1
|
Gibson CM, Duffy D, Korjian S, Bahit MC, Chi G, Alexander JH, Lincoff AM, Heise M, Tricoci P, Deckelbaum LI, Mears SJ, Nicolau JC, Lopes RD, Merkely B, Lewis BS, Cornel JH, Trebacz J, Parkhomenko A, Libby P, Sacks FM, Povsic TJ, Bonaca M, Goodman SG, Bhatt DL, Tendera M, Steg PG, Ridker PM, Aylward P, Kastelein JJP, Bode C, Mahaffey KW, Nicholls SJ, Pocock SJ, Mehran R, Harrington RA. Apolipoprotein A1 Infusions and Cardiovascular Outcomes after Acute Myocardial Infarction. N Engl J Med 2024. [PMID: 38587254 DOI: 10.1056/nejmoa2400969] [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: 04/09/2024]
Abstract
BACKGROUND Cardiovascular events frequently recur after acute myocardial infarction, and low cholesterol efflux - a process mediated by apolipoprotein A1, which is the main protein in high-density lipoprotein - has been associated with an increased risk of cardiovascular events. CSL112 is human apolipoprotein A1 derived from plasma that increases cholesterol efflux capacity. Whether infusions of CSL112 can reduce the risk of recurrent cardiovascular events after acute myocardial infarction is unclear. METHODS We conducted an international, double-blind, placebo-controlled trial involving patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors. Patients were randomly assigned to receive either four weekly infusions of 6 g of CSL112 or matching placebo, with the first infusion administered within 5 days after the first medical contact for the acute myocardial infarction. The primary end point was a composite of myocardial infarction, stroke, or death from cardiovascular causes from randomization through 90 days of follow-up. RESULTS A total of 18,219 patients were included in the trial (9112 in the CSL112 group and 9107 in the placebo group). There was no significant difference between the groups in the risk of a primary end-point event at 90 days of follow-up (439 patients [4.8%] in the CSL112 group vs. 472 patients [5.2%] in the placebo group; hazard ratio, 0.93; 95% confidence interval [CI], 0.81 to 1.05; P = 0.24), at 180 days of follow-up (622 patients [6.9%] vs. 683 patients [7.6%]; hazard ratio, 0.91; 95% CI, 0.81 to 1.01), or at 365 days of follow-up (885 patients [9.8%] vs. 944 patients [10.5%]; hazard ratio, 0.93; 95% CI, 0.85 to 1.02). The percentage of patients with adverse events was similar in the two groups; a higher number of hypersensitivity events was reported in the CSL112 group. CONCLUSIONS Among patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors, four weekly infusions of CSL112 did not result in a lower risk of myocardial infarction, stroke, or death from cardiovascular causes than placebo through 90 days. (Funded by CSL Behring; AEGIS-II ClinicalTrials.gov number, NCT03473223.).
Collapse
Affiliation(s)
- C Michael Gibson
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Danielle Duffy
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Serge Korjian
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - M Cecilia Bahit
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Gerald Chi
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - John H Alexander
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - A Michael Lincoff
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Mark Heise
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Pierluigi Tricoci
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Lawrence I Deckelbaum
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Sojaita Jenny Mears
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jose C Nicolau
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Renato D Lopes
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Bela Merkely
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Basil S Lewis
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jan H Cornel
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jaroslaw Trebacz
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Alexander Parkhomenko
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Peter Libby
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Frank M Sacks
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Thomas J Povsic
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Marc Bonaca
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Shaun G Goodman
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Deepak L Bhatt
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Michal Tendera
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - P Gabriel Steg
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Paul M Ridker
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Philip Aylward
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - John J P Kastelein
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Christoph Bode
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Kenneth W Mahaffey
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Stephen J Nicholls
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Stuart J Pocock
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Roxana Mehran
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Robert A Harrington
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| |
Collapse
|
2
|
Povsic TJ, Korjian S, Bahit MC, Chi G, Duffy D, Alexander JH, Vinereanu D, Tricoci P, Mears SJ, Deckelbaum LI, Bonaca M, Ridker PM, Goodman SG, Cornel JH, Lewis BS, Parkhomenko A, Lopes RD, Aylward P, Lincoff AM, Heise M, Sacks F, Nicolau JC, Merkely B, Trebacz J, Libby P, Nicholls SJ, Pocock S, Bhatt DL, Kastelein J, Bode C, Mahaffey KW, Steg PG, Tendera M, Bainey KR, Harrington RA, Mehran R, Duerschmied D, Kingwell BA, Gibson CM. Effect of CSL112 on Recurrent Myocardial Infarction and Cardiovascular Death: Insights from the AEGIS-II Trial. J Am Coll Cardiol 2024:S0735-1097(24)06702-0. [PMID: 38588930 DOI: 10.1016/j.jacc.2024.03.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The AEGIS-II trial hypothesized that CSL112, an intravenous formulation of human apoA-I, would lower the risk of plaque disruption, decreasing the risk of recurrent events such as myocardial infarction (MI) among high-risk patients with MI. OBJECTIVES This exploratory analysis evaluates the effect of CSL112 therapy on the incidence of CV death and recurrent MI. METHODS The AEGIS-II trial was an international, multicenter, randomized, double-blind, placebo-controlled trial that randomized 18,219 high-risk acute MI patients to 4 weekly infusions of apoA-I (6g CSL112) or placebo. RESULTS The incidence of the composite of cardiovascular death and type 1 MI was 11-16% lower in the CSL112 group over the study period (HR of 0.84 [95% CI 0.7-1.0; p=0.056] day 90, HR 0.86, [95% CI 0.74-0.99; p=0.048] day 180, and HR 0.89, [95% CI 0.79-1.01 p=0.07; p=0.07] day 365). Similarly, the incidence of CV death or any MI was numerically lower in CSL112 treated patients throughout the follow-up period (HR 0.92 [95% CI 0.8-1.05], 0.89 [95% CI 0.79-0.996], 0.91 [0.82-1.01]. The effect of CSL112 treatment on MI was predominantly observed for type 1 MI and type 4b (MI due to stent thrombosis). CONCLUSION While CSL112 did not significantly reduce the occurrence of the primary study endpoints, patients treated with CSL112 infusions had numerically lower rates of CV death and MI, type-1 MI, and stent thrombosis-related MI compared to placebo. These findings could suggest a role of apoA-I in reducing subsequent plaque disruption events via enhanced cholesterol efflux. Further prospective data would be needed to confirm these observations.
Collapse
Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute/Duke University Medical Center, Durham, NC, USA
| | - Serge Korjian
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Gerald Chi
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - John H Alexander
- Duke Clinical Research Institute/Duke University Medical Center, Durham, NC, USA
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Romania
| | | | | | | | - Marc Bonaca
- University of Colorado School of Medicine, Anschutz Medical Campus, USA
| | - Paul M Ridker
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, St. Michael's Hospital, Unity Health Toronto, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan H Cornel
- Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Technion-Israel Institute of Technology, Israel
| | | | - Renato D Lopes
- Duke Clinical Research Institute/Duke University Medical Center, Durham, NC, USA
| | - Philip Aylward
- South Australian Health and Medical Research Institute/SAHMRI, Adelaide, AUS
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, OH, USA
| | | | - Frank Sacks
- Department of Nutrition, Harvard School of Public Health, Harvard Medical School, Boston, MA
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Brazil
| | - Bela Merkely
- Heart and Vascular Center of Semmelweis University, Hungary
| | | | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Kastelein
- Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, CA, USA
| | - P Gabriel Steg
- Universite Paris-Cité, INSERM 1148, FACT, and AP-HP, Hôpital Bichat, Paris, France
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, St. Michael's Hospital, Unity Health Toronto, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Daniel Duerschmied
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | | | - C Michael Gibson
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA;.
| |
Collapse
|
3
|
Kalayci A, Gibson CM, Ridker PM, Wright SD, Kingwell BA, Korjian S, Chi G, Lee JJ, Tricoci P, Kazmi SH, Fitzgerald C, Shaunik A, Berman G, Duffy D, Libby P. ApoA-I Infusion Therapies Following Acute Coronary Syndrome: Past, Present, and Future. Curr Atheroscler Rep 2022; 24:585-597. [PMID: 35524914 PMCID: PMC9236992 DOI: 10.1007/s11883-022-01025-7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW The elevated adverse cardiovascular event rate among patients with low high-density lipoprotein cholesterol (HDL-C) formed the basis for the hypothesis that elevating HDL-C would reduce those events. Attempts to raise endogenous HDL-C levels, however, have consistently failed to show improvements in cardiovascular outcomes. However, steady-state HDL-C concentration does not reflect the function of this complex family of particles. Indeed, HDL functions correlate only weakly with serum HDL-C concentration. Thus, the field has pivoted from simply raising the quantity of HDL-C to a focus on improving the putative anti-atherosclerotic functions of HDL particles. Such functions include the ability of HDL to promote the efflux of cholesterol from cholesterol-laden macrophages. Apolipoprotein A-I (apoA-I), the signature apoprotein of HDL, may facilitate the removal of cholesterol from atherosclerotic plaque, reduce the lesional lipid content and might thus stabilize vulnerable plaques, thereby reducing the risk of cardiac events. Infusion of preparations of apoA-I may improve cholesterol efflux capacity (CEC). This review summarizes the development of apoA-I therapies, compares their structural and functional properties and discusses the findings of previous studies including their limitations, and how CSL112, currently being tested in a phase III trial, may overcome these challenges. RECENT FINDINGS Three major ApoA-I-based approaches (MDCO-216, CER-001, and CSL111/CSL112) have aimed to enhance reverse cholesterol transport. These three therapies differ considerably in both lipid and protein composition. MDCO-216 contains recombinant ApoA-I Milano, CER-001 contains recombinant wild-type human ApoA-I, and CSL111/CSL112 contains native ApoA-I isolated from human plasma. Two of the three agents studied to date (apoA-1 Milano and CER-001) have undergone evaluation by intravascular ultrasound imaging, a technique that gauges lesion volume well but does not assess other important variables that may relate to clinical outcomes. ApoA-1 Milano and CER-001 reduce lecithin-cholesterol acyltransferase (LCAT) activity, potentially impairing the function of HDL in reverse cholesterol transport. Furthermore, apoA-I Milano can compete with and alter the function of the recipient's endogenous apoA-I. In contrast to these agents, CSL112, a particle formulated using human plasma apoA-I and phosphatidylcholine, increases LCAT activity and does not lead to the malfunction of endogenous apoA-I. CSL112 robustly increases cholesterol efflux, promotes reverse cholesterol transport, and now is being tested in a phase III clinical trial. Phase II-b studies of MDCO-216 and CER-001 failed to produce a significant reduction in coronary plaque volume as assessed by IVUS. However, the investigation to determine whether the direct infusion of a reconstituted apoA-I reduces post-myocardial infarction coronary events is being tested using CSL112, which is dosed at a higher level than MDCO-216 and CER-001 and has more favorable pharmacodynamics.
Collapse
Affiliation(s)
- Arzu Kalayci
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Paul M Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Serge Korjian
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jane J Lee
- Baim Institute for Clinical Research, Boston, MA, USA
| | | | - S Hassan Kazmi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Clara Fitzgerald
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Gail Berman
- Paratek Pharmaceuticals, King of Prussia, PA, USA
| | | | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| |
Collapse
|
4
|
Gibson CM, Kastelein JJP, Phillips AT, Aylward PE, Yee MK, Tendera M, Nicholls SJ, Pocock S, Goodman SG, Alexander JH, Lincoff AM, Bode C, Duffy D, Heise M, Berman G, Mears SJ, Tricoci P, Deckelbaum LI, Steg PG, Ridker P, Mehran R. Rationale and design of ApoA-I Event Reducing in Ischemic Syndromes II (AEGIS-II): A phase 3, multicenter, double-blind, randomized, placebo-controlled, parallel-group study to investigate the efficacy and safety of CSL112 in subjects after acute myocardial infarction. Am Heart J 2021; 231:121-127. [PMID: 33065120 DOI: 10.1016/j.ahj.2020.10.052] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 10/06/2020] [Indexed: 12/31/2022]
Abstract
Acute myocardial infarction (MI) patients remain at high risk for recurrent events. Cholesterol efflux, mediated by apolipoprotein A-I, removes excess cholesterol from atherosclerotic plaque and transports it to the liver for excretion. Impaired cholesterol efflux is associated with higher cardiovascular (CV) event rates among both patients with stable coronary artery disease and recent MI. CSL112, a novel intravenous formulation of apolipoprotein A-I (human) derived from human plasma, increases cholesterol efflux capacity. AEGIS-II is a phase 3, multicenter, double-blind, randomized, placebo-controlled, parallel-group trial investigating the efficacy and safety of CSL112 compared to placebo among high-risk acute MI participants. Eligibility criteria include age ≥ 18 years with type 1 (spontaneous) MI, evidence of multivessel stable coronary artery disease, and presence of diabetes requiring pharmacotherapy, or ≥2 of the following: age ≥ 65 years, prior MI, or peripheral artery disease. A target sample of 17,400 participants will be randomized 1:1 to receive 4 weekly infusions of CSL112 6 g or placebo, initiated prior to or on the day of discharge and within 5 days of first medical contact. The primary outcome is the time to first occurrence of the composite of CV death, MI, or stroke through 90 days. Key secondary outcomes include the total number of hospitalizations for coronary, cerebral, or peripheral ischemia through 90 days and time to first occurrence of the composite primary outcome through 180 and 365 days. AEGIS-II will be the first trial to formally test whether enhancing cholesterol efflux can reduce the rate of recurrent major adverse CV events.
Collapse
Affiliation(s)
- C Michael Gibson
- From PERFUSE Study Group, Cardiovascular Division, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - John J P Kastelein
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Adam T Phillips
- From PERFUSE Study Group, Cardiovascular Division, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - Megan K Yee
- From PERFUSE Study Group, Cardiovascular Division, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Katowice, Poland
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, and St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John H Alexander
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Christoph Bode
- Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | - Gail Berman
- Paratek Pharmaceuticals, King of Prussia, PA
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC; CSL Behring, LLC, King of Prussia, PA
| | | | - P Gabriel Steg
- Assistance Publique-Hopitaux de Paris, and Université de Paris, Paris, France
| | - Paul Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | |
Collapse
|
5
|
Zheng B, Duffy D, Tricoci P, Kastrissios H, Pfister M, Wright SD, Gille A, Tortorici MA. Pharmacometric analyses to characterize the effect of CSL112 on apolipoprotein A-I and cholesterol efflux capacity in acute myocardial infarction patients. Br J Clin Pharmacol 2020; 87:2558-2571. [PMID: 33217027 PMCID: PMC8247400 DOI: 10.1111/bcp.14666] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 09/22/2020] [Accepted: 11/12/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS To characterize relationships between apolipoprotein A-I (apoA-I) exposure and cholesterol efflux capacity (CEC) and covariate effects following CSL112 (apoA-I [human]) administration in an integrated population including acute myocardial infarction (AMI) patients. METHODS A pharmacometric analysis utilized data from seven clinical trials, including patients with AMI, subjects with renal impairment and healthy subjects. A population pharmacokinetic (PK) analysis was performed to relate CSL112 doses to changes in apoA-I plasma concentrations. Covariate analysis was conducted to identify sources of variability in apoA-I exposure. Exposure-response modeling was conducted to describe the relationship between apoA-I exposure and total or ATP binding cassette transporter A1-(ABCA1)-dependent CEC and to identify clinical predictors of CEC. RESULTS A two-compartment model described apoA-I PK. ApoA-I clearance was slightly lower in subjects with AMI, whereas baseline apoA-I was marginally higher in female and Japanese subjects. Covariate effects on apoA-I exposure were in the order of 10% and thus not clinically relevant. The relationships between apoA-I exposure and CECs were described by nonlinear models. Simulations showed CEC elevation resulting from apoA-I exposure increment was comparable in AMI and non-AMI subjects; no covariate had clinically meaningful effects on CEC. Simulations also demonstrated that CEC in patients with AMI post 6 g CSL112 dosing was substantially elevated compared to placebo and lower dose levels. CONCLUSIONS The model-based exposure-response analysis demonstrated, irrespective of body weight, sex and race, that fixed 6 g CSL112 dosing causes a desired CEC elevation, which may benefit AMI patients by potentially reducing early recurrent cardiovascular event risk.
