.1, 95% CI 11.9-12.4 per 1,000 person-years). OAC use was associated with a decreased risk of dementia (HR 0.88, 95% CI 0.84-0.92) compared with nonuse. A restricted cubic spline also indicated a decreased risk of dementia, reaching a low at approximately 1.5 years of cumulative OAC use and stabilizing thereafter. Moreover, OAC use decreased the risk in patients aged 75 years and older (HR 0.84, 95% CI 0.80-0.89), but not in younger patients (HR 0.99, 95% CI 0.90-1.10). DISCUSSION In patients with incident NVAF, OACs were associated with a decreased risk of dementia, particularly in elderly individuals. This warrants consideration when weighing the risks and benefits of anticoagulation in this population. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in patients with NVAF, OAC use (vs nonuse) is associated with a decreased risk of dementia.
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Affiliation(s)
- Alvi A Rahman
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Jonathan Michaud
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Sophie Dell'Aniello
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Erica E M Moodie
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - James M Brophy
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Madeleine Durand
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Jason R Guertin
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Jean-François Boivin
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada
| | - Christel Renoux
- From the Departments of Epidemiology, Biostatistics and Occupational Health (A.R., E.E.M.M., J.M.B., J.-F.B., C.R.), Medicine (J.M.B.), and Neurology and Neurosurgery (C.R.), McGill University, Montreal; Centre for Clinical Epidemiology (A.R., J.M., S.D., J.-F.B., C.R.), Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine (M.D.), Université de Montréal; Centre de recherche du Centre Hospitalier de l'Université de Montréal (M.D.); and Département de Médecine Sociale et Préventive (J.R.G.), Faculté de médecine, Université Laval, Montreal, Canada.
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Brophy JM. Numbers don’t lie – but tell only part of the story. CJC Open 2023. [DOI: 10.1016/j.cjco.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
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Barili F, Brophy JM, Ronco D, Myers PO, Uva MS, Almeida RMS, Marin-Cuartas M, Anselmi A, Tomasi J, Verhoye JP, Musumeci F, Mandrola J, Kaul S, Papatheodorou S, Parolari A. Risk of Bias in Randomized Clinical Trials Comparing Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2249321. [PMID: 36595294 PMCID: PMC9857525 DOI: 10.1001/jamanetworkopen.2022.49321] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines highlighted some concerns about the randomized clinical trials (RCTs) comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. Quantification of these biases has not been previously performed. OBJECTIVE To assess whether randomization protects RCTs comparing TAVI and SAVR from biases other than nonrandom allocation. DATA SOURCES A systematic review of the literature between January 1, 2007, and June 6, 2022, on MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was performed. Specialist websites were also checked for unpublished data. STUDY SELECTION The study included RCTs with random allocation to TAVI or SAVR with a maximum 5-year follow-up. DATA EXTRACTION AND SYNTHESIS Data extraction was performed by 2 independent investigators following the PRISMA guidelines. A random-effects meta-analysis was used for quantifying pooled rates and differential rates between treatments of deviation from random assigned treatment (DAT), loss to follow-up, and receipt of additional treatments. MAIN OUTCOMES AND MEASURES The primary outcomes were the proportion of DAT, loss to follow-up, and patients who were provided additional treatments and myocardial revascularization, together with their ratio between treatments. The measures were the pooled overall proportion of the primary outcomes and the risk ratio (RR) in the TAVI vs SAVR groups. RESULTS The search identified 8 eligible trials including 8849 participants randomly assigned to undergo TAVI (n = 4458) or SAVR (n = 4391). The pooled proportion of DAT among the sample was 4.2% (95% CI, 3.0%-5.6%), favoring TAVI (pooled RR vs SAVR, 0.16; 95% CI, 0.08-0.36; P < .001). The pooled proportion of loss to follow-up was 4.8% (95% CI, 2.7%-7.3%). Meta-regression showed a significant association between the proportion of participants lost to follow-up and follow-up time (slope, 0.042; 95% CI, 0.017-0.066; P < .001). There was an imbalance of loss to follow-up favoring TAVI (RR, 0.39; 95% CI, 0.28-0.55; P < .001). The pooled proportion of patients who had additional procedures was 10.4% (95% CI, 4.4%-18.5%): 4.6% (95% CI, 1.5%-9.3%) in the TAVI group and 16.5% (95% CI, 7.5%-28.1%) in the SAVR group (RR, 0.27; 95% CI, 0.15-0.50; P < .001). The imbalance between groups also favored TAVI for additional myocardial revascularization (RR, 0.40; 95% CI, 0.24-0.68; P < .001). CONCLUSIONS AND RELEVANCE This study suggests that, in RCTs comparing TAVI vs SAVR, there are substantial proportions of DAT, loss to follow-up, and additional procedures together with systematic selective imbalance in the same direction characterized by significantly lower proportions of patients undergoing TAVI that might affect internal validity.
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Affiliation(s)
- Fabio Barili
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Cardiac Surgery, S. Croce Hospital, Cuneo, Italy
| | - James M. Brophy
- Department of Medicine, McGill Health University Center, Montreal, Quebec, Canada
| | - Daniele Ronco
- Department of University Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Patrick O. Myers
- Division of Cardiac Surgery, CHUV–Lausanne University Hospital, Lausanne, Switzerland
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Cardiac Surgery and Physiology, Porto University Medical School, Porto, Portugal
| | - Rui M. S. Almeida
- University Center Assis Gurgacz Foundation, Cascavel, Paraná, Brazil
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Amedeo Anselmi
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Francesco Musumeci
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alessandro Parolari
- Department of University Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Albuquerque AM, Eckert I, Tramujas L, Butler-Laporte G, McDonald EG, Brophy JM, Lee TC. Effect of tocilizumab, sarilumab, and baricitinib on mortality among patients hospitalized for COVID-19 treated with corticosteroids: a systematic review and meta-analysis. Clin Microbiol Infect 2023; 29:13-21. [PMID: 35863630 PMCID: PMC9293401 DOI: 10.1016/j.cmi.2022.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 05/27/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Randomized controlled trials (RCT) established the mortality reduction by tocilizumab (Actemra), baricitinib (Olumiant), and sarilumab (Kevzara) in hospitalized COVID-19 patients. However, uncertainty remains about which treatment performs best in patients receiving corticosteroids. OBJECTIVES To estimate probabilities of noninferiority between baricitinib and sarilumab compared to tocilizumab in patients treated with corticosteroids. DATA SOURCES PubMed, Embase, Cochrane Library, and MedRxiv. STUDY ELIGIBILITY CRITERIA Eligible RCTs assigning hospitalized adults with COVID-19 treated with corticosteroids to tocilizumab or baricitinib or sarilumab versus standard of care or placebo (control). METHODS Reviewers independently abstracted published data and assessed study quality with the Risk of Bias 2 tool. Unpublished data, if required, were requested from authors of included studies. The outcome of interest was all-cause mortality at 28 days. PARTICIPANTS Twenty-seven RCTs with 13 549 patients were included. Overall, the risk of bias was low. Bayesian pairwise meta-analyses were used to aggregate results of each treatment versus control. The average odds ratio for mortality was 0.78 (95% credible interval [CrI]: 0.65, 0.94) for tocilizumab; 0.78 (95% CrI: 0.56, 1.03) for baricitinib; and 0.91 (95% CrI: 0.60, 1.40) for sarilumab. The certainty of evidence (GRADE) ranged from moderate to low. Bayesian meta-regressions with multiple priors were used to estimate probabilities of noninferiority (margin of 13% greater effect by tocilizumab). Compared to tocilizumab, there were ≤94% and 90% probabilities of noninferiority with baricitinib and sarilumab, respectively. RESULTS All but two studies included data with only indirect evidence for the comparison of interest. CONCLUSIONS Among hospitalized COVID-19 treated with corticosteroids, there are high probabilities that both baricitinib and sarilumab are associated with similar mortality reductions in comparison to tocilizumab.