Collapse
Affiliation(s)
- Bo Zheng
- CSL Behring, King of Prussia, PA, USA
| | | | | | | | - Marc Pfister
- Certara Strategic Consulting, Princeton, NJ, USA.,University of Basel, Basel, Switzerland
| | | | | | | |
Collapse
|
6
|
White HD, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, Edelberg JM, Erglis A, Goodman SG, Hanotin C, Harrington RA, Jukema JW, Lopes RD, Mahaffey KW, Moryusef A, Pordy R, Roe MT, Sritara P, Tricoci P, Zeiher AM, Schwartz GG. Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial. Eur Heart J 2020; 40:2801-2809. [PMID: 31121022 PMCID: PMC6736383 DOI: 10.1093/eurheartj/ehz299] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/01/2019] [Accepted: 04/24/2019] [Indexed: 12/20/2022] Open
Abstract
Aims The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) were adjudicated as Type 1, 386 (20.8%) as Type 2, and 244 (13.1%) as Type 4. Few events were Type 3 (n = 2) or Type 5 (n = 5). Alirocumab reduced first MIs [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77–0.95; P = 0.003], with reductions in both Type 1 (HR 0.87, 95% CI 0.77–0.99; P = 0.032) and Type 2 (0.77, 0.61–0.97; P = 0.025), but not Type 4 MI. Conclusion After ACS, alirocumab added to intensive statin therapy favourably impacted on Type 1 and 2 MIs. The data indicate for the first time that a lipid-lowering therapy can attenuate the risk of Type 2 MI. Low-density lipoprotein cholesterol reduction below levels achievable with statins is an effective preventive strategy for both MI types. ![]()
Collapse
Affiliation(s)
- Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital, 5 Park Road, Grafton, Auckland, New Zealand
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université Paris-Diderot, Sorbonne Paris-Cité, INSERM U-1148, 46 rue Henri Huchard, Paris, France.,National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, Sydney Street, London, UK
| | - Michael Szarek
- Department of Epidemiology and Biostatistics, SUNY Downstate Medical Center School of Public Health, 450 Clarkson Avenue, Brooklyn, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, 75 Francis Street, Boston, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 701 19th Street South - LHRB 310, Birmingham, USA
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Paraguay 160, Rosario, Santa Fe, Argentina
| | | | - Andrejs Erglis
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, University of Latvia, Pilsonu Street 13, Riga, Latvia
| | - Shaun G Goodman
- Canadian VIGOUR Centre, 2-132 Li Ka Shing Centre for Health Research Innovation University of Alberta, Edmonton, Alberta, Canada.,St. Michael's Hospital, 30 Bond Street, University of Toronto, Toronto, ON, Canada
| | | | - Robert A Harrington
- Stanford Center for Clinical Research, Department of Medicine, 300 Pasteur Drive, S-102, Stanford, CA, USA
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Renato D Lopes
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC, USA
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Grant S-102, Stanford, CA, USA
| | | | - Robert Pordy
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY, USA
| | - Matthew T Roe
- Duke Clinical Research Institute, 200 Morris Street, Durham, NC, USA
| | - Piyamitr Sritara
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital/Mahidol University, Rama VI Road, Thailand
| | | | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, 1700 N. Wheeling Street, Aurora, CO, USA
| | | |
Collapse
|
7
|
Valgimigli M, Garcia-Garcia HM, Vrijens B, Vranckx P, McFadden EP, Costa F, Pieper K, Vock DM, Zhang M, Van Es GA, Tricoci P, Baber U, Steg G, Montalescot G, Angiolillo DJ, Serruys PW, Farb A, Windecker S, Kastrati A, Colombo A, Feres F, Jüni P, Stone GW, Bhatt DL, Mehran R, Tijssen JGP. Standardized classification and framework for reporting, interpreting, and analysing medication non-adherence in cardiovascular clinical trials: a consensus report from the Non-adherence Academic Research Consortium (NARC). Eur Heart J 2020; 40:2070-2085. [PMID: 29992264 DOI: 10.1093/eurheartj/ehy377] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 07/04/2018] [Indexed: 01/02/2023] Open
Abstract
Non-adherence has been well recognized for years to be a common issue that significantly impacts clinical outcomes and health care costs. Medication adherence is remarkably low even in the controlled environment of clinical trials where it has potentially complex major implications. Collection of non-adherence data diverge markedly among cardiovascular randomized trials and, even where collected, is rarely incorporated in the statistical analysis to test the consistency of the primary endpoint(s). The imprecision introduced by the inconsistent assessment of non-adherence in clinical trials might confound the estimate of the calculated efficacy of the study drug. Hence, clinical trials may not accurately answer the scientific question posed by regulators, who seek an accurate estimate of the true efficacy and safety of treatment, or the question posed by payers, who want a reliable estimate of the effectiveness of treatment in the marketplace after approval. The Non-adherence Academic Research Consortium is a collaboration among leading academic research organizations, representatives from the U.S. Food and Drug Administration and physician-scientists from the USA and Europe. One in-person meeting was held in Madrid, Spain, culminating in a document describing consensus recommendations for reporting, collecting, and analysing adherence endpoints across clinical trials. The adoption of these recommendations will afford robustness and consistency in the comparative safety and effectiveness evaluation of investigational drugs from early development to post-marketing approval studies. These principles may be useful for regulatory assessment, as well as for monitoring local and regional outcomes to guide quality improvement initiatives.
Collapse
Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Hector M Garcia-Garcia
- Interventional Cardiology Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium.,Faculty of Medicine and Life Sciences Hasselt University, Hasselt, Belgium
| | | | - Francesco Costa
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.,Department of Clinical and Experimental Medicine, Policlinic "G Martino", University of Messina, Italy
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriel Steg
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Andrew Farb
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Antonio Colombo
- Interventional Cardiology Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Department, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Fausto Feres
- Division of Cardiology, Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Peter Jüni
- Institute of Primary Health Care, Toronto, Canada
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jan G P Tijssen
- European Cardiovascular Research Institute, Rotterdam, The Netherlands.,Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Marquis-Gravel G, Dalgaard F, Jones AD, Lokhnygina Y, James SK, Harrington RA, Wallentin L, Steg PG, Lopes RD, Storey RF, Goodman SG, Mahaffey KW, Tricoci P, White HD, Armstrong PW, Ohman EM, Alexander JH, Roe MT. Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI. J Am Coll Cardiol 2020; 76:162-171. [DOI: 10.1016/j.jacc.2020.05.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 10/23/2022]
|
9
|
Fanaroff AC, Clare R, Pieper KS, Mahaffey KW, Melloni C, Green JB, Alexander JH, Jones WS, Harrison RW, Mehta RH, Povsic TJ, Moreira HG, Al-Khatib SM, Roe MT, Kong DF, Mathews R, Tricoci P, Holman RR, Wallentin L, Held C, Califf RM, Alexander KP, Lopes RD. Frequency, Regional Variation, and Predictors of Undetermined Cause of Death in Cardiometabolic Clinical Trials: A Pooled Analysis of 9259 Deaths in 9 Trials. Circulation 2019; 139:863-873. [PMID: 30586739 DOI: 10.1161/circulationaha.118.037202] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Modern cardiometabolic clinical trials often include cardiovascular death as a component of a composite primary outcome, requiring central adjudication by a clinical events committee to classify cause of death. However, sometimes the cause of death cannot be determined from available data. The US Food and Drug Administration has indicated that this circumstance should occur only rarely, but its prevalence has not been formally assessed. METHODS Data from 9 global clinical trials (2009-2017) with long-term follow-up and blinded, centrally adjudicated cause of death were used to calculate the proportion of deaths attributed to cardiovascular, noncardiovascular, or undetermined causes by therapeutic area (diabetes mellitus/pre-diabetes mellitus, stable atherosclerosis, atrial fibrillation, and acute coronary syndrome), region of patient enrollment, and year of trial manuscript publication. Patient- and trial-level variables associated with undetermined cause of death were identified using a logistic model. RESULTS Across 127 049 enrolled participants from 9 trials, there were 9259 centrally adjudicated deaths: 5012 (54.1%) attributable to cardiovascular causes, 2800 (30.2%) attributable to noncardiovascular causes, and 1447 (15.6%) attributable to undetermined causes. There was variability in the proportion of deaths ascribed to undetermined causes by trial therapeutic area, region of enrollment, and year of trial manuscript publication. On multivariable analysis, acute coronary syndrome or atrial fibrillation trial (versus atherosclerotic vascular disease or diabetes mellitus/pre-diabetes mellitus), longer time from enrollment to death, more recent trial manuscript publication year, enrollment in North America (versus Western Europe), female sex, and older age were associated with greater likelihood of death of undetermined cause. CONCLUSIONS In 9 cardiometabolic clinical trials with long-term follow-up, approximately 16% of deaths had undetermined causes. This provides a baseline for quality assessment of clinical trials and informs operational efforts to potentially reduce the frequency of undetermined deaths in future clinical research.
Collapse
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robert Clare
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Karen S Pieper
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Chiara Melloni
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Jennifer B Green
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Division of Endocrinology (J.B.G.), Duke University School of Medicine, Durham, NC
| | - John H Alexander
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robert W Harrison
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Rajendra H Mehta
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Thomas J Povsic
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Humberto G Moreira
- Heart Institute (InCor), University of São Paulo Medical School, Brazil (H.G.M.)
| | - Sana M Al-Khatib
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Matthew T Roe
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - David F Kong
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robin Mathews
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | | | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, United Kingdom (R.R.H)
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Institute, Uppsala University, Sweden (L.W., C.H.)
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Institute, Uppsala University, Sweden (L.W., C.H.)
| | - Robert M Califf
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Verily Life Sciences, South San Francisco, CA (R.M.C.)
| | - Karen P Alexander
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| |
Collapse
|
10
|
Ungar L, Clare RM, Rodriguez F, Kolls BJ, Armstrong PW, Aylward P, Held C, Moliterno DJ, Strony J, Van de Werf F, Wallentin L, White HD, Tricoci P, Harrington RA, Mahaffey KW, Melloni C. Stroke Outcomes With Vorapaxar Versus Placebo in Patients With Acute Coronary Syndromes: Insights From the TRACER Trial. J Am Heart Assoc 2019; 7:e009609. [PMID: 30526198 PMCID: PMC6405615 DOI: 10.1161/jaha.118.009609] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 12/01/2022]
Abstract
Background Vorapaxar, a protease‐activated receptor‐1 antagonist, is approved for secondary prevention of cardiovascular events but is associated with increased intracranial hemorrhage. Methods and Results TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) was a trial of vorapaxar versus placebo among patients with acute coronary syndrome. Strokes were adjudicated by a central events committee. Of 12 944 patients, 199 (1.5%) had ≥1 stroke during the study period (median follow‐up, 477 days). Four patients had a single stroke of unknown type; 195 patients had ≥1 stroke classified as hemorrhagic or nonhemorrhagic (165 nonhemorrhagic, 28 hemorrhagic, and 2 both). Strokes occurred in 96 of 6473 patients (1.5%) assigned vorapaxar and 103 of 6471 patients (1.6%) assigned placebo. Kaplan‐Meier incidence of stroke for vorapaxar versus placebo was higher for hemorrhagic stroke (0.45% versus 0.14% [hazard ratio, 2.74; 95% confidence interval, 1.22–6.15]), lower but not significantly different for nonhemorrhagic stroke (1.53% versus 1.98% at 2 years [hazard ratio, 0.79; 95% confidence interval, 0.58–1.07]), and similar for stroke overall (1.93% versus 2.13% at 2 years [hazard ratio, 0.94; 95% confidence interval, 0.71–1.24]). Conclusions Stroke occurred in <2% of patients. Vorapaxar‐assigned patients had increased hemorrhagic stroke but a nonsignificant trend toward lower nonhemorrhagic stroke. Overall stroke frequency was similar with vorapaxar versus placebo.
Collapse
Affiliation(s)
- Leo Ungar
- 1 Department of Cardiology University of California Irvine Medical Center Orange CA
| | - Robert M Clare
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| | - Fatima Rodriguez
- 3 Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Bradley J Kolls
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| | | | - Philip Aylward
- 5 South Australian Health and Medical Research Institute Flinders University and Medical Centre Adelaide Australia
| | - Claes Held
- 6 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - David J Moliterno
- 7 Division of Cardiovascular Medicine Gill Heart Institute University of Kentucky Lexington KY
| | | | - Frans Van de Werf
- 9 Department of Cardiovascular Sciences University Hospitals Leuven Leuven Belgium
| | - Lars Wallentin
- 6 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Harvey D White
- 10 Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
| | | | - Robert A Harrington
- 11 Department of Medicine Stanford University School of Medicine Stanford CA
| | - Kenneth W Mahaffey
- 11 Department of Medicine Stanford University School of Medicine Stanford CA
| | - Chiara Melloni
- 2 Department of Medicine Duke Clinical Research Institute Durham NC
| |
Collapse
|
11
|
Tricoci P, Newby LK, Clare RM, Leonardi S, Gibson CM, Giugliano RP, Armstrong PW, Van de Werf F, Montalescot G, Moliterno DJ, Held C, Aylward PE, Wallentin L, Harrington RA, Braunwald E, Mahaffey KW, White HD. Prognostic and Practical Validation of Current Definitions of Myocardial Infarction Associated With Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 11:856-864. [PMID: 29747915 DOI: 10.1016/j.jcin.2018.02.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 10/19/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In 13,038 patients with non-ST-segment elevation acute coronary syndrome undergoing index percutaneous coronary intervention (PCI) in the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndrome) and TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) trials, the relationship between PCI-related myocardial infarction (MI) and 1-year mortality was assessed. BACKGROUND The definition of PCI-related MI is controversial. The third universal definition of PCI-related MI requires cardiac troponin >5 times the 99th percentile of the normal reference limit from a stable or falling baseline and PCI-related clinical or angiographic complications. The definition from the Society for Cardiovascular Angiography and Interventions (SCAI) requires creatine kinase-MB elevation >10 times the upper limit of normal (or 5 times if new electrocardiographic Q waves are present). Implications of these definitions on prognosis, prevalence, and implementation are not established. METHODS In our cohort of patients undergoing PCI, PCI-related MIs were classified using the third universal type 4a MI definition and SCAI criteria. In the subgroup of patients included in the angiographic core laboratory (ACL) substudy of EARLY ACS (n = 1,401) local investigator- versus ACL-reported angiographic complications were compared. RESULTS Altogether, 2.0% of patients met third universal definition of PCI-related MI criteria, and 1.2% met SCAI criteria. One-year mortality was 3.3% with the third universal definition (hazard ratio: 1.96; 95% confidence interval: 1.24 to 3.10) and 5.3% with SCAI criteria (hazard ratio: 2.79; 95% confidence interval: 1.69 to 4.58; p < 0.001). Agreement between ACL and local investigators in detecting angiographic complications during PCI was overall moderate (κ = 0.53). CONCLUSIONS The third universal definition of MI and the SCAI definition were both associated with significant risk for mortality at 1 year. Suboptimal concordance was observed between ACL and local investigators in identifying patients with PCI complications detected on angiography. (Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRA·CER] [Study P04736]; NCT00527943; EARLY ACS: Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome [Study P03684AM2]; NCT00089895).