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Affiliation(s)
| | - Igor Eckert
- Department of Nutrition, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | | | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
| | - James M. Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
| | - Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Corresponding author. Todd C. Lee, Royal Victoria Hospital, 1001 Decarie Blvd Room E5.1820, Montréal, QC H4A3J1, Canada
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Rouette J, McDonald EG, Schuster T, Brophy JM, Azoulay L. Dihydropyridine Calcium Channel Blockers and Risk of Pancreatic Cancer: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e026789. [PMID: 36515246 PMCID: PMC9798809 DOI: 10.1161/jaha.122.026789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Recent studies have reported that dihydropyridine calcium channel blockers (dCCBs) may increase the risk of pancreatic cancer, but these studies had methodological limitations. We thus aimed to determine whether dCCBs are associated with an increased risk of pancreatic cancer compared with thiazide diuretics, a clinically relevant comparator. Methods and Results We conducted a new user, active comparator, population-based cohort study using the UK Clinical Practice Research Datalink. We identified new users of dCCBs and new users of thiazide diuretics between 1990 and 2018, with follow-up until 2019. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% CIs for pancreatic cancer, comparing dCCBs with thiazide diuretics. Models were weighted using standardized morbidity ratio weights based on calendar time-specific propensity scores. We also conducted secondary analyses by cumulative duration of use, time since initiation, and individual drugs and assessed for the presence of effect modification by age, sex, smoking status, body mass index, history of chronic pancreatitis, and diabetes. The cohort included 344 480 initiators of dCCBs and 357 968 initiators of thiazide diuretics, generating 3 360 745 person-years of follow-up. After a median follow-up of 4.5 years, the weighted incidence rate per 100 000 person-years was 37.2 (95% CI, 34.1-40.4) for dCCBs and 39.4 (95% CI, 36.1-42.9) for thiazide diuretics. Overall, dCCBs were not associated with an increased risk of pancreatic cancer (weighted HR, 0.93; 95% CI, 0.80-1.09). Similar results were observed in secondary analyses. Conclusions In this large, population-based cohort study, dCCBs were not associated with an increased risk of pancreatic cancer compared with thiazide diuretics. These findings provide reassurance regarding the long-term pancreatic cancer safety of these drugs.
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Affiliation(s)
- Julie Rouette
- Centre for Clinical EpidemiologyLady Davis Institute, Jewish General HospitalMontrealCanada,Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of MedicineMcGill University Health CentreMontrealCanada,Division of Experimental MedicineMcGill UniversityMontrealCanada
| | - Tibor Schuster
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Department of Family MedicineMcGill UniversityMontrealCanada
| | - James M. Brophy
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Division of Clinical EpidemiologyMcGill University Health Centre–Research InstituteMontrealCanada,Department of MedicineMcGill UniversityMontrealCanada
| | - Laurent Azoulay
- Centre for Clinical EpidemiologyLady Davis Institute, Jewish General HospitalMontrealCanada,Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealCanada,Gerald Bronfman Department of OncologyMcGill UniversityMontrealCanada
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Brophy JM. Understanding Associations, Social Inequities, and Cardiovascular Risks. Can J Cardiol 2022; 38:1918-1920. [PMID: 36183912 DOI: 10.1016/j.cjca.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- James M Brophy
- McGill University Health Center, Centre for Health Outcomes Research (CORE), Montreal, Quebec H4A 3S5, Canada.
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Brophy JM, Nadeau L. Amiodarone vs Dronedarone for Atrial Fibrillation: A Retrospective Cohort Study. CJC Open 2022; 5:8-14. [PMID: 36700187 PMCID: PMC9869347 DOI: 10.1016/j.cjco.2022.09.008] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/18/2022] [Indexed: 12/23/2022] Open
Abstract
Background Atrial fibrillation is one of the most common arrhythmias, but the optimal drug choice for a rhythm-control strategy remains uncertain. Methods This article reports on a retrospective cohort claims database study conducted using the Truven Health Market Scan Commercial Claims and Encounters and Medicare Supplemental databases. Patients with a new diagnosis of atrial fibrillation, and a discharge date between 2011 and 2015, were included. The exposure variables of interest were a discharge prescription for amiodarone or dronedarone. The average treatment effect for the composite of total mortality or a repeat cardiovascular (CV)-related hospitalization was the primary outcome. Sensitivity analyses with other treatment effect metrics were performed. Baseline covariate imbalances between the groups were adjusted using propensity-score methods with inverse probability weighting. Results A total of 1735 patients were discharged on amiodarone, and 338 were discharged on dronedarone, with a median follow-up time of 357 days. A total of 43 (12.7%) CV-related hospitalizations occurred in the dronedarone group, and 146 (8.4%) occurred in the amiodarone group (risk difference 4.3%, 95% confidence interval [CI] 0.4%-8.3%, P = 0.02). A total of 4 (1.2%) deaths occurred in the dronedarone group, and 31 (1.8%) deaths occurred with amiodarone (risk difference -0.6%, 95% CI -2.1%-0.9%, P = 0.6). After adjusting for baseline covariates, the dronedarone hazard ratio for the composite endpoint was 1.47 (95% CI 1.01-2.12). This result was generally robust to sensitivity analyses. Conclusion In this incident cohort of patients hospitalized for atrial fibrillation, compared to those discharged on amiodarone, patients who received a dronedarone discharge prescription had an increase in the composite endpoint of recurrent CV-related hospitalization and death, over a median 1-year follow-up period.
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Affiliation(s)
- James M. Brophy
- Corresponding author: Dr James Brophy, McGill University Health Centre, Centre for Health Outcomes Research (CORE), 5252 Boul. de Maisonneuve West Room 2B.37, Montreal, Quebec, H4A 3S5, Canada. Tel.: +1-514-934-1934 x36771.
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16
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Xie X, Li C, Tiggelaar S, Simbulan F, Falk L, Brophy JM. Developing a cross-validation tool for evaluating economic evidence in rapid literature reviews. J Comp Eff Res 2022; 11:1151-1160. [PMID: 36170031 DOI: 10.2217/cer-2021-0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Rapid economic reviews efficiently summarize economic evidence. However, reporting main findings without assessing quality and credibility can be misleading. The objective of this study was to develop a rapid cross-validation screening tool to evaluate economic evidence when conducting rapid economic literature reviews. Methods: This article outlines our reasoning and the theoretical concepts for developing the screening tool. Results: This cross-validation tool is a qualitative approach under a Bayesian framework that uses prior health economic evidence to gauge the credibility of the rapid economic review's findings. This article describes an application of this tool and highlights practical considerations for its development and deployment. Conclusion: This tool can provide a valuable screening instrument to evaluate the quality and credibility of the economic evidence.
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Affiliation(s)
- Xuanqian Xie
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Chunmei Li
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Sean Tiggelaar
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Frances Simbulan
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Lindsey Falk
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - James M Brophy
- Departments of Medicine & Epidemiology, Biostatistics, & Occupational Health, McGill University, Montreal, QC H3A 0G4, Canada
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Lee TC, Murthy S, Del Corpo O, Senécal J, Butler-Laporte G, Sohani ZN, Brophy JM, McDonald EG. Remdesivir for the treatment of COVID-19: a systematic review and meta-analysis. Clin Microbiol Infect 2022; 28:1203-1210. [PMID: 35598856 PMCID: PMC9117160 DOI: 10.1016/j.cmi.2022.04.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [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: 03/16/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The benefits of remdesivir in the treatment of hospitalized patients with COVID-19 remain debated with the National Institutes of Health and the World Health Organization providing contradictory recommendations for and against use. OBJECTIVES To evaluate the role of remdesivir for hospitalized inpatients as a function of oxygen requirements. DATA SOURCES Beginning with our prior systematic review, we searched MEDLINE using PubMed from 15 January 2021 through 5 May 2022. STUDY ELIGIBILITY CRITERIA Randomised controlled trials; all languages. PARTICIPANTS All hospitalized adults with COVID-19. INTERVENTIONS Remdesivir, in comparison to either placebo, or standard of care. ASSESSMENT OF RISK OF BIAS We used the ROB-2 criteria. METHODS OF DATA SYNTHESIS The primary outcome was mortality, stratified by oxygen use (none, supplemental oxygen without mechanical ventilation, and mechanical ventilation). We conducted a frequentist random effects meta-analysis on the risk ratio scale and, to contextualize the probabilistic benefits, we also performed a Bayesian random effects meta-analysis on the risk difference scale. A ≥1% absolute risk reduction was considered clinically important. RESULTS We identified eight randomized trials, totaling 10 751 participants. The risk ratio for mortality comparing remdesivir vs. control was 0.77 (95% CI, 0.5-1.19) in the patients who did not require supplemental oxygen; 0.89 (95% CI, 0.79-0.99) for nonventilated patients requiring oxygen; and 1.08 (95% CI, 0.88-1.31) in the setting of mechanical ventilation. Using neutral priors, the probabilities that remdesivir reduces mortality were 76.8%, 93.8%, and 14.7%, respectively. The probability that remdesivir reduced mortality by ≥ 1% was 77.4% for nonventilated patients requiring oxygen. CONCLUSIONS Based on this meta-analysis, there is a high probability that remdesivir reduces mortality for nonventilated patients with COVID-19 requiring supplemental oxygen therapy. Treatment guidelines should be re-evaluated.