Collapse
Affiliation(s)
| | | | - Robert M Clare
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gilles Montalescot
- Sorbonne Université Paris 06, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière (AP-HP), Paris, France
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
12
|
Steg PG, Szarek M, Bhatt DL, Bittner VA, Brégeault MF, Dalby AJ, Diaz R, Edelberg JM, Goodman SG, Hanotin C, Harrington RA, Jukema JW, Lecorps G, Mahaffey KW, Moryusef A, Ostadal P, Parkhomenko A, Pordy R, Roe MT, Tricoci P, Vogel R, White HD, Zeiher AM, Schwartz GG. Effect of Alirocumab on Mortality After Acute Coronary Syndromes. Circulation 2019; 140:103-112. [PMID: 31117810 PMCID: PMC6661243 DOI: 10.1161/circulationaha.118.038840] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Previous trials of PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitors demonstrated reductions in major adverse cardiovascular events, but not death. We assessed the effects of alirocumab on death after index acute coronary syndrome. Methods: ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was a double-blind, randomized comparison of alirocumab or placebo in 18 924 patients who had an ACS 1 to 12 months previously and elevated atherogenic lipoproteins despite intensive statin therapy. Alirocumab dose was blindly titrated to target achieved low-density lipoprotein cholesterol (LDL-C) between 25 and 50 mg/dL. We examined the effects of treatment on all-cause death and its components, cardiovascular and noncardiovascular death, with log-rank testing. Joint semiparametric models tested associations between nonfatal cardiovascular events and cardiovascular or noncardiovascular death. Results: Median follow-up was 2.8 years. Death occurred in 334 (3.5%) and 392 (4.1%) patients, respectively, in the alirocumab and placebo groups (hazard ratio [HR], 0.85; 95% CI, 0.73 to 0.98; P=0.03, nominal P value). This resulted from nonsignificantly fewer cardiovascular (240 [2.5%] vs 271 [2.9%]; HR, 0.88; 95% CI, 0.74 to 1.05; P=0.15) and noncardiovascular (94 [1.0%] vs 121 [1.3%]; HR, 0.77; 95% CI, 0.59 to 1.01; P=0.06) deaths with alirocumab. In a prespecified analysis of 8242 patients eligible for ≥3 years follow-up, alirocumab reduced death (HR, 0.78; 95% CI, 0.65 to 0.94; P=0.01). Patients with nonfatal cardiovascular events were at increased risk for cardiovascular and noncardiovascular deaths (P<0.0001 for the associations). Alirocumab reduced total nonfatal cardiovascular events (P<0.001) and thereby may have attenuated the number of cardiovascular and noncardiovascular deaths. A post hoc analysis found that, compared to patients with lower LDL-C, patients with baseline LDL-C ≥100 mg/dL (2.59 mmol/L) had a greater absolute risk of death and a larger mortality benefit from alirocumab (HR, 0.71; 95% CI, 0.56 to 0.90; Pinteraction=0.007). In the alirocumab group, all-cause death declined with achieved LDL-C at 4 months of treatment, to a level of approximately 30 mg/dL (adjusted P=0.017 for linear trend). Conclusions: Alirocumab added to intensive statin therapy has the potential to reduce death after acute coronary syndrome, particularly if treatment is maintained for ≥3 years, if baseline LDL-C is ≥100 mg/dL, or if achieved LDL-C is low. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01663402.
Collapse
Affiliation(s)
- Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Paris, France (P.G.S.)
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Michael Szarek
- State University of New York, Downstate School of Public Health, Brooklyn (M.S.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Vera A. Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham. (V.A.B.)
| | | | - Anthony J. Dalby
- Milpark Hospital, Johannesburg, Republic of South Africa (A.J.D.)
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | | | - Shaun G. Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada and St. Michael’s Hospital, University of Toronto, Canada (S.G.G.)
| | | | - Robert A. Harrington
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, CA (R.A.H., K.W.M.)
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.W.J.)
| | | | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, CA (R.A.H., K.W.M.)
| | | | - Petr Ostadal
- Na Homolce Hospital, Prague, Czech Republic (P.O.)
| | | | - Robert Pordy
- Regeneron Pharmaceuticals Inc, Tarrytown, NY (R.P.)
| | - Matthew T. Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., P.T.)
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R.)
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., P.T.)
| | | | - Harvey D. White
- Green Lane Cardiovascular Services Auckland City Hospital, New Zealand (H.D.W.)
| | - Andreas M. Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Gregory G. Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.)
| |
Collapse
|
13
|
Pordy R, White H, Schwartz G, Alings M, Bhatt D, Bittner V, Chiang CE, Diaz R, Edelberg J, Goodman S, Hanotin C, Harrington R, Jukema J, Kimura T, Kiss RG, Lecorps G, Mahaffey K, Moryusef A, Szarek M, Roe MT, Tricoci P, Xavier D, Zeiher A, Steg G. Alirocumab Reduces Total Nonfatal Cardiovascular and Fatal Events in the ODYSSEY OUTCOMES Trial†. J Clin Lipidol 2019. [DOI: 10.1016/j.jacl.2019.04.090] [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: 10/26/2022]
|
14
|
White HD, Steg P, Szarek M, Bhatt DL, Bittner V, Diaz R, Edelberg J, Erglis A, Goodman S, Hanotin C, Harrington R, Jukema J, Lopes R, Mahaffey K, Moryusef A, Pordy R, Roe M, Sritara P, Tricoci P, Zeiher A, Schwartz G. REDUCTION OF TYPE 1 AND TYPE 2 MYOCARDIAL INFARCTIONS IN PATIENTS TREATED WITH ALIROCUMAB: INSIGHTS FROM THE ODYSSEY TRIAL. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30613-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
15
|
Gibson CM, Kerneis M, Yee MK, Daaboul Y, Korjian S, Mehr AP, Tricoci P, Alexander JH, Kastelein JJ, Mehran R, Bode C, Lewis BS, Mehta R, Duffy D, Feaster J, Halabi M, Angiolillo DJ, Duerschmied D, Ophuis TO, Merkely B. The CSL112-2001 trial: Safety and tolerability of multiple doses of CSL112 (apolipoprotein A-I [human]), an intravenous formulation of plasma-derived apolipoprotein A-I, among subjects with moderate renal impairment after acute myocardial infarction. Am Heart J 2019; 208:81-90. [PMID: 30580130 DOI: 10.1016/j.ahj.2018.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 11/14/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND CSL112 (apolipoprotein A-I [human]) is a plasma-derived apolipoprotein A-I developed for early reduction of cardiovascular risk following an acute myocardial infarction (AMI). The safety of CSL112 among AMI subjects with moderate, stage 3 chronic kidney disease (CKD) is unknown. METHODS CSL112_2001, a multicenter, placebo-controlled, parallel-group, double-blind, randomized phase 2 trial, enrolled patients with moderate CKD within 7 days following AMI. Enrollment was stratified on the basis of estimated glomerular filtration rate and presence of diabetes requiring treatment. Patients were randomized in a 2:1 ratio to receive 4 weekly infusions of CSL112 6 g or placebo. The co-primary safety end points were renal serious adverse events (SAEs) and acute kidney injury, defined as an increase ≥26.5 μmol/L in baseline serum creatinine for more than 24 hours, during the treatment period. RESULTS A total of 83 patients were randomized (55 CSL112 vs 28 placebo). No increase in renal SAEs was observed in the CSL112 group compared with placebo (CSL112 = 1 [1.9%], placebo = 4 [14.3%]). Similarly, no increase in acute kidney injury events was observed (CSL112 = 2 [4.0%], placebo = 4 [14.3%]). Rates of other SAEs were similar between groups. CSL112 administration resulted in increases in ApoA-I and cholesterol efflux similar to those observed in patients with AMI and normal renal function or stage 2 CKD enrolled in the ApoA-I Event Reducing in Ischemic Syndromes I trial. CONCLUSIONS These results demonstrate the acceptable safety of the 6-g dose of CSL112 among AMI subjects with moderate stage 3 CKD and support inclusion of these patients in a phase 3 cardiovascular outcomes trial powered to assess efficacy.
Collapse
|
16
|
Schwartz GG, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, Edelberg JM, Goodman SG, Hanotin C, Harrington RA, Jukema JW, Lecorps G, Mahaffey KW, Moryusef A, Pordy R, Quintero K, Roe MT, Sasiela WJ, Tamby JF, Tricoci P, White HD, Zeiher AM. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome. N Engl J Med 2018; 379:2097-2107. [PMID: 30403574 DOI: 10.1056/nejmoa1801174] [Citation(s) in RCA: 1839] [Impact Index Per Article: 306.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients who have had an acute coronary syndrome are at high risk for recurrent ischemic cardiovascular events. We sought to determine whether alirocumab, a human monoclonal antibody to proprotein convertase subtilisin-kexin type 9 (PCSK9), would improve cardiovascular outcomes after an acute coronary syndrome in patients receiving high-intensity statin therapy. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving 18,924 patients who had an acute coronary syndrome 1 to 12 months earlier, had a low-density lipoprotein (LDL) cholesterol level of at least 70 mg per deciliter (1.8 mmol per liter), a non-high-density lipoprotein cholesterol level of at least 100 mg per deciliter (2.6 mmol per liter), or an apolipoprotein B level of at least 80 mg per deciliter, and were receiving statin therapy at a high-intensity dose or at the maximum tolerated dose. Patients were randomly assigned to receive alirocumab subcutaneously at a dose of 75 mg (9462 patients) or matching placebo (9462 patients) every 2 weeks. The dose of alirocumab was adjusted under blinded conditions to target an LDL cholesterol level of 25 to 50 mg per deciliter (0.6 to 1.3 mmol per liter). The primary end point was a composite of death from coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. RESULTS The median duration of follow-up was 2.8 years. A composite primary end-point event occurred in 903 patients (9.5%) in the alirocumab group and in 1052 patients (11.1%) in the placebo group (hazard ratio, 0.85; 95% confidence interval [CI], 0.78 to 0.93; P<0.001). A total of 334 patients (3.5%) in the alirocumab group and 392 patients (4.1%) in the placebo group died (hazard ratio, 0.85; 95% CI, 0.73 to 0.98). The absolute benefit of alirocumab with respect to the composite primary end point was greater among patients who had a baseline LDL cholesterol level of 100 mg or more per deciliter than among patients who had a lower baseline level. The incidence of adverse events was similar in the two groups, with the exception of local injection-site reactions (3.8% in the alirocumab group vs. 2.1% in the placebo group). CONCLUSIONS Among patients who had a previous acute coronary syndrome and who were receiving high-intensity statin therapy, the risk of recurrent ischemic cardiovascular events was lower among those who received alirocumab than among those who received placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; ODYSSEY OUTCOMES ClinicalTrials.gov number, NCT01663402 .).
Collapse
Affiliation(s)
- Gregory G Schwartz
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - P Gabriel Steg
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Michael Szarek
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Deepak L Bhatt
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Vera A Bittner
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Rafael Diaz
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Jay M Edelberg
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Shaun G Goodman
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Corinne Hanotin
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Robert A Harrington
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - J Wouter Jukema
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Guillaume Lecorps
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Kenneth W Mahaffey
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Angèle Moryusef
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Robert Pordy
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Kirby Quintero
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Matthew T Roe
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - William J Sasiela
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Jean-François Tamby
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Pierluigi Tricoci
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Harvey D White
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| | - Andreas M Zeiher
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (G.G.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris Diderot University, Sorbonne Paris Cité, FACT (French Alliance for Cardiovascular Trials), and INSERM Unité 1148 (P.G.S.), and Sanofi (C.H., G.L.) - all in Paris; the National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.); the State University of New York Downstate School of Public Health, Brooklyn (M.S.), and Regeneron Pharmaceuticals, Tarrytown (R.P., W.J.S.) - both in New York; Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston (D.L.B.); the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (V.A.B.); Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina (R.D.); Sanofi, Bridgewater, NJ (J.M.E., A.M., J.-F.T.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, University of Toronto, Toronto - both in Canada (S.G.G.); Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA (R.A.H., K.W.M.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.W.J.); Duke Clinical Research Institute, Duke University Medical Center (K.Q., M.T.R., P.T.), and the Division of Cardiology, Department of Medicine, Duke University School of Medicine (M.T.R.), Durham, NC; Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the Department of Medicine III, Goethe University, Frankfurt am Main, Germany (A.M.Z.)
| |
Collapse
|
17
|
Gurbel PA, Tantry US, D'Andrea D, Chung T, Alexander JH, Bliden KP, Wright SD, Tricoci P. Evaluation of potential antiplatelet effects of CSL112 (Apolipoprotein A-I [Human]) in patients with atherosclerosis: results from a phase 2a study. J Thromb Thrombolysis 2018; 45:469-476. [PMID: 29582212 PMCID: PMC5889770 DOI: 10.1007/s11239-018-1644-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CSL112 (Apolipoprotein A-I [Human]), an infusible, plasma-derived apolipoprotein A-I, is being developed to reduce cardiovascular events following acute myocardial infarction (AMI). A predecessor compound (CSL111) demonstrated a potential antiplatelet effect. A phase 2a multicentre, randomised, single-ascending dose study in patients with stable atherosclerotic disease receiving dual antiplatelet therapy (DAPT) assessed the potential additive effects of CSL112 administration on platelet function and increase bleeding risk in the subacute period after AMI. Patients (n = 44) on aspirin (75–325 mg/day) and either clopidogrel (75 mg/day, n = 37) or prasugrel (10 mg/day, n = 7) for > 30 days alongside standard-of-care therapy were randomised to a single dose of placebo or CSL112: 1.7, 3.4, or 6.8 g. Light transmission aggregometry was used to assess platelet aggregation in response to 2 mM arachidonic acid, 5 and 20 µM adenosine diphosphate, and 4 µg/mL collagen, pre-dose (baseline) and up to 48 h post-dosing. Compared to placebo, CSL112 had no clinically meaningful time- or dose-dependent effects on maximum platelet aggregation in response to any agonist, by either dose or renal function subgroup (p > 0.05). Coagulation parameters showed little variation over time or between treatment groups (p > 0.05). CSL112, when co-administered with standard DAPT, did not significantly influence platelet aggregation in response to agonists and is, therefore, not expected to significantly increase bleeding risk when administered with antiplatelet therapies.
Collapse
Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA.
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | | | | | | | - Kevin P Bliden
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | | | | |
Collapse
|
18
|
Tricoci P, Neely M, Whitley MJ, Edelstein LC, Simon LM, Shaw C, Fortina P, Moliterno DJ, Armstrong PW, Aylward P, White H, Van de Werf F, Jennings LK, Wallentin L, Held C, Harrington RA, Mahaffey KW, Bray PF. Effects of genetic variation in protease activated receptor 4 after an acute coronary syndrome: Analysis from the TRACER trial. Blood Cells Mol Dis 2018; 72:37-43. [PMID: 30055940 DOI: 10.1016/j.bcmd.2018.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 01/05/2023]
Abstract
Variation in platelet response to thrombin may affect the safety and efficacy of PAR antagonism. The Thr120 variant of the common single nucleotide polymorphism (SNP) rs773902 in the protease-activated receptor (PAR) 4 gene is associated with higher platelet aggregation compared to the Ala120 variant. We investigated the relationship between the rs773902 SNP with major bleeding and ischemic events, safety, and efficacy of PAR1 inhibition in 6177 NSTE ACS patients in the TRACER trial. There was a lower rate of GUSTO moderate/severe bleeding in patients with the Thr120 variant. The difference was driven by a lower rate in the smaller homozygous group (recessive model, HR 0.13 [0.02-0.92] P = 0.042). No significant differences were observed in the ischemic outcomes. The excess in bleeding observed with PAR1 inhibition was attenuated in patients with the Thr120 variant, but the interactions were not statistically significant. In summary, lower major bleeding rates were observed in the overall TRACER cohort with the hyperreactive PAR4 Thr120 variant. The increase in bleeding with vorapaxar was attenuated with the Thr120 variant, but we could not demonstrate an interaction with PAR1 inhibition. These findings warrant further exploration, including those of African ancestry where the A allele (Thr120) frequency is ~65%.
Collapse
Affiliation(s)
| | - Megan Neely
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Michael J Whitley
- The Cardeza Foundation for Hematologic Research and the Department of Medicine, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Leonard C Edelstein
- The Cardeza Foundation for Hematologic Research and the Department of Medicine, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Lukas M Simon
- Department of Human & Molecular Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Chad Shaw
- Department of Human & Molecular Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Statistics, Rice University, Houston, TX, USA
| | - Paolo Fortina
- Cancer Genomics and Bioinformatics Laboratory, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | | | - Philip Aylward
- Division of Medicine, Cardiac & Critical Care Services, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Harvey White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Lisa K Jennings
- CirQuest Labs, LLC, and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Claes Held
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala, Sweden
| | | | | | - Paul F Bray
- Division of Hematology and Hematologic Malignancies in the Department of Internal Medicine and the Molecular Medicine Program, University of Utah, Salt Lake City, UT, USA.
| |
Collapse
|
19
|
Inohara T, Pieper K, Wojdyla DM, Patel MR, Jones WS, Tricoci P, Mahaffey KW, James SK, Alexander JH, Lopes RD, Wallentin L, Ohman EM, Roe MT, Vemulapalli S. Incidence, timing, and type of first and recurrent ischemic events in patients with and without peripheral artery disease after an acute coronary syndrome. Am Heart J 2018; 201:25-32. [PMID: 29910052 DOI: 10.1016/j.ahj.2018.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/21/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) are known to have an increased risk of ischemic cardiovascular events. However, the influence of concomitant PAD on first and subsequent recurrent ischemic events after an acute coronary syndrome (ACS) remains poorly characterized. METHODS We analyzed the combined data set from 4 randomized trials (PLATO, APPRAISE-2, TRA-CER, and TRILOGY ACS) in ACS for a follow-up length of 1 year. Using multivariable regression, we examined the association between PAD and major adverse cardiovascular events, a composite of cardiovascular death, myocardial infarction, and stroke. Among patients with a nonfatal first event, we evaluated the incidence and type of a second recurrent event. RESULTS A total of 4,098 of 48,094 (8.5%) post-ACS patients had a history of PAD. The unadjusted frequency of major adverse cardiovascular events was 2-fold higher in patients with PAD (14.3% vs 7.5%) over a median (25th-75th) follow-up of 353 (223-365) days with an adjusted hazard ratio of 1.63 (95% CI: 1.48-1.78; P < .001). The frequency of recurrent ischemic events among those patients with a first, nonfatal event was higher among those with PAD (40.0% vs 27.7%). The relative frequency of each event type (cardiovascular death, noncardiovascular death, myocardial infarction, or stroke) within first and subsequent ischemic events was similar regardless of PAD status at baseline. CONCLUSIONS Patients with PAD have a significantly higher risk of first and recurrent ischemic events in the post-ACS setting. These findings highlight the opportunity for improved treatments in patients with PAD who experience an ACS.
Collapse
Affiliation(s)
- Taku Inohara
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University, Stanford, CA; Stanford Center for Clinical Research, Stanford, CA
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Erik Magnus Ohman
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | |
Collapse
|
20
|
Gibson CM, Yee M, Daaboul Y, Korjian S, Mehr AP, Kerneis M, Tricoci P, Alexander J, Kastelein J, Mehran R, Bode C, Lewis B, Mehta R, Duffy D, Feaster J, Halabi M, Angiolillo D, Duerschmied D, Ophius TO, Merkely B. THE SAFETY AND TOLERABILITY OF MULTIPLE DOSE ADMINISTRATION OF CSL112, AN INTRAVENOUS FORMULATION OF PLASMA-DERIVED APOA-I, AMONG SUBJECTS WITH MODERATE RENAL IMPAIRMENT AFTER ACUTE MYOCARDIAL INFARCTION. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30706-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
21
|
Guimarães PO, Leonardi S, Huang Z, Wallentin L, de Werf FV, Aylward PE, Held C, Harrington RA, Moliterno DJ, Armstrong PW, White HD, Alexander KP, Lopes RD, Mahaffey KW, Tricoci P. Clinical features and outcomes of patients with type 2 myocardial infarction: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J 2018; 196:28-35. [PMID: 29421012 DOI: 10.1016/j.ahj.2017.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/12/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Type 2 myocardial infarction (MI) is characterized by an imbalance between myocardial blood supply and demand, leading to myocardial ischemia without coronary plaque rupture, but its diagnosis is challenging. METHODS In the TRACER trial, patients with non-ST-segment elevation acute coronary syndromes were included. We aimed to describe provoking factors, cardiac biomarker profiles, treatment patterns, and clinical outcomes of patients with type 2 MIs. MI events during trial follow-up were adjudicated by an independent clinical events classification committee (CEC) and were classified according to the Third Universal Definition of MI. Using available source documents retrieved as part of the CEC process, we performed a retrospective chart abstraction to collect details on the type 2 MIs. Cox regression models were used to explore the association between MI type (type 1 or type 2) and cardiovascular death. RESULTS Overall, 10.3% (n=1327) of TRACER participants had a total of 1579 adjudicated MIs during a median follow-up of 502 days (25th and 75th percentiles [IQR] 349-667). Of all MIs, 5.2% (n=82) were CEC-adjudicated type 2 MIs, occurring in 76 patients. The incidence of type 2 MI was higher in the first month following randomization, after which the distribution became more scattered. The most frequent potential provoking factors for type 2 MIs were tachyarrhythmias (38.2%), anemia/bleeding (21.1%), hypotension/shock (14.5%), and hypertensive emergencies (11.8%). Overall, 36.3% had a troponin increase >10× the upper limit of normal. Coronary angiography was performed in 22.4% (n=17) of patients during hospitalizations due to type 2 MIs. The hazard of cardiovascular death was numerically higher following type 2 MI (vs. no MI, adj. HR 11.82, 95% CI 5.71-24.46; P<.0001) than that of type 1 MI (vs. no MI, adj. HR 8.90, 95% CI 6.93-11.43; P<.0001). CONCLUSIONS Type 2 MIs were more prevalent in the first month after ACS, were characterized by the presence of triggers and infrequent use of an invasive strategy, and were associated with a high risk of death. Further efforts are needed to better define the role and implications of type 2 MI in both clinical practice and research.
Collapse
|
22
|
Koshizaka M, Lopes RD, Newby LK, Clare RM, Schulte PJ, Tricoci P, Mahaffey KW, Ogawa H, Moliterno DJ, Giugliano RP, Huber K, James S, Harrington RA, Alexander JH. Obesity, Diabetes, and Acute Coronary Syndrome: Differences Between Asians and Whites. Am J Med 2017; 130:1170-1176. [PMID: 28396226 DOI: 10.1016/j.amjmed.2017.03.030] [Citation(s) in RCA: 7] [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] [Received: 02/23/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most diabetes and cardiovascular studies have been conducted in white patients, with data being extrapolated to other population groups. METHODS For this analysis, patient-level data were extracted from 5 randomized clinical trials in patients with acute coronary syndrome; we compared obesity levels between Asian and white populations, stratified by diabetes status. By using an adjusted Cox proportional hazards model, hazard ratios (HRs) for cardiovascular outcomes after an acute coronary syndrome were determined. RESULTS We identified 49,224 patient records from the 5 trials, with 3176 Asians and 46,048 whites. Whites with diabetes had higher body mass index values than those without diabetes (median 29.3 vs 27.2 kg/m2; P < .0001), whereas Asians with diabetes and without diabetes had similar body mass index (24.7 vs 24.2 kg/m2). Asians with diabetes (HR, 1.63; 95% confidence interval [CI], 1.32-2.02), whites with diabetes (HR, 1.15; 95% CI, 1.06-1.25), and Asians without diabetes (HR, 1.36; 95% CI, 1.14-1.64) had higher rates of the composite of death, myocardial infarction, or stroke at 30 days than whites without diabetes. Asians with diabetes (HR, 1.84; 95% CI, 1.47-2.31), whites with diabetes (HR, 1.47; 95% CI, 1.33-1.62), and Asians without diabetes (HR, 1.38; 95% CI, 1.11-1.73) had higher rates of death at 1 year compared with whites without diabetes. There were no significant interactions between race and diabetes for ischemic outcomes. CONCLUSIONS Although Asians with diabetes and acute coronary syndrome are less likely to be obese than their white counterparts, their risk for death or recurrent ischemic events was not lower.
Collapse
Affiliation(s)
- Masaya Koshizaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Division of Diabetes, Metabolism and Endocrinology, Clinical Research Center, Chiba University Hospital, Japan.
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Robert M Clare
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Phillip J Schulte
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Hisao Ogawa
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Boston, Mass
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Vienna, Austria
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University and Uppsala Clinical Research Center, Sweden
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| |
Collapse
|
23
|
Tricoci P, Neely M, Whitley M, Edelstein L, Simon L, Shaw C, Moliterno D, Armstrong P, White H, Van de Werf F, Jennings L, Wallentin L, Harrington R, Mahaffey K, Bray P. 3111Genetic variability in PAR4 platelet response in relation to bleeding and ischemic outcomes: a genetic substudy of the TRACER trial. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
24
|
Vranckx P, White HD, Huang Z, Mahaffey KW, Armstrong PW, Van de Werf F, Moliterno DJ, Wallentin L, Held C, Aylward PE, Cornel JH, Bode C, Huber K, Nicolau JC, Ruzyllo W, Harrington RA, Tricoci P. Validation of BARC Bleeding Criteria in Patients With Acute Coronary Syndromes: The TRACER Trial. J Am Coll Cardiol 2017; 67:2135-2144. [PMID: 27151345 DOI: 10.1016/j.jacc.2016.02.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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: 12/16/2015] [Revised: 02/09/2016] [Accepted: 02/24/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Bleeding Academic Research Consortium (BARC) scale has been proposed to standardize bleeding endpoint definitions and reporting in cardiovascular trials. Validation in large cohorts of patients is needed. OBJECTIVES This study sought to investigate the relationship between BARC-classified bleeding and mortality and compared its prognostic value against 2 validated bleeding scales: TIMI (Thrombolysis In Myocardial Infarction) and GUSTO (Global Use of Strategies to Open Occluded Arteries). METHODS We analyzed bleeding in 12,944 patients with acute coronary syndromes without ST-segment elevation, with or without early invasive strategy. The main outcome measure was all-cause death. RESULTS During follow-up (median: 502 days), noncoronary artery bypass graft (CABG) bleeding occurred in 1,998 (15.4%) patients according to BARC (grades 2, 3, or 5), 484 (3.7%) patients according to TIMI minor/major, and 514 (4.0%) patients according to GUSTO moderate/severe criteria. CABG-related bleeding (BARC 4) occurred in 155 (1.2%) patients. Patients with BARC (2, 3, or 4) bleeding had a significant increase in risk of death versus patients without bleeding (BARC 0 or 1); the hazard was highest in the 30 days after bleeding (hazard ratio: 7.35; 95% confidence interval: 5.59 to 9.68; p < 0.0001) and remained significant up to 1 year. The hazard of mortality increased progressively with non-CABG BARC grades. BARC 4 bleeds were significantly associated with mortality within 30 days (hazard ratio: 10.05; 95% confidence interval: 5.41 to 18.69; p < 0.0001), but not thereafter. Inclusion of BARC (2, 3, or 4) bleeding in the 1-year mortality model with baseline characteristics improved it to an extent comparable to TIMI minor/major and GUSTO moderate/severe bleeding. CONCLUSIONS In patients with acute coronary syndromes without ST-segment elevation, bleeding assessed with the BARC scale was significantly associated with risk of subsequent death up to 1 year after the event and risk of mortality increased gradually with higher BARC grades. Our results support adoption of the BARC bleeding scale in ACS clinical trials. (Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER] [Study P04736]; NCT00527943).
Collapse
Affiliation(s)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Zhen Huang
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philip E Aylward
- SAHMRI, Flinders University and Medical Centre, Adelaide, Australia
| | - Jan H Cornel
- Department of Cardiology, Medisch Centrum Alkmaar, Alkmaar, the Netherlands
| | - Christoph Bode
- Internal Medicine and Cardiology, Universitätsklinikum, Freiburg, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - José C Nicolau
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Witold Ruzyllo
- Department of Coronary Artery Disease and Cardiac Catheterization Laboratory, Institute of Cardiology, Warsaw, Poland
| | | | | |
Collapse
|
25
|
Hess CN, Clare RM, Neely ML, Tricoci P, Mahaffey KW, James SK, Alexander JH, Held C, Lopes RD, Fox KA, White HD, Wallentin L, Armstrong PW, Harrington RA, Ohman EM, Roe MT. Differential occurrence, profile, and impact of first recurrent cardiovascular events after an acute coronary syndrome. Am Heart J 2017; 187:194-203. [PMID: 28454804 DOI: 10.1016/j.ahj.2017.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Acute coronary syndrome (ACS) trials typically use a composite primary outcome (myocardial infarction [MI], stroke, or cardiovascular death), but differential patient characteristics, timing, and consequences associated with individual component end points as first events have not been well studied. We compared patient characteristics and prognostic significance associated with first cardiovascular events in the post-ACS setting for initially stabilized patients. METHODS We combined patient-level data from 4 trials of post-ACS antithrombotic therapies (PLATO, APPRAISE-2, TRACER, and TRILOGY ACS) to characterize the timing of and characteristics associated with first cardiovascular events (MI, stroke, or cardiovascular death). Landmark analysis at 7 days after index ACS presentation was used to focus on spontaneous, postdischarge events that were not confounded by in-hospital procedural complications. Using a competing risk framework, we tested for differential associations between prespecified covariates and the occurrence of nonfatal stroke vs MI as the first event, and we examined subsequent events after the first nonfatal event. RESULTS Among 46,694 patients with a median follow-up of 358 (25th, 75th percentiles 262, 486) days, a first ischemic event occurred in 4,307 patients (9.2%) as follows: MI in 5.8% (n = 2,690), stroke in 1.0% (n = 477), and cardiovascular death in 2.4% (n = 1,140). Older age, prior stroke/transient ischemic attack, prior atrial fibrillation, and higher diastolic blood pressure were associated with a significantly greater risk of stroke vs MI, whereas prior percutaneous coronary intervention was associated with a greater risk of MI vs stroke. Second events occurred in 32% of those with a first nonfatal stroke at a median of 13 (3, 59) days after the first event and in 32% of those with a first nonfatal MI at a median of 35 (5, 137) days after the first event. The most common second event was a recurrent MI among those with MI as the first event and cardiovascular death among those with stroke as the first event. CONCLUSIONS Approximately 9% of patients experienced a first cardiovascular event in the post-ACS setting during a median follow-up of 1 year. Although the profile and prognostic implications of stroke vs MI as the first nonfatal event differ substantially, approximately one-third of these patients experienced a second event, typically soon after the first event. These findings have implications for improving post-ACS care and influencing the design of future cardiovascular trials.