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Affiliation(s)
- Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Corresponding author. Todd C. Lee, Royal Victoria Hospital, 1001 Decarie Blvd, Room E5.1820, Montréal H4A3J1, QC. Canada
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Olivier Del Corpo
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Julien Senécal
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Zahra N. Sohani
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada
| | - James M. Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
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Brophy JM. In HF, SGLT2 inhibitors reduce HF hospitalizations at up to 2 y. Ann Intern Med 2022; 175:JC87. [PMID: 35914263 DOI: 10.7326/j22-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
SOURCE CITATION Zou X, Shi Q, Vandvik PO, et al. Sodium-glucose cotransporter-2 inhibitors in patients with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2022;175:851-61. 35404670.
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Brophy JM. mRNA COVID-19 vaccines were linked to myocarditis at 28 d (0.15 to 10 excess events/100 000 vaccinated persons). Ann Intern Med 2022; 175:JC94. [PMID: 35914261 DOI: 10.7326/j22-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Karlstad Ø, Hovi P, Husby A, et al. SARS-CoV-2 vaccination and myocarditis in a Nordic cohort study of 23 million residents. JAMA Cardiol. 2022;7:600-12. 35442390.
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Brophy JM. Big data, big expectations and big judgements. Can J Cardiol 2022; 38:1567-1569. [PMID: 35817216 DOI: 10.1016/j.cjca.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- James M Brophy
- McGill University Health Center, Montreal, Quebec, Canada.
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Samuel M, Brophy JM. Diabetes and Atrial Fibrillation: Does the type of diabetes matter? Eur J Prev Cardiol 2022; 29:1756-1758. [PMID: 35776833 DOI: 10.1093/eurjpc/zwac131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
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Rouette J, McDonald EG, Schuster T, Brophy JM, Azoulay L. Treatment and prescribing trends of antihypertensive drugs in 2.7 million UK primary care patients over 31 years: a population-based cohort study. BMJ Open 2022; 12:e057510. [PMID: 35688595 PMCID: PMC9189823 DOI: 10.1136/bmjopen-2021-057510] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines. DESIGN Population-based cohort study. SETTING AND PARTICIPANTS We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB). PRIMARY AND SECONDARY OUTCOME MEASURES We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines. RESULTS The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1-2) after first-line treatment. CONCLUSION Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.
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Affiliation(s)
- Julie Rouette
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Tibor Schuster
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada
- Departmenf of Medicine, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
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Razaghizad A, Oulousian E, Randhawa VK, Ferreira JP, Brophy JM, Greene SJ, Guida J, Felker GM, Fudim M, Tsoukas M, Peters TM, Mavrakanas TA, Giannetti N, Ezekowitz J, Sharma A. Clinical Prediction Models for Heart Failure Hospitalization in Type 2 Diabetes: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e024833. [PMID: 35574959 PMCID: PMC9238543 DOI: 10.1161/jaha.121.024833] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
Abstract
Background Clinical prediction models have been developed for hospitalization for heart failure in type 2 diabetes. However, a systematic evaluation of these models' performance, applicability, and clinical impact is absent. Methods and Results We searched Embase, MEDLINE, Web of Science, Google Scholar, and Tufts' clinical prediction registry through February 2021. Studies needed to report the development, validation, clinical impact, or update of a prediction model for hospitalization for heart failure in type 2 diabetes with measures of model performance and sufficient information for clinical use. Model assessment was done with the Prediction Model Risk of Bias Assessment Tool, and meta-analyses of model discrimination were performed. We included 15 model development and 3 external validation studies with data from 999 167 people with type 2 diabetes. Of the 15 models, 6 had undergone external validation and only 1 had low concern for risk of bias and applicability (Risk Equations for Complications of Type 2 Diabetes). Seven models were presented in a clinically useful manner (eg, risk score, online calculator) and 2 models were classified as the most suitable for clinical use based on study design, external validity, and point-of-care usability. These were Risk Equations for Complications of Type 2 Diabetes (meta-analyzed c-statistic, 0.76) and the Thrombolysis in Myocardial Infarction Risk Score for Heart Failure in Diabetes (meta-analyzed c-statistic, 0.78), which was the simplest model with only 5 variables. No studies reported clinical impact. Conclusions Most prediction models for hospitalization for heart failure in patients with type 2 diabetes have potential concerns with risk of bias or applicability, and uncertain external validity and clinical impact. Future research is needed to address these knowledge gaps.
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Affiliation(s)
- Amir Razaghizad
- Centre for Outcomes Research and EvaluationResearch Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
- DREAM‐CV LaboratoryMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - Emily Oulousian
- DREAM‐CV LaboratoryMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - Varinder Kaur Randhawa
- Department of Cardiovascular MedicineKaufman Center for Heart Failure and RecoveryHeart, Vascular and Thoracic InstituteCleveland ClinicClevelandOH
| | - João Pedro Ferreira
- University of LorraineInserm, Centre d'Investigations Cliniques, ‐ Plurithématique 14‐33, Inserm U1116CHRUF‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)NancyFrance
- Department of Surgery and PhysiologyCardiovascular Research and Development CenterFaculty of Medicine of the University of PortoPortoPortugal
| | - James M. Brophy
- Centre for Outcomes Research and EvaluationResearch Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - Stephen J. Greene
- Division of CardiologyDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDurhamNC
| | - Julian Guida
- DREAM‐CV LaboratoryMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - G. Michael Felker
- Division of CardiologyDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDurhamNC
| | - Marat Fudim
- Division of CardiologyDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDurhamNC
| | - Michael Tsoukas
- Division of EndocrinologyDepartment of MedicineMcGill UniversityMontrealQCCanada
| | - Tricia M. Peters
- Division of EndocrinologyDepartment of MedicineMcGill UniversityMontrealQCCanada
- Centre for Clinical EpidemiologyLady Davis Institute for Medical ResearchMontrealQCCanada
| | - Thomas A. Mavrakanas
- Division of NephrologyDepartment of MedicineMcGill University Health Centre and Research InstituteMontrealCanada
| | - Nadia Giannetti
- Division of CardiologyMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - Justin Ezekowitz
- Division of CardiologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Abhinav Sharma
- Centre for Outcomes Research and EvaluationResearch Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
- DREAM‐CV LaboratoryMcGill University Health CentreMcGill UniversityMontrealQuebecCanada
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24
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Brophy JM. After DES implantation, DAPT for 1 y vs. ≤6 mo increased major bleeding in patients with high baseline bleeding risk. Ann Intern Med 2022; 175:JC45. [PMID: 35377722 DOI: 10.7326/j22-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Palmerini T, Bruno AG, Redfors B, et al. Risk-benefit of 1-year DAPT after DES implantation in patients stratified by bleeding and ischemic risk. J Am Coll Cardiol. 2021;78:1968-86. 34763774.
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25
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Affiliation(s)
- James M Brophy
- McGill University Health Center, Montreal, Quebec, Canada
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26
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Albuquerque AM, Tramujas L, Sewanan LR, Williams DR, Brophy JM. Mortality Rates Among Hospitalized Patients With COVID-19 Infection Treated With Tocilizumab and Corticosteroids: A Bayesian Reanalysis of a Previous Meta-analysis. JAMA Netw Open 2022; 5:e220548. [PMID: 35226077 PMCID: PMC8886529 DOI: 10.1001/jamanetworkopen.2022.0548] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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] [Received: 09/17/2021] [Accepted: 01/11/2022] [Indexed: 12/29/2022] Open
Abstract
Importance A World Health Organization (WHO) meta-analysis found that tocilizumab was associated with reduced mortality in hospitalized patients with COVID-19. However, uncertainty remains concerning the magnitude of tocilizumab's benefits and whether its association with mortality benefit is similar across respiratory subgroups. Objective To use bayesian methods to assess the magnitude of mortality benefit associated with tocilizumab and the differences between respiratory support subgroups in hospitalized patients with COVID-19. Design, Setting, and Participants A bayesian hierarchical reanalysis of the WHO meta-analysis of tocilizumab studies published in 2020 and 2021 was performed. Main results were estimated using weakly informative priors to exert little influence on the observed data. The robustness of these results was evaluated using vague and informative priors. The studies featured in the meta-analysis were randomized clinical tocilizumab trials of hospitalized patients with COVID-19. Only patients receiving corticosteroids were included. Interventions Usual care plus tocilizumab in comparison with usual care or placebo. Main Outcomes and Measures All-cause mortality at 28 days after randomization. Results Among the 5339 patients included in this analysis, most were men, with mean ages between 56 and 66 years. There were 2117 patients receiving simple oxygen only, 2505 receiving noninvasive ventilation (NIV), and 717 receiving invasive mechanical ventilation (IMV) in 15 studies from multiple countries and continents. Assuming weakly informative priors, the overall odds ratios (ORs) for survival were 0.70 (95% credible interval [CrI], 0.50-0.91) for patients receiving simple oxygen only, 0.81 (95% CrI, 0.63-1.03) for patients receiving NIV, and 0.89 (95% CrI, 0.61-1.22) for patients receiving IMV, respectively. The posterior probabilities of any benefit (OR <1) were notably different between patients receiving simple oxygen only (98.9%), NIV (95.5%), and IMV (75.4%). The posterior probabilities of a clinically meaningful association (absolute mortality risk difference >1%) were greater than 95% in patients receiving simple oxygen only and greater than 90% in patients receiving NIV. In contrast, the posterior probability of this clinically meaningful association was only approximately 67% in patients receiving IMV. The probabilities of tocilizumab superiority in the simple oxygen only subgroup compared with the NIV and IMV subgroups were 85% and 90%, respectively. Predictive intervals highlighted that only 72.1% of future tocilizumab IMV studies would show benefit. The conclusions did not change with different prior distributions. Conclusions and Relevance In this bayesian reanalysis of a previous meta-analysis of 15 studies of hospitalized patients with COVID-19 treated with tocilizumab and corticosteroids, use of simple oxygen only and NIV was associated with a probability of a clinically meaningful mortality benefit from tocilizumab. Future research should clarify whether patients receiving IMV also benefit from tocilizumab.