Collapse
|
26
|
Pagidipati NJ, Hess CN, Clare RM, Akerblom A, Tricoci P, Wojdyla D, Keenan RT, James S, Held C, Mahaffey KW, Klein AB, Wallentin L, Roe MT. An examination of the relationship between serum uric acid level, a clinical history of gout, and cardiovascular outcomes among patients with acute coronary syndrome. Am Heart J 2017; 187:53-61. [PMID: 28454808 PMCID: PMC9806969 DOI: 10.1016/j.ahj.2017.02.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/17/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Studies have suggested a relationship between higher baseline serum uric acid (sUA) levels and an elevated risk of subsequent ischemic cardiovascular outcomes among acute coronary syndrome (ACS) patients; this relationship may be modified by a clinical history of gout and has not been studied in large patient cohorts. We sought to understand the effect of sUA and gout on ACS outcomes. METHODS Using PLATO and TRACER data on 27,959 ACS patients, we evaluated baseline sUA levels in relation to a composite of cardiovascular death, myocardial infarction (MI), or stroke. We assessed interaction terms to determine if a baseline clinical diagnosis of gout modified this putative relationship; 46% (n=12,882) had sUA levels elevated >6.0 mg/dL. RESULTS Patients with elevated levels were more often male with a history of prior MI, diabetes, and heart failure compared with those with sUA <6.0 mg/dL. The unadjusted risk of the composite endpoint increased with corresponding elevations in sUA levels (per 1 mg/dL increase) (HR=1.23 [95% CI: 1.20-1.26]) above the statistical inflection point of 5.0 mg/dL. After adjustment, the association between sUA level and the composite outcome remained significant (HR=1.07 [95% CI: 1.04-1.10]), and baseline gout did not modify this relationship. CONCLUSIONS In patients with ACS, increasing levels of sUA are associated with an elevated risk of cardiovascular events, regardless of a clinical diagnosis of gout. Further investigation is warranted to determine the mechanism behind this relationship and to delineate whether sUA is an appropriate therapeutic target to reduce cardiovascular risk.
Collapse
Affiliation(s)
- Neha J. Pagidipati
- Duke University Health System, Duke Clinical Research Institute, Durham, NC
| | | | - Robert M. Clare
- Duke University Health System, Duke Clinical Research Institute, Durham, NC
| | - Axel Akerblom
- Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Pierluigi Tricoci
- Duke University Health System, Duke Clinical Research Institute, Durham, NC
| | - Daniel Wojdyla
- Duke University Health System, Duke Clinical Research Institute, Durham, NC
| | | | - Stefan James
- Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Claes Held
- Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | | | | | - Lars Wallentin
- Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Matthew T. Roe
- Duke University Health System, Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
27
|
Alfredsson J, Neely B, Neely ML, Bhatt DL, Goodman SG, Tricoci P, Mahaffey KW, Cornel JH, White HD, Fox KA, Prabhakaran D, Winters KJ, Armstrong PW, Ohman EM, Roe MT. Predicting the risk of bleeding during dual antiplatelet therapy after acute coronary syndromes. Heart 2017; 103:1168-1176. [PMID: 28381584 DOI: 10.1136/heartjnl-2016-310090] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Dual antiplatelet therapy (DAPT) with aspirin + a P2Y12 inhibitor is recommended for at least 12 months for patients with acute coronary syndrome (ACS), with shorter durations considered for patients with increased bleeding risk. However, there are no decision support tools available to predict an individual patient's bleeding risk during DAPT treatment in the post-ACS setting. METHODS To develop a longitudinal bleeding risk prediction model, we analy sed 9240 patients with unstable angina/non-ST segment elevation myocardial infarction (NSTEMI) from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial, who were managed without revasculari sation and treated with DAPT for a median of 14.8 months. RESULTS We identified 10 significant baseline predictors of non-coronary artery bypass grafting (CABG)-related Global Use of Strategies to Open Occluded Arteries (GUSTO) severe/life-threatening/moderate bleeding: age, sex, weight, NSTEMI (vs unstable angina), angiography performed before randomi sation, prior peptic ulcer disease, creatinine, systolic blood pressure, haemoglobin and treatment with beta-blocker. The five significant baseline predictors of Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding included age, sex, angiography performed before randomi sation, creatinine and haemoglobin. The models showed good predictive accuracy with Therneau's C-indices: 0.78 (SE = 0.024) for the GUSTO model and 0.67 (SE = 0.023) for the TIMI model. Internal validation with bootstrapping gave similar C-indices of 0.77 and 0.65, respectively. External validation demonstrated an attenuated C-index for the GUSTO model (0.69) but not the TIMI model (0.68). CONCLUSIONS Longitudinal bleeding risks during treatment with DAPT in patients with ACS can be reliably predicted using selected baseline characteristics. The TRILOGY ACS bleeding models can inform risk -benefit considerations regarding the duration of DAPT following ACS. TRIAL REGISTRATION ClinicalTrials.gov identifier: https://clinicaltrials.gov/ct2/show/NCT00699998.
Collapse
Affiliation(s)
- Joakim Alfredsson
- Duke Clinical Research Institute, Durham, USA.,Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, USA
| | - Shaun G Goodman
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, Toronto, Canada.,Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, Canada
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Durham, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, USA
| | | | - Jan H Cornel
- Medisch Centrum Alkmaar, Alkmaar, The Netherlands
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, Canada
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, USA
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, USA
| | | |
Collapse
|
28
|
Valgimigli M, Costa F, Lokhnygina Y, Clare RM, Wallentin L, Moliterno DJ, Armstrong PW, White HD, Held C, Aylward PE, Van de Werf F, Harrington RA, Mahaffey KW, Tricoci P. Trade-off of myocardial infarction vs. bleeding types on mortality after acute coronary syndrome: lessons from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) randomized trial. Eur Heart J 2017; 38:804-810. [PMID: 28363222 PMCID: PMC5837470 DOI: 10.1093/eurheartj/ehw525] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/20/2016] [Accepted: 10/06/2016] [Indexed: 11/12/2022] Open
Abstract
AIMS Dual antiplatelet therapy reduces non-fatal ischaemic events after acute coronary syndrome (ACS) but increases bleeding to a similar extent. We sought to determine the prognostic impact of myocardial infarction (MI) vs. bleeding during an extended follow-up period to gain insight into the trade-off between efficacy and safety among patients after ACS. METHODS AND RESULTS In 12 944 patients with non-ST-segment elevation ACS from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial, we investigated the relative impact of MI and bleeding occurring >30 days post-ACS and subsequent all-cause mortality. Bleeding was graded according to Bleeding Academic Research Consortium (BARC) criteria. MI was associated with a five-fold increase in mortality. BARC type 2 and 3, but not type 1, bleeding had a significant impact on mortality. MI was associated with a greater risk of mortality compared with BARC 2 [relative risk (RR) 3.5; 95% confidence interval (CI) 2.08-4.77; P < 0.001] and BARC 3a bleeding (RR 2.23; 95% CI 1.36-3.64; P = 0.001), and a risk similar to BARC 3b bleeding (RR 1.37; 95% CI 0.81-2.30; P = 0.242). Risk of death after MI was significantly lower than after BARC 3c bleeding (RR 0.22; 95% CI 0.13-0.36; P < 0.001). MI and bleeding had similar time-associations with mortality, which remained significant for several months, still being higher early after the event. CONCLUSION In patients treated with antiplatelet therapy after ACS, both MI and bleeding significantly impacted mortality with similar time-dependency. Although BARC 2 and 3a bleeding were less prognostic for death than MI, the risk of mortality was equivalent between BARC 3b bleeding and MI, and was higher following BARC 3c bleeding.
Collapse
Affiliation(s)
- Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, CH-3010 Bern, Switzerland
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Francesco Costa
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Clinical and Experimental Medicine, Policlinic ‘G. Martino’, University of Messina, Messina, Italy
| | | | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David J. Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | | | - Harvey D. White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philip E. Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, SA, Australia
| | | | | | | | | |
Collapse
|
29
|
Tricoci P. Consensus or Controversy?: Evolution of Criteria for Myocardial Infarction After Percutaneous Coronary Intervention. Clin Chem 2017; 63:82-90. [DOI: 10.1373/clinchem.2016.255208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 09/20/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The definition and the clinical implications of myocardial infarction (MI) occurring in the setting of percutaneous coronary intervention have been subjects of unresolved controversy. As a result of the use of more sensitive diagnostic tools such as cardiac troponin, the expanding evidence, and the ensuing debate, the definition of procedural MI (pMI) has evolved, leading to several revisions, different proposed definitions, and lack of standardization in randomized clinical trials.
CONTENT
In this review, we will describe the key clinical data on cardiac biomarkers, creatine kinase isoenzyme MB and cTn, in the setting of percutaneous coronary intervention and the main issues that have lead to various consensus documents with a proposed definition of pMI. We will focus on the rationale of the current “Third Universal Definition of Myocardial Infarction” and of the alternative approach proposed by the Society for Cardiovascular Angiography and Interventions.
SUMMARY
The definition of pMI is an evolving field where the Third Universal MI definition represents the best attempt to date to incorporate available evidence along with scientific and clinical judgment into criteria to ensure adequate specificity in the diagnosis and the relevant prognostic significance, while trying to maintain sensitivity. Questions on the recommended criteria and their practical implementation remain, but the Third Universal definition document represents an important milestone toward a better standardization and enhanced consensus on the pMI definition.
Collapse
Affiliation(s)
- Pierluigi Tricoci
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| |
Collapse
|
30
|
Popma CJ, Sheng S, Korjian S, Daaboul Y, Chi G, Tricoci P, Huang Z, Moliterno DJ, White HD, Van de Werf F, Harrington RA, Wallentin L, Held C, Armstrong PW, Aylward PE, Strony J, Mahaffey KW, Gibson CM. Lack of Concordance Between Local Investigators, Angiographic Core Laboratory, and Clinical Event Committee in the Assessment of Stent Thrombosis: Results From the TRACER Angiographic Substudy. Circ Cardiovasc Interv 2016; 9:e003114. [PMID: 27162212 DOI: 10.1161/circinterventions.115.003114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 08/21/2015] [Accepted: 03/16/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stent thrombosis (ST) is an important end point in cardiovascular clinical trials. Adjudication is traditionally based on clinical event committee (CEC) review of case report forms and source documentation rather than angiograms. However, the degree to which this method of adjudication is concordant with the review of independent angiographic core laboratories (ACLs) has not been studied. This report represents the first assessment of variability between local investigators (LIs), a CEC, and an ACL. METHODS AND RESULTS Serial angiograms of 329 patients with acute coronary syndrome without ST-segment-elevation who underwent percutaneous coronary intervention at entry in the Trial to Assess the Effects of Vorapaxar in Preventing Heart Attack and Stroke in Particpants With Acute Coronary Syndrome (TRACER) and who met criteria for possible ST subsequent to the index event were reviewed by an ACL. The ACL was blinded to the assessment by both LIs and the CEC regarding the presence or absence of ST. CEC adjudication was based on Academic Research Consortium definitions of ST, using case report form data and source documents, including catheterization laboratory reports. The ACL, CEC, and LIs agreed on the presence or absence of ST in 52.9% events (κ=0.32; 95% confidence interval, 0.26-0.39). The ACL and CEC agreed on 82.7% of events (κ=0.57; 95% confidence interval, 0.47-0.67); the ACL and LIs agreed on 61.1% of events (κ=0.25; 95% confidence interval, 0.16-0.34); and the CEC and LIs agreed on 62% of events (κ=0.28; 95% confidence interval, 0.21-0.36). CONCLUSIONS ST reporting by an ACL, a CEC, and LIs is discordant. The assessment of ST is more often detected by direct review of angiograms by an ACL. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00527943.
Collapse
Affiliation(s)
- Christopher J Popma
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Shi Sheng
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Serge Korjian
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Yazan Daaboul
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Gerald Chi
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Pierluigi Tricoci
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Zhen Huang
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - David J Moliterno
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Harvey D White
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Frans Van de Werf
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Robert A Harrington
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Lars Wallentin
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Claes Held
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Paul W Armstrong
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Philip E Aylward
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - John Strony
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - Kenneth W Mahaffey
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.)
| | - C Michael Gibson
- From the Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.J.P., S.K., Y.D., G.C., C.M.G.); Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.S.); Duke Clinical Research Institute, Durham, NC (P.T., Z.H.); Department of Medicine, Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Cardiology, University of Leuven, Leuven, Belgium (F.V.d.W.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W., C.H.); Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Cardiac and Critical Care Services, Department of Medicine, South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.); and Merck Clinical Research, Merck & Co, Whitehouse Station, NJ (J.S.).
| |
Collapse
|
31
|
Abstract
Thrombin is a potent platelet agonist, and protease-activated receptor-1 (PAR-1) is the main thrombin receptor in human platelets and thrombin. PAR-1 antagonism has attracted interest as a potential therapeutic target to reduce atherothrombotic events in patients with atherosclerotic disease, especially coronary artery disease. In this review, the author describes the rationale of PAR-1 antagonism for the reduction of atherothrombotic events and reviews the key phase 3 trial results, with special attention to analyses in percutaneous coronary intervention patients.
Collapse
Affiliation(s)
- Pierluigi Tricoci
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, 0311 Terrace Level, Box 3850 DUMC, Durham, NC 27705, USA.
| |
Collapse
|
32
|
Michael Gibson C, Korjian S, Tricoci P, Daaboul Y, Yee M, Jain P, Alexander JH, Steg PG, Lincoff AM, Kastelein JJP, Mehran R, D'Andrea DM, Deckelbaum LI, Merkely B, Zarebinski M, Ophuis TO, Harrington RA. Safety and Tolerability of CSL112, a Reconstituted, Infusible, Plasma-Derived Apolipoprotein A-I, After Acute Myocardial Infarction: The AEGIS-I Trial (ApoA-I Event Reducing in Ischemic Syndromes I). Circulation 2016; 134:1918-1930. [PMID: 27881559 PMCID: PMC5147036 DOI: 10.1161/circulationaha.116.025687] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/22/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human or recombinant apolipoprotein A-I (apoA-I) has been shown to increase high-density lipoprotein-mediated cholesterol efflux capacity and to regress atherosclerotic disease in animal and clinical studies. CSL112 is an infusible, plasma-derived apoA-I that has been studied in normal subjects or those with stable coronary artery disease. This study aimed to characterize the safety, tolerability, pharmacokinetics, and pharmacodynamics of CSL112 in patients with a recent acute myocardial infarction. METHODS The AEGIS-I trial (Apo-I Event Reducing in Ischemic Syndromes I) was a multicenter, randomized, double-blind, placebo-controlled, dose-ranging phase 2b trial. Patients with myocardial infarction were stratified by renal function and randomized 1:1:1 to CSL112 (2 g apoA-I per dose) and high-dose CSL112 (6 g apoA-I per dose), or placebo for 4 consecutive weekly infusions. Coprimary safety end points were occurrence of either a hepatic safety event (an increase in alanine transaminase >3 times the upper limit of normal or an increase in total bilirubin >2 times the upper limit of normal) or a renal safety event (an increase in serum creatinine >1.5 times the baseline value or a new requirement for renal replacement therapy). RESULTS A total of 1258 patients were randomized, and 91.2% received all 4 infusions. The difference in incidence rates for an increase in alanine transaminase or total bilirubin between both CSL112 arms and placebo was within the protocol-defined noninferiority margin of 4%. Similarly, the difference in incidence rates for an increase in serum creatinine or a new requirement for renal replacement therapy was within the protocol-defined noninferiority margin of 5%. CSL112 was associated with increases in apoA-I and ex vivo cholesterol efflux similar to that achieved in patients with stable coronary artery disease. In regard to the secondary efficacy end point, the risk for the composite of major adverse cardiovascular events among the groups was similar. CONCLUSIONS Among patients with acute myocardial infarction, 4 weekly infusions of CSL112 are feasible, well tolerated, and not associated with any significant alterations in liver or kidney function or other safety concern. The ability of CSL112 to acutely enhance cholesterol efflux was confirmed. The potential benefit of CSL112 to reduce major adverse cardiovascular events needs to be assessed in an adequately powered phase 3 trial. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT02108262.
Collapse
Affiliation(s)
- C Michael Gibson
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
| | - Serge Korjian
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Pierluigi Tricoci
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Yazan Daaboul
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Megan Yee
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Purva Jain
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John H Alexander
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - P Gabriel Steg
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - A Michael Lincoff
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John J P Kastelein
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Roxana Mehran
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Denise M D'Andrea
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Lawrence I Deckelbaum
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Bela Merkely
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Maciej Zarebinski
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Ton Oude Ophuis
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert A Harrington
- From PERFUSE Study Group, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA (C.M.G., S.K., Y.D., M.Y., P.J.); Duke Clinical Research Institute, Cardiovascular Division, Department of Medicine, Duke University Health, Durham, NC (P.T., J.H.A.); INSERM-Unité 1148, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France Université Paris-Diderot, Sorbonne- Paris Cité, France National Heart and Lung Institute, Paris, France (P.G.S.); Imperial College London, UK Institute of Cardiovascular Medicine and Science, and Royal Brompton Hospital, London, UK (P.G.S.); Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH (A.M.L.); Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (J.J.P.K.); Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York (R.M.); CSL Behring, LLC, King of Prussia, PA (D.M.D., L.I.D.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Department of Cardiology, Warsaw Medical University, Warsaw, Poland (M.Z.); Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands (T.O.O.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| |
Collapse
|
33
|
Gibson CM, Korjian S, Tricoci P, Daaboul Y, Alexander JH, Steg PG, Lincoff AM, Kastelein JJ, Mehran R, D'Andrea D, Merkely B, Zarebinski M, Ophius TO, Harrington RA. Rationale and design of Apo-I Event Reduction in Ischemic Syndromes I (AEGIS-I): A phase 2b, randomized, placebo-controlled, dose-ranging trial to investigate the safety and tolerability of CSL112, a reconstituted, infusible, human apoA-I, after acute myocardial infarction. Am Heart J 2016; 180:22-8. [PMID: 27659879 DOI: 10.1016/j.ahj.2016.06.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite aggressive pharmacotherapy and stenting, there is a residual risk of major adverse cardiovascular events among patients with acute coronary syndrome. High-density lipoprotein (HDL) has been a major target for secondary acute coronary syndrome prevention; however, a better understanding of the physiologic function of HDL has demonstrated that a high cholesterol efflux capacity, rather than high HDL concentrations alone, may be critical to improving outcomes. CSL112, a reconstituted, infusible human apolipoprotein A-I, has been demonstrated to increase cholesterol efflux capacity and to have a protective effect in experimental models of atherosclerotic cardiovascular disease. DESIGN The AEGIS-I trial (ClinicalTrials.govNCT02108262) is a phase 2b, multicenter, randomized, placebo-controlled, dose-ranging clinical trial to evaluate the hepatic and renal safety of multiple administrations of 2 doses of CSL112 among subjects with acute myocardial infarction (AMI). Approximately 1,200 subjects (400 per treatment group) with either normal renal function or mild renal impairment will be enrolled up to 7 days after an AMI and will be stratified by renal function and randomized in a 1:1:1 ratio to either 1 of 2 doses of CSL112 (either 2 g or 6 g) or placebo as a weekly 2-hour infusion over the course of 4 consecutive weeks. The coprimary safety endpoints will be the incidence of hepatic and renal toxicity, defined as either confirmed ALT >3 × ULN, total bilirubin >2 × ULN, serum creatinine ≥1.5×baseline value, or a new requirement for renal replacement therapy through the end of the active treatment period. SUMMARY The AEGIS-I trial will characterize the safety profile of CSL112, a reconstituted formulation of apolipoprotein A-I, and will assess if administration to patients with a recent AMI is associated with a clinically significant alteration in either liver or kidney function when compared with placebo.
Collapse
|
34
|
Åkerblom A, Clare RM, Lokhnygina Y, Wallentin L, Held C, Van de Werf F, Moliterno DJ, Patel UD, Leonardi S, Armstrong PW, Harrington RA, White HD, Aylward PE, Mahaffey KW, Tricoci P. Albuminuria and cardiovascular events in patients with acute coronary syndromes: Results from the TRACER trial. Am Heart J 2016; 178:1-8. [PMID: 27502846 DOI: 10.1016/j.ahj.2016.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Albuminuria is associated with cardiovascular (CV) outcomes. We evaluated albuminuria, alone and in combination with estimated glomerular filtration rate (eGFR), as a predictor of mortality and CV morbidity in 12,944 patients with non-ST-segment elevation acute coronary syndromes. METHODS Baseline serum creatinine and urinary dipsticks were obtained, with albuminuria stratified into no/trace albuminuria, microalbuminuria (≥30 but <300 mg/dL), or macroalbuminuria (≥300 mg/dL). Kaplan-Meier rates and proportional Cox hazards models of CV death, overall mortality, CV death or myocardial infarction (MI), and bleeding were calculated. Incidence of acute kidney injury, identified by adverse event reporting and creatinine increase (absolute ≥0.3 mg/dL or relative ≥50%), was descriptively reported. RESULTS Both dipstick albuminuria and creatinine values were available in 9473 patients (73.2%). More patients with macroalbuminuria, versus no/trace albuminuria, had diabetes (66% vs 27%) or hypertension (86% vs 68%). Rates for CV death and overall mortality per strata were 3.1% and 4.8% (no/trace albuminuria); 5.8% and 9.0% (microalbuminuria); and 7.7% and 12.6% (macroalbuminuria) at 2 years of follow-up. Corresponding rates for CV death or MI were 12.2%, 16.9%, and 23.5%, respectively. Observed acute kidney injury rates were 0.6%, 1.2%, and 2.9% (n = 79), respectively. Adjusted HRs for macroalbuminuria on CV mortality were 1.65 (95% CI 1.15-2.37), and after adjustment with eGFR, 1.37 (95% CI 0.93-2.01). Corresponding HRs for overall mortality were 1.82 (95% CI 1.37-2.42) and 1.47 (95% CI 1.08-1.98). CONCLUSIONS High-risk patients with non-ST-segment elevation acute coronary syndromes and albuminuria have increased morbidity and increased overall mortality independent of eGFR.
Collapse
Affiliation(s)
- Axel Åkerblom
- Duke Clinical Research Institute, Durham, NC; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala, Sweden.
| | | | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | | | | | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | | |
Collapse
|
35
|
Armaganijan LV, Alexander KP, Huang Z, Tricoci P, Held C, Van de Werf F, Armstrong PW, Aylward PE, White HD, Moliterno DJ, Wallentin L, Chen E, Harrington RA, Strony J, Mahaffey KW, Lopes RD. Effect of age on efficacy and safety of vorapaxar in patients with non-ST-segment elevation acute coronary syndrome: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J 2016; 178:176-84. [PMID: 27502866 DOI: 10.1016/j.ahj.2016.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antithrombotic therapy plays an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS) but is associated with bleeding risk. Advanced age may modify the relationship between efficacy and safety. METHODS Efficacy and safety of vorapaxar (a protease-activated receptor 1 antagonist) was analyzed across ages as a continuous and a categorical variable in the 12,944 patients with NSTE ACS enrolled in the TRACER trial. To evaluate the effect of age, Cox regression models were developed to estimate hazard ratios (HRs) with the adjustment of other baseline characteristics and randomized treatment for the primary efficacy composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization, and the primary safety composite of moderate or severe Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding. RESULTS The median age of the population was 64years (25th, 75th percentiles = 58, 71). Also, 1,791 patients (13.8%) were ≤54years of age, 4,968 (38.4%) were between 55 and 64 years, 3,979 (30.7%) were between 65 and 74 years, and 2,206 (17.1%) were 75years or older. Older patients had higher rates of hypertension, renal insufficiency, and previous stroke and worse Killip class. The oldest age group (≥75years) had substantially higher 2-year rates of the composite ischemic end point and moderate or severe GUSTO bleeding compared with the youngest age group (≤54years). The relationships between treatment assignment (vorapaxar vs placebo) and efficacy outcomes did not vary by age. For the primary efficacy end point, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were as follows: 1.12 (0.88-1.43), 0.88 (0.76-1.02), 0.89 (0.76-1.04), and 0.88 (0.74-1.06), respectively (P value for interaction = .435). Similar to what was observed for efficacy outcomes, we did not observe any interaction between vorapaxar and age on bleeding outcomes. For the composite of moderate or severe bleeding according to the GUSTO classification, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were 1.73 (0.89-3.34), 1.39 (1.04-1.86), 1.10 (0.85-1.42), and 1.73 (1.29-2.33), respectively (P value for interaction = .574). CONCLUSION Older patients had a greater risk for ischemic and bleeding events; however, the efficacy and safety of vorapaxar in NSTE ACS were not significantly influenced by age.
Collapse
Affiliation(s)
| | | | - Zhen Huang
- Duke Clinical Research Institute, Durham, NC
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Frans Van de Werf
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Center, Adelaide, Australia
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland, New Zealand
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Edmond Chen
- Bayer HealthCare Pharmaceuticals Inc, Whippany, NJ
| | | | | | | | | |
Collapse
|
36
|
Zimerman A, Lopes RD, Stebbins AL, Guimarães PO, Haque G, Melloni C, Trollinger K, James SK, Alexander JH, Tricoci P, Roe MT, Ohman EM, Mahaffey KW, Held C, Tinga B, Pieper KS, Alexander KP. Pooled analysis of adverse event collection from 4 acute coronary syndrome trials. Am Heart J 2016; 174:60-7. [PMID: 26995371 DOI: 10.1016/j.ahj.2016.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Adverse event collection in randomized clinical trials establishes drug safety. Although costly and regulated, it is rarely studied. METHODS Adverse event data from 4 clinical trials (APPRAISE-2, PLATO, TRACER, TRILOGY ACS) comprising 48,118 participants with acute coronary syndromes were pooled to compare patterns and determinants of reporting. Events were classified as serious (SAE) or nonserious (AE) from hospital discharge to 1 year; study end points were excluded. RESULTS In total, 84,901 events were reported. Of those, 12,266 (14.4%) were SAEs and 72,635 (85.6%) were AEs. Of all participants, 7,823 (16.3%) had SAEs, 18,124 (37.7%) had only AEs, and 22,171 (46.1%) had neither. Nonserious adverse events were distributed across system organ classes: general disorders (11%), infection (10%), gastrointestinal (10%), respiratory (9%), cardiovascular (8.4%), and other (35%). Serious adverse events had a higher proportion of cardiovascular causes (14.0%). Event reporting was highest after hospital discharge, decreasing rapidly during the following 3 months. In a Cox proportional hazards model, chronic obstructive pulmonary disease (hazard ratio 1.58, 95% CI 1.44-1.74), heart failure (1.55, 1.40-1.70), older age, and female sex were independent predictors of more SAEs, whereas enrollment in Eastern Europe (0.63, 0.58-0.69) or Asia (0.84, 0.75-0.94) were independent predictors of fewer SAEs. CONCLUSIONS Half of all participants reported adverse events in the year after acute coronary syndrome; most were AEs and occurred within 3 months. The high volume of events, as well as the variation in SAE reporting by characteristics and enrollment region, indicates that efforts to refine event collection in large trials are warranted.
Collapse
|
37
|
Hess PL, Wojdyla DM, Al-Khatib SM, Lokhnygina Y, Wallentin L, Armstrong PW, Roe MT, Ohman EM, Harrington RA, Alexander JH, White HD, Van de Werf F, Piccini JP, Held C, Aylward PE, Moliterno DJ, Mahaffey KW, Tricoci P. Sudden Cardiac Death After Non–ST-Segment Elevation Acute Coronary Syndrome. JAMA Cardiol 2016; 1:73-9. [DOI: 10.1001/jamacardio.2015.0359] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul L. Hess
- Veterans Affairs Eastern Colorado and Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine, Aurora
| | | | - Sana M. Al-Khatib
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Matthew T. Roe
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - E. Magnus Ohman
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | | | - John H. Alexander
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Harvey D. White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Jonathan P. Piccini
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philip E. Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - David J. Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington
| | | | - Pierluigi Tricoci
- Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| |
Collapse
|
38
|
Kragholm K, Goldstein SA, Yang Q, Lopes RD, Schulte PJ, Bernacki GM, White HD, Mahaffey KW, Giugliano RP, Armstrong PW, Harrington RA, Tricoci P, Van de Werf F, Alexander JH, Alexander KP, Newby LK. Trends in Enrollment, Clinical Characteristics, Treatment, and Outcomes According to Age in Non-ST-Segment-Elevation Acute Coronary Syndromes Clinical Trials. Circulation 2016; 133:1560-73. [PMID: 26957532 DOI: 10.1161/circulationaha.115.017299] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/01/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Representation by age ensures appropriate translation of clinical trial results to practice, but, historically, older patients have been underrepresented in clinical trial populations. As the general population has aged, it is unknown whether clinical trial enrollment has changed in parallel. METHODS AND RESULTS We studied time trends in enrollment, clinical characteristics, treatment, and outcomes by age among 76 141 patients with non-ST-segment-elevation acute coronary syndrome enrolled in 11 phase III clinical trials over 17 years (1994-2010). Overall, 19.7% of patients were ≥75 years; this proportion increased from 16% during 1994 to 1997 to 21% during 1998 to 2001 and 23.2% during 2002 to 2005, but declined to 20.2% in 2006 to 2010. The number of comorbidities increased with successive time periods irrespective of age. There were substantial increases in the use of evidence-based medication in-hospital and at discharge regardless of age. Although predicted 6-month mortality increased slightly over time, observed 6-month mortality declined significantly in all age strata (1994-1997 versus 2006-2010: <65 years: 3.0% versus 1.9%; 65-74 years: 7.5% versus 3.4%; 75-79 years: 13.0% versus 6.5%; 80-84 years: 17.6% versus 8.2%; and ≥85 years: 24.8% versus 12.6%). CONCLUSIONS The distribution of enrollment by age in phase III non-ST-segment-elevation acute coronary syndrome trials was unchanged over time. Irrespective of age, post-myocardial infarction mortality decreased significantly over time, concurrent with increased evidence-based care and despite increasing comorbidities. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00089895.