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Affiliation(s)
| | | | - Lorenzo R. Sewanan
- Department of Internal Medicine, Columbia University, New York, New York
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27
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Brophy JM. SARS-CoV-2 testing in travellers: Can we be smarter? CMAJ 2022; 194:E20. [PMID: 35012952 PMCID: PMC8800472 DOI: 10.1503/cmaj.80779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- James M Brophy
- Cardiologist and epidemiologist, McGill University Health Centre, Montréal, Que
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28
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Nakhlé G, Brophy JM, Renoux C, Khairy P, Bélisle P, LeLorier J. Domperidone increases harmful cardiac events in Parkinson's disease: A Bayesian re-analysis of an observational study. J Clin Epidemiol 2021; 140:93-100. [PMID: 34508851 DOI: 10.1016/j.jclinepi.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/19/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess the risks of ventricular tachyarrhythmia/sudden cardiac death (VT/SCD) with domperidone use in Parkinson's disease (PD). STUDY DESIGNS AND SETTINGS Using Bayesian methods, results from an observationalstudy were combined with prior beliefs to calculate posterior probabilities of increasedrelative risk (RR)) of VT/SCD with use of domperidone compared to non-use and ofharm, defined as risk exceeding 15%. The analyses were carried with normallydistributed priors (log (RR)): uninformative (N(0,10)) or informative (N(0.53,179)),derived from a meta-analysis (OR (95%CI):1.70 (1.47-1.97)). Sensitivity analyses used:different priors' strengths, different priors, and Bayesian meta-analysis RESULTS: The uninformative prior yielded a RR: 1.23 (95% credible interval (CrI):0.94-1.62), like the published frequentist RR: 1.22 (95% CI:0.99-1.50), with 69% probabilityof harm. With an informative prior weighted at 100%, 50% and 10%, the RR were 1.63(1.41-1.88), 1.57 (1.31-1.91) and 1.39 (1.10-1.93), respectively. The correspondingprobabilities of harm were 100%, 99%, and 94%, respectively. CONCLUSION While both the frequentist and Bayesian approaches with anuninformative prior were unable to reach a definitive conclusion concerning thearrhythmic risk of domperidone in PD patients, the Bayesian analysis with informativepriors showed a high probability of increased risk that was robust to multiple priorsensitivity analyses.
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Affiliation(s)
- Gisèle Nakhlé
- CHUM Research Center, Pavillon S, 850, St-Denis St., Montreal, Quebec, Canada; The Canadian Network for Observational Drug Effect Studies (CNODES), Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine H-485, Montreal, Quebec Canada; University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec Canada.
| | - James M Brophy
- Department of Medicine, McGill University, 3605 de la Montagne St., Montreal, Quebec Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Ave W, Montreal, Quebec Canada
| | - Christel Renoux
- The Canadian Network for Observational Drug Effect Studies (CNODES), Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine H-485, Montreal, Quebec Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Ave W, Montreal, Quebec Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec Canada; Department of Neurology and Neurosurgery, McGill University, 3801 University St., Montreal, Quebec Canada
| | - Paul Khairy
- Montreal Heart Institute, 5000 Bélanger St., Montreal, Quebec Canada; Clinical Epidemiology and Outcomes Research, Montreal Health Innovations Coordinating Center, 5000 Bélanger St., Montreal, Quebec Canada; University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec Canada
| | - Patrick Bélisle
- Montreal Heart Institute, 5000 Bélanger St., Montreal, Quebec Canada
| | - Jacques LeLorier
- CHUM Research Center, Pavillon S, 850, St-Denis St., Montreal, Quebec, Canada; The Canadian Network for Observational Drug Effect Studies (CNODES), Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine H-485, Montreal, Quebec Canada; University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec Canada
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29
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Etminan M, Brophy JM, Collins G, Nazemipour M, Mansournia MA. To Adjust or Not to Adjust: The Role of Different Covariates in Cardiovascular Observational Studies. Am Heart J 2021; 237:62-67. [PMID: 33722586 DOI: 10.1016/j.ahj.2021.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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: 08/11/2020] [Accepted: 03/08/2021] [Indexed: 12/22/2022]
Abstract
Covariate adjustment is integral to the validity of observational studies assessing causal effects. It is common practice to adjust for as many variables as possible in observational studies in the hopes of reducing confounding by other variables. However, indiscriminate adjustment for variables using standard regression models may actually lead to biased estimates. In this paper, we differentiate between confounders, mediators, colliders, and effect modifiers. We will discuss that while confounders should be adjusted for in the analysis, one should be wary of adjusting for colliders. Mediators should not be adjusted for when examining the total effect of an exposure on an outcome. Automated statistical programs should not be used to decide which variables to include in causal models. Using a case scenario in cardiology, we will demonstrate how to identify confounders, colliders, mediators and effect modifiers and the implications of adjustment or non-adjustment for each of them.
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Affiliation(s)
- Mahyar Etminan
- Departments of Ophthalmology and Visual Sciences, Medicine and Pharmacology, University of British Columbia, Vancouver, British Columbia
| | - James M Brophy
- Department of Epidemiology and Medicine, McGill University, Montreal, Canada
| | - Gary Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Maryam Nazemipour
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran; Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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30
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Kutcher SA, Brophy JM, Banack HR, Kaufman JS, Samuel M. Emulating a Randomised Controlled Trial With Observational Data: An Introduction to the Target Trial Framework. Can J Cardiol 2021; 37:1365-1377. [PMID: 34090982 DOI: 10.1016/j.cjca.2021.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/19/2021] [Accepted: 05/29/2021] [Indexed: 01/21/2023] Open
Abstract
Randomised controlled trials (RCTs) are often considered to be the highest quality of evidence owing to the absence of baseline confounding, the simplicity of analyses, and direct estimation of causal effects. However, observational studies can be designed to mimic RCTs and estimate causal treatment effects. In this review, we describe the target trial framework to illustrate how observational studies can successfully emulate RCTs. We focus on key design elements of RCTs and how to emulate them with observational data. These elements include 1) eligibility criteria, 2) treatment assignment and randomisation, 3) specification of "time zero", 4) outcomes, 5) follow-up, 6) causal contrasts (intention-to-treat vs per-protocol), and 7) statistical analyses. In addition, we describe the design of an example target trial created to emulate the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38 trial and compare effect estimates. Overall, careful design of a target trial using observational data can produce causal effect estimates that are often comparable to RCTs.