Collapse
Affiliation(s)
- Kristian Kragholm
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Sarah A Goldstein
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Qinghong Yang
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Renato D Lopes
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Phillip J Schulte
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Gwen M Bernacki
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Harvey D White
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Kenneth W Mahaffey
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Robert P Giugliano
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Paul W Armstrong
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Robert A Harrington
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Pierluigi Tricoci
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Frans Van de Werf
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - John H Alexander
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - Karen P Alexander
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.)
| | - L Kristin Newby
- From Duke Clinical Research Institute, Durham, NC (K.K., S.A.G., Q.Y., R.D.L., P.J.S., G.M.B., J.H.A., K.P.A., L.K.N.); Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.); Department of Medicine, Stanford University, CA (K.W.M., R.A.H.,); Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); and Department of Cardiology, University Hospitals Leuven, Belgium (F.V.d.W.).
| |
Collapse
|
39
|
Harskamp RE, Clare RM, Ambrosio G, Held C, Lokhnygina Y, Moliterno DJ, White HD, Aylward PE, Armstrong PW, Mahaffey KW, Harrington RA, Van de Werf F, Wallentin L, Strony J, Tricoci P. Use of thienopyridine prior to presentation with non-ST-segment elevation acute coronary syndrome and association with safety and efficacy of vorapaxar: insights from the TRACER trial. Eur Heart J Acute Cardiovasc Care 2016; 6:155-163. [PMID: 26895973 DOI: 10.1177/2048872616633880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vorapaxar is effective in the prevention of secondary atherothrombotic events, although the efficacy/safety balance appears less favorable in the treatment of patients with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS). We hypothesized that patients with NSTE ACS already receiving thienopyridine prior to the ACS event may show differential efficacy/safety effects with vorapaxar vs. placebo added to their standard care. METHODS We studied 12,944 patients from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial with respect to thienopyridine use before admission for the index NSTE ACS event. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, rehospitalization for ischemia, and urgent revascularization. The key secondary endpoint was a composite of cardiovascular death, myocardial infarction, and stroke. Safety endpoints were bleeding complications. RESULTS Only 1513 patients (11.7%) were receiving thienopyridine before admission for the index NSTE ACS event. In these patients, Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) moderate/severe bleeding occurred in 5.7% treated with vorapaxar and 5.3% treated with a placebo (hazards ratio (HR) 1.10, 95% confidence interval (CI) 0.70-1.71); in thienopyridine-naïve patients, the rates were 5.7% and 4.1%, respectively (HR 1.32, 95% CI 1.11-1.57; Pint=0.45). GUSTO severe bleeding in the prior thienopyridine group occurred in 0.5% of patients treated with vorapaxar and 1.3% of patients treated with placebo (HR 0.34, 95% CI 0.09-1.30); in thienopyridine-naïve patients, the rates were 2.0% and 1.0%, respectively (HR 1.89, 95% CI 1.36-2.62; Pint=0.01). No interaction was observed between vorapaxar efficacy and prior thienopyridine use on the primary (adjusted Pint=0.53) or key secondary endpoints ( Pint=0.61). CONCLUSIONS TRACER was largely conducted in thienopyridine-naïve patients with unknown tolerance to multiple antiplatelet treatments. Patients receiving thienopyridine before the index event may have had an attenuated increase in bleeding when adding vorapaxar, whereas concomitantly adding vorapaxar and thienopyridine in naïve patients may have uncovered a latent susceptibility to bleeding.
Collapse
Affiliation(s)
- Ralf E Harskamp
- 1 Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Giuseppe Ambrosio
- 3 Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | - Claes Held
- 4 Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - David J Moliterno
- 5 Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Harvey D White
- 6 Green Lane Cardiovascular Service, Auckland City Hospital and Auckland University, Auckland, New Zealand
| | - Philip E Aylward
- 7 SAHMRI, Flinders University and Medical Centre, Adelaide, Australia
| | - Paul W Armstrong
- 8 Division of Cardiology, University of Alberta, Edmonton, Canada
| | | | | | | | - Lars Wallentin
- 4 Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John Strony
- 11 Johnson & Johnson, New Brunswick, NJ, USA.,12 Merck, Whitehouse Station, NJ, USA
| | | |
Collapse
|
40
|
Déry JP, Mahaffey KW, Tricoci P, White HD, Podder M, Westerhout CM, Moliterno DJ, Harrington RA, Chen E, Strony J, Van de Werf F, Ziada KM, Held C, Aylward PE, Armstrong PW, Rao SV. Arterial access site and outcomes in patients undergoing percutaneous coronary intervention with and without vorapaxar. Catheter Cardiovasc Interv 2015; 88:163-73. [DOI: 10.1002/ccd.26335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/24/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Jean-Pierre Déry
- Department of Cardiology and Cardiovascular Surgery; Institut Universitaire De Cardiologie Et De Pneumologie De Québec, Laval University; Quebec City Canada
| | - Kenneth W. Mahaffey
- Department of Medicine; Department of Medicine; Stanford University; Stanford California
| | - Pierluigi Tricoci
- Department of Medicine; Duke Clinical Research Institute; Durham North Carolina
| | - Harvey D. White
- Department of Cardiology; Green Lane Cardiovascular Service; Auckland New Zealand
| | - Mohua Podder
- Department of Economics; Canadian VIGOUR Centre, University of Alberta; Edmonton Alberta Canada
| | - Cynthia M. Westerhout
- Department of Economics; Canadian VIGOUR Centre, University of Alberta; Edmonton Alberta Canada
| | - David J. Moliterno
- Department of Internal Medicine; Gill Heart Institute and Division of Cardiovascular Medicine; University of Kentucky; Lexington Kentucky
| | - Robert A. Harrington
- Department of Medicine; Department of Medicine; Stanford University; Stanford California
| | - Edmond Chen
- Bayer HealthCare Pharmaceuticals; Department of Internal Medicine; Bayer HealthCare Pharmaceuticals; Whippany New Jersey
| | | | - Frans Van de Werf
- Department of Cardiovascular Sciences; University Hospitals Leuven; Belgium
| | - Khaled M. Ziada
- Department of Internal Medicine; Gill Heart Institute and Division of Cardiovascular Medicine; University of Kentucky; Lexington Kentucky
| | - Claes Held
- Department of Medical Sciences; Uppsala Clinical Research Center, Uppsala University; Sweden
| | - Philip E. Aylward
- Division of Medicine; SAHMRI, Flinders University and Medical Center; Adelaide Australia
| | - Paul W. Armstrong
- Department of Economics; Canadian VIGOUR Centre, University of Alberta; Edmonton Alberta Canada
| | - Sunil V. Rao
- Department of Medicine; Duke Clinical Research Institute; Durham North Carolina
| |
Collapse
|
41
|
van Diepen S, Tricoci P, Podder M, Westerhout CM, Aylward PE, Held C, Van de Werf F, Strony J, Wallentin L, Moliterno DJ, White HD, Mahaffey KW, Harrington RA, Armstrong PW. Efficacy and Safety of Vorapaxar in Non-ST-Segment Elevation Acute Coronary Syndrome Patients Undergoing Noncardiac Surgery. J Am Heart Assoc 2015; 4:JAHA.115.002546. [PMID: 26672080 PMCID: PMC4845287 DOI: 10.1161/jaha.115.002546] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 11/22/2022]
Abstract
Background Perioperative antiplatelet agents potentially increase bleeding after non–ST‐segment elevation (NSTE) acute coronary syndromes (ACS). The protease‐activated receptor 1 antagonist vorapaxar reduced cardiovascular events and was associated with increased bleeding versus placebo in NSTE ACS, but its efficacy and safety in noncardiac surgery (NCS) remain unknown. We aimed to evaluate ischemic, bleeding, and long‐term outcomes of vorapaxar in NCS after NSTE ACS. Methods and Results In the TRACER trial, 2202 (17.0%) patients underwent major or minor NCS after NSTE ACS over 1.5 years (median); continuing study treatment perioperatively was recommended. The primary ischemic end point for this analysis was cardiovascular death, myocardial infarction, stent thrombosis, or urgent revascularization within 30 days of NCS. Safety outcomes included 30‐day NCS bleeding and GUSTO moderate/severe bleeding. Overall, 1171 vorapaxar and 1031 placebo patients underwent NCS. Preoperative aspirin and thienopyridine use was 96.8% versus 97.7% (P=0.235) and 89.1% versus 86.1% (P=0.036) for vorapaxar versus placebo, respectively. Within 30 days of NCS, no differences were observed in the primary ischemic end point between vorapaxar and placebo groups (3.4% versus 3.9%; adjusted odds ratio 0.81, 95% CI 0.50 to 1.33, P=0.41). Similarly, no differences in NCS bleeding (3.9% versus 3.4%; adjusted odds ratio 1.41, 95% CI 0.87 to 2.31, P=0.17) or GUSTO moderate/severe bleeding (4.2% versus 3.7%; adjusted odds ratio 1.15, 95% CI, 0.72 to 1.83, P=0.55) were observed. In a 30‐day landmarked analysis, NCS patients had a higher long‐term risk of the ischemic end point (adjusted hazard ratio 1.62, 95% CI 1.33 to 1.97, P<0.001) and GUSTO moderate/severe bleeding (adjusted hazard ratio 5.63, 95% CI 3.98 to 7.97, P<0.001) versus patients who did not undergo NCS, independent of study treatment. Conclusion NCS after NSTE ACS is common and associated with more ischemic outcomes and bleeding. Vorapaxar after NSTE ACS was not associated with increased perioperative ischemic or bleeding events in patients undergoing NCS.
Collapse
Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada (S.D.) Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (S.D., M.P., C.M.W., P.W.A.)
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (P.T.)
| | - Mohua Podder
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (S.D., M.P., C.M.W., P.W.A.)
| | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (S.D., M.P., C.M.W., P.W.A.)
| | - Philip E Aylward
- SAHMRI, Flinders University and Medical Centre, Adelaide, Australia (P.E.A.)
| | - Claes Held
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala, Sweden (C.H., L.W.)
| | | | | | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala, Sweden (C.H., L.W.)
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.)
| | | | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (S.D., M.P., C.M.W., P.W.A.) Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada (P.W.A.)
| |
Collapse
|
42
|
Tricoci P, D'Andrea DM, Gurbel PA, Yao Z, Cuchel M, Winston B, Schott R, Weiss R, Blazing MA, Cannon L, Bailey A, Angiolillo DJ, Gille A, Shear CL, Wright SD, Alexander JH. Infusion of Reconstituted High-Density Lipoprotein, CSL112, in Patients With Atherosclerosis: Safety and Pharmacokinetic Results From a Phase 2a Randomized Clinical Trial. J Am Heart Assoc 2015; 4:e002171. [PMID: 26307570 PMCID: PMC4599471 DOI: 10.1161/jaha.115.002171] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [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: 12/24/2022]
Abstract
Background CSL112 is a new formulation of human apolipoprotein A-I (apoA-I) being developed to reduce cardiovascular events following acute coronary syndrome. This phase 2a, randomized, double-blind, multicenter, dose-ranging trial represents the first clinical investigation to assess the safety and pharmacokinetics/pharmacodynamics of a CSL112 infusion among patients with stable atherosclerotic disease. Methods and Results Patients were randomized to single ascending doses of CSL112 (1.7, 3.4, or 6.8 g) or placebo, administered over a 2-hour period. Primary safety assessments consisted of alanine aminotransferase or aspartate aminotransferase elevations >3× upper limits of normal and study drug–related adverse events. Pharmacokinetic/pharmacodynamic assessments included apoA-I plasma concentration and measures of the ability of serum to promote cholesterol efflux from cells ex vivo. Of 45 patients randomized, 7, 12, and 14 received 1.7-, 3.4-, and 6.8-g CSL112, respectively, and 11 received placebo. There were no clinically significant elevations (>3× upper limit of normal) in alanine aminotransferase or aspartate aminotransferase. Adverse events were nonserious and mild and occurred in 5 (71%), 5 (41%), and 6 (43%) patients in the CSL112 1.7-, 3.4-, and 6.8-g groups, respectively, compared with 3 (27%) placebo patients. The imbalance in adverse events was attributable to vessel puncture/infusion-site bruising. CSL112 resulted in rapid (Tmax≈2 hours) and dose-dependent increases in apoA-I (145% increase in the 6.8-g group) and total cholesterol efflux (up to 3.1-fold higher than placebo) (P<0.001). Conclusions CSL112 infusion was well tolerated in patients with stable atherosclerotic disease. CSL112 immediately raised apoA-I levels and caused a rapid and marked increase in the capacity of serum to efflux cholesterol. This potential novel approach for the treatment of atherosclerosis warrants further investigation. Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT01499420.
Collapse
Affiliation(s)
| | | | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore and Johns Hopkins University School of Medicine, Baltimore, MD (P.A.G.)
| | - Zhenling Yao
- CSL Behring, King of Prussia, PA (D.M.A., Z.Y., C.L.S., S.D.W.)
| | | | - Brion Winston
- Black Hills Cardiovascular Research, Rapid City, SD (B.W.)
| | | | | | | | - Louis Cannon
- Cardiac and Vascular Research Center of Northern Michigan, Petoskey, MI (L.C.)
| | - Alison Bailey
- Gill Heart Institute, University of Kentucky, Lexington, KY (A.B.)
| | | | | | - Charles L Shear
- CSL Behring, King of Prussia, PA (D.M.A., Z.Y., C.L.S., S.D.W.)
| | - Samuel D Wright
- CSL Behring, King of Prussia, PA (D.M.A., Z.Y., C.L.S., S.D.W.)
| | - John H Alexander
- Duke Clinical Research Institute, Durham, NC (P.T., M.A.B., J.H.A.)
| |
Collapse
|
43
|
Abstract
INTRODUCTION Clopidogrel, prasugrel, and ticagrelor are the currently available oral P2Y12 inhibitors for the treatment of ST-segment elevation myocardial infarction (STEMI), in association with aspirin. These agents bind the P2Y12 platelet receptor and thus inhibit platelet aggregation. Large randomized clinical trials have provided efficacy and safety data on P2Y12 inhibitors in STEMI patients. AREAS COVERED This review focuses on key pharmacologic and clinical aspects of clopidogrel, prasugrel, and ticagrelor, highlighting their differences. Results from the main clinical trials are discussed, as well as the current STEMI guideline recommendations, to help inform agent selection for patients presenting with STEMI. EXPERT OPINION Clinical trials studying newer P2Y12 inhibitors with increased potency have shown further reduction of cardiovascular events compared with clopidogrel, therefore suggesting the use of ticagrelor or prasugrel as a first-line agent for STEMI treatment. There are still clinical situations - such as fibrinolysis, high risk of bleeding, use of oral anticoagulant, and financial hurdles - in which clopidogrel maintains a role in the treatment of STEMI.