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Affiliation(s)
- Stephen A Kutcher
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Hailey R Banack
- Department of Epidemiology and Environmental Health, State University of New York, Buffalo, New York, USA
| | - Jay S Kaufman
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Michelle Samuel
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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31
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Rinfret S, Jahan I, McKenzie K, Dendukuri N, Bainey KR, Mansour S, Natarajan M, Ybarra LF, Chong AY, Bérubé S, Breton R, Curtis MJ, Rodés-Cabau J, Amlani S, Bagherli A, Ball W, Barolet A, Beydoun HK, Brass N, Chan AW, Colizza F, Constance C, Fam NP, Gobeil F, Haghighat T, Hodge S, Joyal D, Kim HH, Lutchmedial S, MacDougall A, Malik P, Miner S, Minhas K, Orvold J, Palisaitis D, Parfrey B, Potvin JM, Puley G, Radhakrishnan S, Spaziano M, Tanguay JF, Vijayaraghaban R, Webb JG, Zimmermann RH, Wood DA, Brophy JM. COVID-19 pandemic and coronary angiography for ST-elevation myocardial infarction, use of mechanical support and mechanical complications in Canada; a Canadian Association of Interventional Cardiology national survey. CJC Open 2021; 3:1125-1131. [PMID: 33997751 PMCID: PMC8114614 DOI: 10.1016/j.cjco.2021.04.017] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/15/2022] Open
Abstract
Background As a result of the COVID-19 pandemic first wave, reductions in ST-elevation myocardial infarction (STEMI) invasive care, ranging from 23% to 76%, have been reported from various countries. Whether this change had any impact on coronary angiography (CA) volume or on mechanical support device use for STEMI and post-STEMI mechanical complications in Canada is unknown. Methods We administered a Canada-wide survey to all cardiac catheterization laboratory directors, seeking the volume of CA use for STEMI performed during the period from March 1 2020 to May 31, 2020 (pandemic period), and during 2 control periods (March 1, 2019 to May 31, 2019 and March 1, 2018 to May 31, 2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects and papillary muscle rupture cases diagnosed, was also recorded. We also assessed whether the number of COVID-19 cases recorded in each province was associated with STEMI-related CA volume. Results A total of 41 of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (incidence rate ratio [IRR] 0.84; 95% confidence interval 0.80-0.87) in CA for STEMI during the first wave of the pandemic, compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95% confidence interval 0.61-0.89) in the use of intra-aortic balloon pump use for STEMI. Use of an Impella pump and mechanical complications from STEMI were exceedingly rare. Conclusions We observed a modest 16% decrease in use of CA for STEMI during the pandemic first wave in Canada, lower than the level reported in other countries. Provincial COVID-19 caseload did not influence this reduction.
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Affiliation(s)
- Stéphane Rinfret
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
| | - Israth Jahan
- Department of medicine and biostatistics, McGill University Health Centre, McGill University, Montreal, QC
| | | | - Nandini Dendukuri
- Department of medicine and biostatistics, McGill University Health Centre, McGill University, Montreal, QC
| | - Kevin R Bainey
- Division of cardiology, Mazankowski Alberta Heart Institute, Edmonton, AB
| | - Samer Mansour
- Division of cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC.,Division of cardiology, Hôpital de la Cité-de-la-Santé, Laval, QC
| | - Madhu Natarajan
- Division of cardiology, Hamilton Health Sciences Centre, Hamilton, ON
| | - Luiz F Ybarra
- Division of cardiology, London Health Sciences Centre, London, ON
| | - Aun-Yeong Chong
- Division of cardiology, University of Ottawa Heart Institute, Ottawa, ON
| | - Simon Bérubé
- Division of cardiology, CIUSSS de l'Estrie - CHUS, Sherbrooke, QC
| | - Robert Breton
- Division of cardiology, CIUSSS Saguenay Lac Saint Jean, Saguenay, QC
| | | | - Josep Rodés-Cabau
- Multidisciplinary department of cardiology, Institut universitaire de cardiologie et de pneumologie de Québec-Hôpital Laval, Quebec City, QC
| | - Shy Amlani
- Division of cardiology, William Osler Health System, Brampton, ON
| | | | - Warren Ball
- Division of cardiology, Peterborough Regional Health Centre, Peterborough, ON
| | - Alan Barolet
- Division of cardiology, University Health Network - Toronto General Hospital, Toronto, ON
| | | | - Neil Brass
- Division of cardiology, CK Hui Heart Centre/Royal Alexandra Hospital, Edmonton, AB
| | - Albert W Chan
- Division of cardiology, Royal Columbian Hospital, New Westminster, BC
| | - Franco Colizza
- Division of cardiology, Centre Hospitalier Pierre-Boucher, Longueuil, QC
| | | | - Neil P Fam
- Division of cardiology, St. Michael's Hospital, Montreal, QC
| | - François Gobeil
- Division of cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC
| | | | - Steven Hodge
- Division of cardiology, Kelowna General Hospital, Kelowna, BC
| | - Dominique Joyal
- Division of cardiology, Jewish General Hospital, Montreal, QC
| | - Hahn Hoe Kim
- Division of cardiology, St-Mary's Regional Cardiac Care Centre, Kitchener-Waterloo, ON
| | | | - Andrea MacDougall
- Division of cardiology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON
| | - Paul Malik
- Division of cardiology, Kingston General Hospital, Kingston, ON
| | - Steve Miner
- Division of cardiology, Southlake Regional Health Centre, Newmarket, ON
| | - Kunal Minhas
- Division of cardiology, St. Boniface General Hospital, Winnipeg, MB
| | - Jason Orvold
- Division of cardiology, Royal University Hospital, Saskatoon, SK
| | | | - Brendan Parfrey
- Division of cardiology, Health Sciences Center, St-John's, NF
| | | | - Geoffrey Puley
- Division of cardiology, Trillium Health Centre, Mississauga, ON
| | - Sam Radhakrishnan
- Division of cardiology, Sunnybrook Health Sciences Centre, Toronto, ON
| | - Marco Spaziano
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
| | | | | | - John G Webb
- Division of cardiology, St. Paul's Hospital, Vancouver BC
| | | | - David A Wood
- Division of cardiology, Vancouver General Hospital, Vancouver, BC
| | - James M Brophy
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
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32
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Cohen S, Liu A, Abrahamowicz M, Brophy JM, Marelli AJ. Reply to "Risk prediction models for heart failure admissions in adults with congenital heart disease: Methodological issues". Int J Cardiol 2021; 333:96. [PMID: 33753182 DOI: 10.1016/j.ijcard.2021.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Sarah Cohen
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Aihua Liu
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Canada
| | - Ariane J Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Canada.
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Samuel M, Brophy JM, D’Aronco L, Tardif JC, Khairy P. Distorting Effect of Immortal Time Bias on the Association Between Catheter Ablation for Atrial Fibrillation and Incident Stroke: Caveat Emptor. Can J Cardiol 2021; 37:377-381. [DOI: 10.1016/j.cjca.2020.09.010] [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] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 10/23/2022] Open
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Perreault S, Dragomir A, Côté R, Lenglet A, White-Guay B, de Denus S, Schnitzer ME, Dubé MP, Brophy JM, Dorais M, Tardif JC. Comparative effectiveness and safety of high-dose rivaroxaban and apixaban for atrial fibrillation: A propensity score-matched cohort study. Pharmacotherapy 2021; 41:379-393. [PMID: 33544915 DOI: 10.1002/phar.2509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE Observational studies assessing direct oral anticoagulant (DOACs) dosage in atrial fibrillation (AF) reported that a lower proportion of patients received high-dose DOACs compared to those in randomized controlled trials (RCTs). Effectiveness and safety of high-dose DOACs relative to apixaban in a real-world AF population need to be addressed. The aim is to assess comparative effectiveness and safety of high-dose rivaroxaban relative to apixaban. DESIGN We conducted a cohort study. Setting We built a cohort of patients hospitalized and discharged in community with a primary or secondary AF diagnosis from 2011-2017 using Quebec administrative databases (Med-Echo and RAMQ). Patients Cohort entry was defined as the first OAC claim in new users of high-dose rivaroxaban and apixaban, with no OAC claims in the prior year. Intervention To compare effectiveness and safety of high-dose rivaroxaban to apixaban. Measurement We ascertained patient demographics, comorbidities, CHA2DS2-VASc and HASBLED scores and Charlson score within 3 years prior to cohort entry. Primary effectiveness and safety were a composite of ischemic stroke/systemic thrombosis, death, myocardial infarction, and of intracranial bleeding (ICH), extracranial major bleeding, in the first year following drug initiation. We conducted propensity score matching and estimated hazard ratios (HRs) for outcomes using Cox proportional hazard models. All the analyses were conducted to account for competing risks. Main results The cohort consisted of 4,632 and 6,771 patients received high-dose rivaroxaban and apixaban, respectively. High-dose rivaroxaban users were younger with a mean age of 73.2 years, presented less associated comorbidities and had lower CHA2DS2-VASc scores compared to apixaban. High-dose rivaroxaban at the intention to treat was associated with a higher risk of stroke/SE/death (HR 1.21, 95% CI 1.04-1.40) and worse composite effectiveness (HR 1.21: 1.05-1.40); under treatment exposure, those values were at HR (1.66: 1.21-2.29) and HR (1.58:1.19-2.10), respectively. And, rivaroxaban presented a less favorable safety profile relative to apixaban. Conclusion In this study, composite effectiveness and safety varied between rivaroxaban and apixaban. High-dose apixaban was observed to have a better effectiveness and safety.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Alice Dragomir
- Faculty of Medicine, Department of Urology, McGill University, Montreal, Quebec, Canada
| | - Robert Côté
- Faculty of Medicine, Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Aurélie Lenglet
- Faculty of Pharmacy, EA 7517, Laboratory MP3CV, Jules Verne University of Picardie, Amiens, France.,Department of Pharmacy, Amiens-Picardie University Hospital, Amiens, France
| | - Brian White-Guay
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Mireille E Schnitzer
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Dubé
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - James M Brophy
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Jean-Claude Tardif
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
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Lee TC, McDonald EG, Butler-Laporte G, Harrison LB, Cheng MP, Brophy JM. Remdesivir and systemic corticosteroids for the treatment of COVID-19: A Bayesian re-analysis. Int J Infect Dis 2021; 104:671-676. [PMID: 33540128 PMCID: PMC7849442 DOI: 10.1016/j.ijid.2021.01.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
Background The global death toll from coronavirus disease 2019 (COVID-19) has exceeded 2 million, and treatments to decrease mortality are needed urgently. Objectives To examine the probabilities of a clinically meaningful reduction in mortality for remdesivir and systemic corticosteroids. Design, setting and participants This was a probabilistic re-analysis of clinical trial data for corticosteroids and remdesivir in the treatment of hospitalized patients with COVID-19 using a Bayesian random effects meta-analytic approach. Studies were identified from existing meta-analyses performed by the World Health Organization. Main outcomes and measures Posterior probabilities of an absolute decrease in mortality compared with control patients, by subgroups based on oxygen requirements, were calculated for corticosteroids and remdesivir. Probabilities of ≥1%, ≥2% and ≥5% absolute decrease in mortality were quantified. Results For patients needing mechanical ventilation, the probability of ≥1% absolute decrease in mortality was 4% for remdesivir and 93% for corticosteroids. For patients needing supplemental oxygen without mechanical ventilation, the probability of ≥1% absolute decrease in mortality was 81% for remdesivir and 93% for dexamethasone. Finally, for patients who did not need oxygen support, the probability of ≥1% absolute decrease in mortality was 29% for remdesivir and 4% for dexamethasone. Conclusions and relevance Using a Bayesian analytic approach, remdesivir had low probability of achieving a clinically meaningful reduction in mortality, except for patients needing supplemental oxygen without mechanical ventilation. Corticosteroids were more promising for patients needing oxygen support, especially mechanical ventilation. While awaiting more definitive studies, this probabilistic interpretation of the evidence will help to guide treatment decisions for clinicians, as well as guideline and policy makers.
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Affiliation(s)
- Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada; Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada; Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada.
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada; Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Luke B Harrison
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada
| | - James M Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada; Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
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Wang F, Sterling LH, Liu A, Brophy JM, Paradis G, Marelli A. Risk of readmission after heart failure hospitalization in older adults with congenital heart disease. Int J Cardiol 2020; 320:70-76. [DOI: 10.1016/j.ijcard.2020.06.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/12/2020] [Accepted: 06/14/2020] [Indexed: 11/29/2022]
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Gaudino M, Brophy JM. The controversy on the treatment of left main coronary artery disease. J Thorac Cardiovasc Surg 2020; 163:1864-1869. [PMID: 33640131 DOI: 10.1016/j.jtcvs.2020.08.122] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/23/2020] [Accepted: 08/28/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - James M Brophy
- McGill University Health Center, Montreal, Quebec, Canada
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Puri R, Brophy JM, Mack MJ. Revascularizing Diabetic Multivessel Coronary Artery Disease in the 2020s: Forever Surgically Sweet? J Am Coll Cardiol 2020; 76:1165-1167. [PMID: 32883409 DOI: 10.1016/j.jacc.2020.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
| | - James M Brophy
- Departments of Medicine and Epidemiology and Biostatistics, McGill University, Montréal, Quebec, Canada
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Abstract
BACKGROUND Propensity score (PS) methods are frequently used in cardiovascular clinical research. Previous evaluations revealed poor reporting of PS methods, however a comprehensive and current evaluation of PS use and reporting is lacking. The objectives of the present survey were to (1) evaluate the quality of PS methods in cardiovascular publications, (2) summarise PS methods and (3) propose key reporting elements for PS publications. METHODS A PubMed search for cardiovascular PS articles published between 2010 and 2017 in high-impact general medical (top five by impact factor) and cardiovascular (top three by impact factor) journals was performed. Articles were evaluated for the reporting of PS techniques and methods. Data extraction elements were identified from the PS literature and extraction forms were pilot tested. RESULTS Of the 306 PS articles identified, most were published in Journal of the American College of Cardiology (29%; n=88), and Circulation (27%, n=81), followed by European Heart Journal (15%; n=47). PS matching was performed most often, followed by direct adjustment, inverse probability of treatment weighting and stratification. Most studies (77%; n=193) selected variables to include in the PS model a priori. A total of 38% (n=116) of studies did not report standardised mean differences, but instead relied on hypothesis testing. For matching, 92% (n=193) of articles presented the balance of covariates. Overall, interpretations of the effect estimates corresponded to the PS method conducted or described in 49% (n=150) of the reviewed articles. DISCUSSION Although PS methods are frequently used in high-impact medical journals, reporting of methodological details has been inconsistent. Improved reporting of PS results is warranted and these proposals should aid both researchers and consumers in the presentation and interpretation of PS methods.
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Affiliation(s)
- Michelle Samuel
- Center for Health Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Brice Batomen
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Julie Rouette
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Joanne Kim
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Robert W Platt
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Center for Health Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jay S Kaufman
- Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Cohen S, Liu A, Wang F, Guo L, Brophy JM, Abrahamowicz M, Therrien J, Beauchesne LM, Bédard E, Grewal J, Khairy P, Oechslin E, Roche SL, Silversides CK, Muhll IFV, Marelli AJ. Risk prediction models for heart failure admissions in adults with congenital heart disease. Int J Cardiol 2020; 322:149-157. [PMID: 32798623 DOI: 10.1016/j.ijcard.2020.08.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/04/2020] [Accepted: 08/07/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Heart failure (HF) is the leading cause of death in adult patients with congenital heart disease (ACHD). No risk prediction model exists for HF hospitalization (HFH) for ACHD patients. We aimed to develop a clinically relevant one-year risk prediction system to identify ACHD patients at high risk for HFH. METHODS Data source was the Quebec CHD Database. A retrospective cohort including all ACHD patients aged 18-64 (1995-2010) was constructed for assessing the cumulative risk of HFH adjusting for competing risk of death. To identify one-year predictors of incident HFH, multivariable logistic regressions were employed to a nested case-control sample of all ACHD patients aged 18-64 in 2009. The final model was used to create a risk score system based on adjusted odds ratios. RESULTS The cohort included 29,991 ACHD patients followed for 648,457 person-years. The cumulative HFH risk by age 65 was 12.58%. The case-control sample comprised 26,420 subjects, of whom 189 had HFHs. Significant one-year predictors were age ≥ 50, male sex, CHD lesion severity, recent 12-month HFH history, pulmonary arterial hypertension, chronic kidney disease, coronary artery disease, systemic arterial hypertension, and diabetes mellitus. The created risk score ranged from 0 to 19. The corresponding HFH risk rose rapidly beyond a score of 8. The risk scoring system demonstrated excellent prediction performance. CONCLUSIONS One eighth of ACHD population experienced HFH before age 65. Age, sex, CHD lesion severity, recent 12-month HFH history, and comorbidities constructed a risk prediction model that successfully identified patients at high risk for HFH.
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Affiliation(s)
- Sarah Cohen
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Aihua Liu
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Fei Wang
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Liming Guo
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada; Division of Cardiology, McGill University Health Centre, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Judith Therrien
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Luc M Beauchesne
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Elisabeth Bédard
- Quebec Heart & Lung Institute, Laval University, Quebec City, Québec, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Jasmine Grewal
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Paul Khairy
- Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - S Lucy Roche
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Candice K Silversides
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Isabelle F Vonder Muhll
- Division of Cardiology, Department of Internal Medicine, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada
| | - Ariane J Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada; iCACH Net Group (Canadian Adult Congenital Heart Disease Network Investigators' Group), Canada.