Collapse
Affiliation(s)
- Patrícia O Guimarães
- Duke Clinical Research Institute, Duke University Medical Center , 2400 Pratt Street, Durham, NC 27715-7969 , USA +1 919 668 7536 ; +1 919 668 7056 ;
| | | |
Collapse
|
44
|
Kragholm K, Halim SA, Yang Q, Schulte PJ, Hochman JS, Melloni C, Mahaffey KW, Moliterno DJ, Harrington RA, White HD, Armstrong PW, Ohman EM, Van de Werf F, Tricoci P, Alexander JH, Giugliano RP, Newby LK. Sex-Stratified Trends in Enrollment, Patient Characteristics, Treatment, and Outcomes Among Non-ST-Segment Elevation Acute Coronary Syndrome Patients: Insights From Clinical Trials Over 17 Years. Circ Cardiovasc Qual Outcomes 2015; 8:357-67. [PMID: 26152683 DOI: 10.1161/circoutcomes.114.001615] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 06/08/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Adequate representation by sex in trials allows generalizability of results. We examined representation of women in clinical trials during a 17-year period in which inclusion criteria were broadened and federal mandates for representativeness were launched. METHODS AND RESULTS Using mixed models, we studied sex-stratified temporal trends in enrollment, clinical characteristics, treatment, and outcomes among 76 148 non-ST-segment elevation acute coronary syndrome patients using patient-level data merged from 11 phase III trials conducted from 1994 to 2010. Overall, 33.3% of patients were women, which changed minimally over time. Women were consistently 4 to 5 years older than men (median age 68 [interquartile range 61-75] versus 64 [interquartile range 56-72] years) and more frequently had diabetes mellitus, hypertension, and heart failure; men more frequently had prior myocardial infarction and revascularization. GRACE risk scores increased over time for both sexes with the inclusion of older patients with more comorbidities. Use of percutaneous coronary intervention, in-hospital and discharge angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers, β-blockers, and lipid-lowering drugs also increased among both sexes. Kaplan-Meier estimates of 6-month mortality declined from 7.0% [95% confidence interval 6.5%-7.6%] to 4.5% [95% confidence interval 4.0%-5.0%] among women and 6.3% [95% confidence interval 6.0%-6.7%] to 3.1% [95% confidence interval 2.9%-3.4%] among men during the 17-year period. CONCLUSIONS The relative proportion of women in non-ST-segment elevation acute coronary syndrome trials changed minimally over time. Nevertheless, in parallel with men, use of evidence-based care and outcomes improved significantly over time among women.
Collapse
Affiliation(s)
- Kristian Kragholm
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Sharif A Halim
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Qinghong Yang
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Judith S Hochman
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Chiara Melloni
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Kenneth W Mahaffey
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - David J Moliterno
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Robert A Harrington
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Harvey D White
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Paul W Armstrong
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - E Magnus Ohman
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Frans Van de Werf
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Pierluigi Tricoci
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - Robert P Giugliano
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.)
| | - L Kristin Newby
- From the Duke Clinical Research Institute, Durham, NC (K.K., S.A.H., Q.Y., P.J.S., C.M., E.M.O., P.T., J.H.A., L.K.N.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York, NY (J.S.H.); Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.); Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY (D.J.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Department of Cardiology, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.); and Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (R.P.G.).
| |
Collapse
|
45
|
Mahaffey KW, Hager R, Wojdyla D, White HD, Armstrong PW, Alexander JH, Tricoci P, Lopes RD, Ohman EM, Roe MT, Harrington RA, Wallentin L. Meta-analysis of intracranial hemorrhage in acute coronary syndromes: incidence, predictors, and clinical outcomes. J Am Heart Assoc 2015; 4:e001512. [PMID: 26089177 PMCID: PMC4599523 DOI: 10.1161/jaha.114.001512] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the incidence, predictors, or outcomes of intracranial hemorrhage (ICH) in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). We aimed to determine the incidence and timing of ICH, characterize the location of ICH, and identify independent baseline predictors of ICH in NSTE ACS patients. METHODS AND RESULTS We pooled patient-level data from 4 contemporary antithrombotic therapy trials. Multivariable modeling identified independent predictors of ICH. ICHs were adjudicated by a clinical events committee. Of 37 815 patients, 135 (0.4%) had an ICH. The median (25th, 75th percentiles) follow-up was 332 (184, 434) days but differed across trials. Locations of ICH were intracerebral (50%), subdural (31%), subarachnoid (18.5%), and intraventricular (11%). Independent predictors of ICH were older age (HR per 10 years, 1.61; 95% CI, 1.35 to 1.91); prior stroke/transient ischemic attack; HR, 1.95; 95% CI, 1.14 to 3.35), higher systolic blood pressure; HR per 10 mm Hg increase, 1.09; 95% CI, 1.01 to 1.18), and larger number of antithrombotic agents (HR per each additional agent, 2.06; 95% CI, 1.49 to 2.84). Of all ICHs, 45 (33%) were fatal. CONCLUSIONS In patients with NSTE ACS enrolled in recent clinical trials of antithrombotic therapies, ICH was uncommon. Patients with older age, prior transient ischemic attack/stroke, higher systolic blood pressure, or larger number of antithrombotic agents were at increased risk. One-third of patients with ICH died. These data may be useful to trialists and data and safety monitoring committees for trial conduct and monitoring. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifiers: TRACER: NCT00527943, PLATO: NCT00391872, APPRAISE-2: NCT00831441, TRILOGY ACS: NCT00699998.
Collapse
Affiliation(s)
- Kenneth W Mahaffey
- Department of Medicine, Stanford University, Stanford, CA (K.W.M., R.A.H.)
| | - Rebecca Hager
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.)
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta, Edmonton, Canada (P.W.A.)
| | - John H Alexander
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, NC (R.H., D.W., J.H.A., P.T., R.D.L., M.O., M.T.R.)
| | | | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (L.W.)
| |
Collapse
|
46
|
Bagai A, Huang Z, Lokhnygina Y, Harrington RA, Armstrong PW, Strony J, White HD, Leonardi S, Held C, Van de Werf F, Wallentin L, Tricoci P, Mahaffey KW. Magnitude of Troponin Elevation and Long-Term Clinical Outcomes in Acute Coronary Syndrome Patients Treated With and Without Revascularization. Circ Cardiovasc Interv 2015; 8:e002314. [DOI: 10.1161/circinterventions.115.002314] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In patients with non–ST-segment–elevation acute coronary syndrome (NSTE ACS), elevated troponin levels identify patients at high risk for adverse outcomes; however, it is unknown whether the magnitude of troponin elevation during hospitalization remains predictive of subsequent events in patients undergoing coronary revascularization.
Methods and Results—
We studied 12 635 patients with NSTE ACS in the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) study with at least 1 troponin measurement during index hospitalization. Cox proportional hazards regression was used to examine the relationship between peak troponin level (standardized as the ratio of peak troponin value measured during hospitalization and local laboratory upper reference limit [URL]) and revascularization on all-cause mortality at 2 years. Revascularization (percutaneous coronary intervention or coronary artery bypass graft) was performed during index hospitalization in 8586 patients (68.0%); revascularized patients had higher peak troponin ratios (median, 23 versus 9.5× URL). Among patients that did not undergo revascularization, the mortality rate at 2 years increased in a curvilinear fashion with increasing levels of peak troponin. In contrast, the mortality rate at 2 years remained constant irrespective of peak troponin levels among revascularized patients (
P
for interaction=0.004). This relationship was unchanged after multivariable adjustment.
Conclusions—
There is a differential relationship between the magnitude of troponin elevation and long-term mortality in ACS patients treated with and without revascularization. Although prognostically important in patients treated without revascularization, the prognostic implications of peak troponin level seem to be minimal in revascularized patients.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00527943.
Collapse
Affiliation(s)
- Akshay Bagai
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Zhen Huang
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Yuliya Lokhnygina
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Robert A. Harrington
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Paul W. Armstrong
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - John Strony
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Harvey D. White
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Sergio Leonardi
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Claes Held
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Frans Van de Werf
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Lars Wallentin
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Pierluigi Tricoci
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| | - Kenneth W. Mahaffey
- From the Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane
| |
Collapse
|
47
|
Cornel JH, Tricoci P, Lokhnygina Y, Moliterno DJ, Wallentin L, Armstrong PW, Aylward PE, Clare RM, Chen E, Leonardi S, Van de Werf F, White HD, Held C, Strony J, Mahaffey KW, Harrington RA. Glycoprotein IIb/IIIa Receptor Inhibitors in Combination With Vorapaxar, a Platelet Thrombin Receptor Antagonist, Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes (from the TRACER Trial). Am J Cardiol 2015; 115:1325-32. [PMID: 25776457 DOI: 10.1016/j.amjcard.2015.02.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/13/2015] [Accepted: 02/13/2015] [Indexed: 11/29/2022]
Abstract
We evaluated the interaction between protease-activated receptor-1 antagonist vorapaxar and concomitant glycoprotein (GP) IIb/IIIa receptor inhibitors in patients with non-ST-segment elevation acute coronary syndromes who underwent PCI. In Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome trial, 12,944 patients with non-ST-segment elevation acute coronary syndromes were randomized to vorapaxar or placebo. Administration of GP IIb/IIIa receptor inhibitors was allowed at the treating physician's discretion. We investigated whether use of GP IIb/IIIa receptor inhibitors modified vorapaxar's effect on non-coronary artery bypass grafting (CABG)-related bleeding at 7 days and ischemic events at 30 days. In total, 7,455 patients underwent PCI during index hospitalization. Of these, 2,023 patients (27.1%) received inhibitors and 5,432 (72.9%) did not. Vorapaxar was associated with a numerically higher rate of non-CABG-related moderate/severe Global Use of Strategies to Open Occluded Arteries (GUSTO) bleeding at 7 days compared with placebo in those who did (1.3% vs 1.0%) and did not (0.6% vs 0.4%) receive GP IIb/IIIa receptor inhibitors. Ischemic end point rates at 30 days were not significantly lower with vorapaxar versus placebo. Increased rates of non-CABG GUSTO moderate/severe bleeding were observed in patients who received GP IIb/IIIa receptor inhibitors versus those who did not (adjusted hazard ratio [HR] 1.77, 95% confidence interval [CI] 0.43 to 7.35 in placebo arm; adjusted HR 2.02, 95% CI 0.62 to 6.61 in vorapaxar arm) and in those who received vorapaxar versus placebo (adjusted HR 1.54, 95% CI 0.36 to 6.56 in the GP IIb/IIIa group; adjusted HR 1.34, 95% CI 0.44 to 4.07 in the no-GP IIb/IIIa group). No interaction was found between vorapaxar and inhibitor use up to 7 days (P interaction = 0.89) nor at the end of the treatment (P interaction = 0.74); however, the event rate was low. Also, no interaction was observed for efficacy end points after PCI at 30 days or at the end of the treatment. In conclusion, GP IIb/IIIa receptor inhibitor use plus dual antiplatelet therapy in a population with non-ST-segment elevation myocardial infarction planned for PCI was frequent but did not interact with vorapaxar's efficacy or safety. Nonetheless, GP IIb/IIIa receptor inhibitors and vorapaxar were associated with increased bleeding risk, and their combined use may result in additive effects on bleeding rates.
Collapse
Affiliation(s)
- Jan H Cornel
- Department of cardiology, Medisch Centrum Alkmaar, Alkmaar, the Netherlands.
| | | | | | - David J Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - Robert M Clare
- Duke Clinical Research Institute, Durham, North Caroline
| | - Edmond Chen
- Global Clinical Development, Bayer HealthCare Pharmaceuticals Inc., Whippany, New Jersey
| | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | | | | |
Collapse
|
48
|
Vagnarelli F, Taglieri N, Ortolani P, Norscini G, Cinti L, Bacchi Reggiani ML, Marino M, Lorenzini M, Bugani G, Corsini A, Semprini F, Nanni S, Tricoci P, De Palma R, Rapezzi C, Melandri G. Long-term outcomes and causes of death after acute coronary syndrome in patients in the Bologna, Italy, area. Am J Cardiol 2015; 115:171-7. [PMID: 25465930 DOI: 10.1016/j.amjcard.2014.10.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 11/18/2022]
Abstract
We sought to evaluate the rates, time course, and causes of death in the long-term follow-up of unselected patients with acute coronary syndromes (ACS). We enrolled 2046 consecutive patients hospitalized from January 2004 to December 2005 with an audited final diagnosis of ACS. The primary study end point was 5-year all-cause mortality. In our series, 896 patients had ST-segment elevation (STE) and 1,150 non-ST-segment elevation (NSTE). Mean age of the study population was 71.6 years. Primary percutaneous coronary intervention was performed in 86% of STE-ACS, and 70% of NSTE-ACS was managed invasively. The 5-year all-cause mortality was 36.4% for STE-ACS and 42.0% for NSTE-ACS, with patients with STE-ACS showing a trend boarding statistical significance toward a lower risk of mortality (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.76 to 1.02, p = 0.08). Landmark analysis demonstrated that patients with STE-ACS had a higher risk of 30-day mortality (STE-ACS vs NSTE-ACS HR = 1.53, 95% CI 1.16 to 2.06, p = 0.003) whereas the risk of NSTE-ACS increased markedly after 1 year (STE-ACS vs NSTE-ACS HR = 0.67, 95% CI 0.53 to 0.84, p = 0.001). The contribution of noncardiovascular (CV) causes to overall mortality increased from 3% at 30 days to 34% at 5 years, with cancer and infections being the most common causes of non-CV death both in STE-ACS and NSTE-ACS. In conclusion, long-term mortality after ACS is still too high both for STE-ACS and NSTE-ACS. Although patients with STE-ACS have a higher mortality during the first year, the mortality of patients with NSTE-ACS increases later, when non-CV co-morbidities gain greater importance.
Collapse
Affiliation(s)
- Fabio Vagnarelli
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Nevio Taglieri
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Paolo Ortolani
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Giulia Norscini
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Laura Cinti
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | | | | | - Massimiliano Lorenzini
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Giulia Bugani
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Anna Corsini
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Franco Semprini
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Samuele Nanni
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | | | | | - Claudio Rapezzi
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy.
| | - Giovanni Melandri
- Istituto di Cardiologia, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| |
Collapse
|
49
|
Tricoci P, Leonardi S. Determining myocardial infarction after PCI: CK-MB, troponin, both, or neither? MLO Med Lab Obs 2015; 47:14-16. [PMID: 26281113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
|
50
|
Affiliation(s)
- Pierluigi Tricoci
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| |
Collapse
|