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Wang F, Liu A, Brophy JM, Cohen S, Abrahamowicz M, Paradis G, Marelli A. Determinants of Survival in Older Adults With Congenital Heart Disease Newly Hospitalized for Heart Failure. Circ Heart Fail 2020; 13:e006490. [PMID: 32673500 DOI: 10.1161/circheartfailure.119.006490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nearly 90% of patients with adult congenital heart disease (ACHD) die after the age of 40 years, and heart failure (HF) is the most common cause of death. We aimed to characterize the association between an incident HF hospitalization (HFH) and mortality and to identify the predictors of 1-year postdischarge mortality after incident and repeated HFHs, respectively. METHODS Patients with ACHD aged ≥40 years between 2000 and 2010 were identified from the Québec CHD database. We conducted a propensity score-matched study to explore the association between an incident HFH and mortality. We performed Bayesian model averaging to identify the predictors of 1-year postdischarge mortality with a posterior probability ≥50% considered to be evidence of a significant association. RESULTS The mortality hazard ratio was high at 6.01 (95% CI, 4.02-10.72) within 1-year postdischarge, decreasing significantly but entering an elevated equilibrium until year 4 with a continued 3-fold increase in death. Kidney dysfunction (hazard ratio, 2.28 [95% credible interval, 1.59-3.28], posterior probability, 100.0%) and a history of ≥2 HFHs in the past 12 months (hazard ratio, 1.77 [95% credible interval, 1.18-2.66], posterior probability: 82.2%) were the most robust predictors of 1-year mortality after incident and repeated HFHs, respectively. CONCLUSIONS In patients with ACHD aged ≥40 years, incident HFH was associated with high mortality risk at 1 year, declining but remaining elevated for 4 years. Kidney dysfunction was a potent predictor of 1-year mortality risk after incident HFHs. Repeated HFHs further increased mortality risk. These observations should inform early risk-tailored health services interventions for monitoring and prevention of HF and its associated complications in older patients with ACHD.
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Affiliation(s)
- Fei Wang
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada (F.W., J.M.B., M.A., G.P.).,McGill Adult Unit for Congenital Heart Disease Excellence, Montreal, QC, Canada (F.W., A.L., A.M.)
| | - Aihua Liu
- McGill Adult Unit for Congenital Heart Disease Excellence, Montreal, QC, Canada (F.W., A.L., A.M.)
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada (F.W., J.M.B., M.A., G.P.).,Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada (J.M.B.)
| | - Sarah Cohen
- Hospital Marie Lannelongue, Congenital Heart Diseases Department, Complex Congenital Heart Diseases M3C Network, Paris-Sud University, Paris-Saclay University, Plessis-Robinson, France (S.C.)
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada (F.W., J.M.B., M.A., G.P.)
| | - Gilles Paradis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada (F.W., J.M.B., M.A., G.P.)
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, Montreal, QC, Canada (F.W., A.L., A.M.)
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Abstract
IMPORTANCE Patients with left main coronary artery disease have improved outcomes with coronary revascularization compared with medical therapy, but the choice of optimal revascularization technique is unresolved. OBJECTIVE To use bayesian methods to analyze the risk differences for patients with left main coronary artery disease randomized to treatment with coronary artery bypass surgery (CABG) compared with those randomized to percutaneous coronary intervention (PCI) in recent randomized clinical trials (RCTs). DESIGN, SETTING, AND PARTICIPANTS A systematic review using the PubMed database with the query string "(left main disease) and (PCI or CABG) and (5-year follow-up) and (clinical trial)" identified all RCTs from January 1996 to January 2020 comparing CABG to PCI for treatment of patients with left main coronary artery disease and with 5-year follow-up data. With the use of bayesian methods, the largest and most publicized RCT (EXCEL; Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; 2019) was reanalyzed (1) as an isolated entity using noninformative priors and (2) in the context of previous knowledge using informative priors derived from similar trials. Published aggregate data were used with assignments from each trial following the original intention-to-treat principle. Combining EXCEL data with varying levels of prior information using Bayes theorem provided final (posterior) probability distributions for primary and secondary outcomes. MAIN OUTCOMES AND MEASURES A composite end point of death, nonfatal myocardial infarction, and stroke was the primary EXCEL outcome and was accordingly the primary outcome for this reanalysis. Secondary analyses were performed for isolated all-cause mortality and for the composite outcome along with repeated revascularization procedures. RESULTS When EXCEL data were analyzed using the originally stated noninferiority design, the 5-year primary outcome difference reported (2.8%; 95% CI, -0.9% to 6.5%) exceeded the predefined 4.2% noninferiority margin; thus, the null hypothesis of PCI inferiority could not be rejected. By contrast, the present bayesian analysis of the EXCEL primary outcome estimated 95% probability that the 5-year primary outcome difference was increased with PCI compared with CABG and 87% probability that this difference was greater than 1 extra event per 100 patients treated. Bayesian analyses also suggested 99% probability that EXCEL total mortality was increased with PCI and 94% probability that this absolute difference exceeded 1 extra deaths per 100 treated. A systematic review identified 3 other RCTs that studied the same question. The incorporation of this prior knowledge reduced the estimated probability of any excess mortality with PCI to 85%. For the secondary composite end point, which also included repeated revascularizations, there were estimated probabilities of 98% for at least 4 extra events and of 90% for at least 5 extra events per 100 patients treated with PCI. CONCLUSIONS AND RELEVANCE Bayesian analysis assisted in RCT data interpretation and specifically suggested, whether based on EXCEL results alone or on the totality of available evidence, that PCI was associated with inferior long-term results for all events, including mortality, compared with CABG for patients with left main coronary artery disease.
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Affiliation(s)
- James M Brophy
- McGill University Health Center, Montreal, Quebec, Canada
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Brophy JM. Targeting all-comers-Are we doing as well as we can? Am Heart J 2020; 221:155-156. [PMID: 31831134 DOI: 10.1016/j.ahj.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
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Abstract
Background The ODYSSEY OUTCOMES (Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome) trial demonstrated that alirocumab reduced major cardiovascular events. However, because of the hierarchical testing strategy used for the multiple outcomes examined, the observed reduction in all‐cause mortality was labeled “nominally significant” which has clouded its interpretation. Methods and Results We re‐analyzed data from ODYSSEY OUTCOMES using Bayesian methods and generated various prior probabilities by incorporating mortality data from previous similar PCSK9 (proprotein convertase subtilisin‐kexin type 9) inhibitor trials. We first used data from the ODYSSEY OUTCOMES trial with a non‐informative prior, then sequentially added data from ODYSSEY LONG TERM and the FOURIER trial, giving FOURIER full weight, 50% weight and 10%. The posterior probability of a mortality reduction using only the ODYSSEY OUTCOMES data was hazard ratio 0.85 (95% CI 0.74–0.99) which corresponded to a 98.4% probability of a mortality benefit. When the ODYSSEY LONG TERM data were added to the analysis, the posterior probability was hazard ratio 0.84 (95% CI 0.72–0.97) with a 99.9% probability of mortality reduction, and when the FOURIER data were added to the analysis the posterior probability was hazard ratio 0.94 (95% CI 0.85–1.04) with an 89.1% probability of a mortality reduction. When the FOURIER trial was given only 50% or 10% weight, the probability of a mortality reduction rose 95.4% and 98.7%, respectively. We estimate that the probability of >1% absolute risk reduction ranges from 8% to 24%, while the probability of >0.5% absolute risk reduction ranges from 66% to 89%. Conclusions Our analysis demonstrates a high likelihood that alirocumab confers a reduction in all‐cause mortality, despite the equivocal interpretation of the data in the original ODYSSEY OUTCOMES publication.
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Samuel M, Brophy JM. Challenges in Assessing the Incidence of Atrial Fibrillation Hospitalizations. Can J Cardiol 2019; 35:1291-1293. [PMID: 31500888 DOI: 10.1016/j.cjca.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 05/30/2019] [Accepted: 06/01/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michelle Samuel
- Division of Clinical Epidemiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Division of Clinical Epidemiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada.
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Brophy JM, Dagenais GR, Boyer L, Garcia-Labbé D, Bogaty P. Variability in High-Sensitivity Cardiac Troponin T Testing in Stable Patients With and Without Coronary Artery Disease. Can J Cardiol 2019; 35:1505-1512. [PMID: 31679620 DOI: 10.1016/j.cjca.2019.08.022] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/21/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is used to diagnosis acute myocardial infarction, often based on values exceeding the 99th percentile threshold (14 ng/L) of normal populations. The short- and long-term variability of hs-cTnT in stable patients with or without coronary artery disease (CAD) is unknown. METHODS Prospective cohort study of 75 stable patients with CAD and 3 differing clinical profiles (stable angina [SA]; remote myocardial infarction [MI]; repetitive acute coronary syndrome [ACS]) and 25 controls without angiographic CAD, each with 15 hs-cTnT measurements over 1 year. RESULTS Individual results (1491 measurements) did not vary over within-day, daily, weekly, monthly, seasonal, or yearly time windows. The overall median was 2.8 ng/L (interquartile range [IQR] 5.2 ng/L) with the highest median (6.3 ng/L) and variability (IQR 6. 9 ng/L) in the repetitive ACS group. Diabetes, impaired renal function, and raised C-reactive protein were independent predictors of higher hs-cTnT values (average increase by 8.5 ng/L [95% CI, 5.0-11.9], 5.0 ng/L [95% CI, 2.0-8.1] and 4.0 ng/L (95% CI, 1.0-7.0), respectively). The 99th percentile value of all hs-cTnT measurements in the combined stable patients with CAD was 39 ng/L compared with 14 ng/L in the non-CAD patients. CONCLUSIONS Individual hs-cTnT readings in both patients with and without CAD were stable over hours, days, weeks, and months. Diabetes, poor renal function, and elevated C-reactive protein were independent predictors of higher median and IQR hs-cTnT values, often exceeding conventional thresholds. These findings highlight the need for caution and clinical contextualization in the interpretation of hs-cTnT results.
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Affiliation(s)
- James M Brophy
- McGill University Health Center, Montréal, Québec, Canada.
| | - Gilles R Dagenais
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Luce Boyer
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - David Garcia-Labbé
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Peter Bogaty
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
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Wang F, Harel-Sterling L, Cohen S, Liu A, Brophy JM, Paradis G, Marelli AJ. Heart failure risk predictions in adult patients with congenital heart disease: a systematic review. Heart 2019; 105:1661-1669. [DOI: 10.1136/heartjnl-2019-314977] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/15/2019] [Accepted: 06/21/2019] [Indexed: 01/05/2023] Open
Abstract
To summarise existing heart failure (HF) risk prediction models and describe the risk factors for HF-related adverse outcomes in adult patients with congenital heart disease (CHD). We performed a systematic search of MEDLINE, EMBASE and Cochrane databases from January 1996 to December 2018. Studies were eligible if they developed multivariable models for risk prediction of decompensated HF in adult patients with CHD (ACHD), death in patients with ACHD-HF or both, or if they reported corresponding predictors. A standardised form was used to extract information from selected studies. Twenty-five studies met the inclusion criteria and all studies were at moderate to high risk of bias. One study derived a model to predict the risk of a composite outcome (HF, death or arrhythmia) with a c-statistic of 0.85. Two studies applied an existing general HF model to patients with ACHD but did not report model performance. Twenty studies presented predictors of decompensated HF, and four examined patient characteristics associated with mortality (two reported predictors of both). A wide variation in population characteristics, outcome of interest and candidate risk factors was observed between studies. Although there were substantial inconsistencies regarding which patient characteristics were predictive of HF-related adverse outcomes, brain natriuretic peptide, New York Heart Association class and CHD lesion characteristics were shown to be important predictors. To date, evidence in the published literature is insufficient to accurately profile patients with ACHD. High-quality studies are required to develop a unique ACHD-HF prediction model and confirm the predictive roles of potential risk factors.
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Aloosh M, Leclerc S, Long S, Zhong G, Brophy JM, Schuster T, Steele R, Shrier I. One-year test-retest reliability of ten vision tests in Canadian athletes. F1000Res 2019; 8:1032. [PMID: 32953085 PMCID: PMC7484722 DOI: 10.12688/f1000research.19587.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Vision tests are used in concussion management and baseline testing. Concussions, however, often occur months after baseline testing and reliability studies generally examine intervals limited to days or one week. Our objective was to determine the one-year test-retest reliability of these tests. Methods: We assessed one-year test-retest reliability of ten vision tests in elite Canadian athletes followed by the Institut National du Sport du Quebec. We included athletes who completed two baseline (preseason) annual evaluations by one clinician within 365±30 days. We excluded athletes with any concussion or vision training in between the annual evaluations or presented with any factor that is believed to affect the tests (e.g. migraines). Data were collected from clinical charts. We evaluated test-retest reliability using Intraclass Correlation Coefficient (ICC) and 95% limits of agreement (LoA). Results: We examined nine female and seven male athletes with a mean age of 22.7 (SD 4.5) years. Among the vision tests, we observed excellent test-retest reliability in Positive Fusional Vergence at 30cm (ICC=0.93) but this dropped to 0.53 when an outlier was excluded in a sensitivity analysis. There was good to moderate reliability in Negative Fusional Vergence at 30cm (ICC=0.78), Phoria at 30cm (ICC=0.68), Near Point of Convergence break (ICC=0.65) and Saccades (ICC=0.61). The ICC for Positive Fusional Vergence at 3m (ICC=0.56) also decreased to 0.45 after removing two outliers. We found poor reliability in Near Point of Convergence (ICC=0.47), Gross Stereoscopic Acuity (ICC=0.03) and Negative Fusional Vergence at 3m (ICC=0.0). ICC for Phoria at 3m was not appropriate because scores were identical in 14/16 athletes. 95% LoA of the majority of tests were ±40% to ±90%. Conclusions: Five tests had good to moderate one-year test-retest reliability. The remaining tests had poor reliability. The tests would therefore be useful only if concussion has a moderate-large effect on scores.
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Affiliation(s)
- Mehdi Aloosh
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | | | - Stephanie Long
- Department of Family Medicine, McGill University, Montreal, Canada
| | - Guowei Zhong
- Department of Family Medicine, McGill University, Montreal, Canada
| | - James M Brophy
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Canada
| | - Russell Steele
- Department of Mathematics and Statistics, McGill University, Montreal, Canada
| | - Ian Shrier
- Department of Family Medicine, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Canada
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Boulet J, Peña J, Hulten EA, Neilan TG, Dragomir A, Freeman C, Lambert C, Hijal T, Nadeau L, Brophy JM, Mousavi N. Statin Use and Risk of Vascular Events Among Cancer Patients After Radiotherapy to the Thorax, Head, and Neck. J Am Heart Assoc 2019; 8:e005996. [PMID: 31213106 PMCID: PMC6662340 DOI: 10.1161/jaha.117.005996] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background This study aimed to explore whether statins reduce radiation‐induced vascular complications in cancer patients postradiotherapy to the thorax, head, and neck. Methods and Results We conducted a retrospective cohort study within a provincial linked database of 5718 cardiac patients with thorax and head or neck cancer having undergone radiotherapy between 2000 and 2011. One thousand five hundred fifty‐two patients were identified as nonstatin users and 4166 as statin users. The primary outcome of interest was the composite of cerebrovascular (transient ischemic attack, and fatal or nonfatal stroke) or cardiovascular events (fatal or nonfatal myocardial infarction). Time‐dependent Cox proportional hazard analyses were performed. The crude event rate was 10.31% for nonusers and 9.03% for statin users (hazard ratio of 0.92 [95% CI 0.76–1.10, P=0.3451]), over a mean time to event/censoring of 534±687 days for nonusers and 594±706 days for the statin users. After adjusting for age, sex, prior history of stroke/transient ischemic attack or myocardial infarction, diabetes mellitus, dyslipidemia, atrial fibrillation, chronic kidney disease, heart failure, and hypertension, statin use postradiotherapy was associated with a nonsignificant 15% relative risk reduction, but a strong trend toward reducing the primary outcome (hazard ratio=0.85 95% CI 0.69–1.04, P=0.0811). The use of statins was associated with a significant reduction of 32% for the outcome of stroke alone (hazard ratio=0.68, 95% CI 0.48–0.98, P=0.0368). Conclusions Statin use post radiation therapy was associated with a significant reduction in stroke, with a trend toward significantly reducing cardiovascular and cerebrovascular events.
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Affiliation(s)
- Jacinthe Boulet
- 1 Department of Internal Medicine McGill University Health Centre Montreal Quebec Canada
| | - Jessica Peña
- 5 Dalio Institute of Cardiovascular Imaging Weill Cornell Medicine Weill Cornell University New York NY
| | - Edward A Hulten
- 6 Division of Cardiology Walter Reed National Military Medical Centre Washington DC
| | - Tomas G Neilan
- 7 Cardio-Oncology Program Division of Cardiology Massachusetts General Hospital Boston MA
| | - Alice Dragomir
- 2 Division of Urology Surgical Research McGill University Health Centre Montreal Quebec Canada
| | - Carolyn Freeman
- 3 Division of Radiation Oncology McGill University Health Centre Montreal Quebec Canada
| | - Christine Lambert
- 3 Division of Radiation Oncology McGill University Health Centre Montreal Quebec Canada
| | - Tarek Hijal
- 3 Division of Radiation Oncology McGill University Health Centre Montreal Quebec Canada
| | - Lyne Nadeau
- 4 Division of Clinical Epidemiology Department of Medicine McGill University Health Centre Montreal Quebec Canada
| | - James M Brophy
- 4 Division of Clinical Epidemiology Department of Medicine McGill University Health Centre Montreal Quebec Canada.,8 Departments of Cardiology and Epidemiology, Biostatistics and Occupational Health McGill University Montreal Quebec Canada
| | - Negareh Mousavi
- 4 Division of Clinical Epidemiology Department of Medicine McGill University Health Centre Montreal Quebec Canada
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