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William WN, Zhang J, Zhao X, Parra ER, Uraoka N, Lin HY, Peng SA, El-Naggar AK, Rodriguez-Canales J, Song J, Gillenwater AM, Wistuba II, Myers JN, Gold KA, Ferrarotto R, Hwu P, Davoli T, Lee JJ, Heymach JV, Papadimitrakopoulou VA, Lippman SM. Spatial PD-L1, immune-cell microenvironment, and genomic copy-number alteration patterns and drivers of invasive-disease transition in prospective oral precancer cohort. Cancer 2023; 129:714-727. [PMID: 36597662 PMCID: PMC10508302 DOI: 10.1002/cncr.34607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Studies of the immune landscape led to breakthrough trials of programmed death-1 (PD-1) inhibitors for recurrent/metastatic head and neck squamous cell carcinoma therapy. This study investigated the timing, influence of somatic copy-number alterations (SCNAs), and clinical implications of PD-L1 and immune-cell patterns in oral precancer (OPC). METHODS The authors evaluated spatial CD3, CD3/8, and CD68 density (cells/mm2 ) and PD-L1 (membranous expression in cytokeratin-positive intraepithelial neoplastic cells and CD68) patterns by multiplex immunofluorescence in a 188-patient prospective OPC cohort, characterized by clinical, histologic, and SCNA risk factors and protocol-specified primary end point of invasive cancer. The authors used Wilcoxon rank-sum and Fisher exact tests, linear mixed effect models, mediation, and Cox regression and recursive-partitioning analyses. RESULTS Epithelial, but not CD68 immune-cell, PD-L1 expression was detected in 28% of OPCs, correlated with immune-cell infiltration, 9p21.3 loss of heterozygosity (LOH), and inferior oral cancer-free survival (OCFS), notably in OPCs with low CD3/8 cell density, dysplasia, and/or 9p21.3 LOH. High CD3/8 cell density in dysplastic lesions predicted better OCFS and eliminated the excess risk associated with prior oral cancer and dysplasia. PD-L1 and CD3/8 patterns revealed inferior OCFS in PD-L1 high intrinsic induction and dysplastic immune-cold subgroups. CONCLUSION This report provides spatial insight into the immune landscape and drivers of OPCs, and a publicly available immunogenomic data set for future precancer interrogation. The data suggest that 9p21.3 LOH triggers an immune-hot inflammatory phenotype; whereas increased 9p deletion size encompassing CD274 at 9p24.1 may contribute to CD3/8 and PD-L1 depletion during invasive transition. The inferior OCFS in PD-L1-high, immune-cold OPCs support the development of T-cell recruitment strategies.
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Affiliation(s)
- William N William
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Hospital BP, a Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Jianjun Zhang
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Zhao
- Department of Biochemistry and Molecular Pharmacology, Institute for Systems Genetics, New York University Langone Health, New York, New York, USA
| | - Edwin R Parra
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naohiro Uraoka
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heather Y Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - S Andrew Peng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaime Rodriguez-Canales
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaejoon Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann M Gillenwater
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn A Gold
- Moores Cancer Center, University of California San Diego, La Jolla, California, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Teresa Davoli
- Department of Biochemistry and Molecular Pharmacology, Institute for Systems Genetics, New York University Langone Health, New York, New York, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vassiliki A Papadimitrakopoulou
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Pfizer Inc, New York, New York, USA
| | - Scott M Lippman
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Moores Cancer Center, University of California San Diego, La Jolla, California, USA
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Granger CB, Bates ER, Jollis JG, Antman EM, Nichol G, O'Connor RE, Gregory T, Roettig ML, Peng SA, Ellrodt G, Henry TD, French WJ, Jacobs AK. Improving Care of STEMI in the United States 2008 to 2012. J Am Heart Assoc 2020; 8:e008096. [PMID: 30596310 PMCID: PMC6405711 DOI: 10.1161/jaha.118.008096] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001). Conclusions Quality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.
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Affiliation(s)
| | - Eric R Bates
- 2 Department of Internal Medicine University of Michigan Ann Arbor MI
| | - James G Jollis
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Graham Nichol
- 4 University of Washington-Harborview Center for Prehospital Emergency Care University of Washington Seattle WA
| | - Robert E O'Connor
- 5 Department of Emergency Medicine University of Virginia School of Medicine Charlottesville VA
| | | | - Mayme L Roettig
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Gray Ellrodt
- 8 Department of Medicine Berkshire Medical Center Pittsfield MA
| | | | - William J French
- 10 Department of Medicine Harbor-University of California at Los Angeles Medical Center Torrance CA
| | - Alice K Jacobs
- 11 Department of Medicine Boston University School of Medicine Boston MA
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Tidwell RSS, Peng SA, Chen M, Liu DD, Yuan Y, Lee JJ. Bayesian clinical trials at The University of Texas MD Anderson Cancer Center: An update. Clin Trials 2019; 16:645-656. [PMID: 31450957 DOI: 10.1177/1740774519871471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS In our 2009 article, we showed that Bayesian methods had established a foothold in developing therapies in our institutional oncology trials. In this article, we will document what has happened since that time. In addition, we will describe barriers to implementing Bayesian clinical trials, as well as our experience overcoming them. METHODS We reviewed MD Anderson Cancer Center clinical trials submitted to the institutional protocol office for scientific and ethical review between January 2009 and December 2013, the same length time period as the previous article. We tabulated Bayesian methods implemented for design or analyses for each trial and then compared these to our previous findings. RESULTS Overall, we identified 1020 trials and found that 283 (28%) had Bayesian components so we designated them as Bayesian trials. Among MD Anderson-only and multicenter trials, 56% and 14%, respectively, were Bayesian, higher rates than our previous study. Bayesian trials were more common in phase I/II trials (34%) than in phase III/IV (6%) trials. Among Bayesian trials, the most commonly used features were for toxicity monitoring (65%), efficacy monitoring (36%), and dose finding (22%). The majority (86%) of Bayesian trials used non-informative priors. A total of 75 (27%) trials applied Bayesian methods for trial design and primary endpoint analysis. Among this latter group, the most commonly used methods were the Bayesian logistic regression model (N = 22), the continual reassessment method (N = 20), and adaptive randomization (N = 16). Median institutional review board approval time from protocol submission was the same 1.4 months for Bayesian and non-Bayesian trials. Since the previous publication, the Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) trial was the first large-scale decision trial combining multiple treatments in a single trial. Since then, two regimens in breast cancer therapy have been identified and published from the cooperative Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis (I-SPY 2), enhancing cooperation among investigators and drug developers across the nation, as well as advancing information needed for personalized medicine. Many software programs and Shiny applications for Bayesian trial design and calculations are available from our website which has had more than 21,000 downloads worldwide since 2004. CONCLUSION Bayesian trials have the increased flexibility in trial design needed for personalized medicine, resulting in more cooperation among researchers working to fight against cancer. Some disadvantages of Bayesian trials remain, but new methods and software are available to improve their function and incorporation into cancer clinical research.
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Affiliation(s)
- Rebecca S Slack Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Andrew Peng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Minxing Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Schvartsman G, Peng SA, Bis G, Lee JJ, Benveniste MF, Zhang J, Roarty EB, Lacerda L, Swisher S, Heymach JV, Fossella FV, William WN. Response rates to single-agent chemotherapy after exposure to immune checkpoint inhibitors in advanced non-small cell lung cancer. Lung Cancer 2017; 112:90-95. [DOI: 10.1016/j.lungcan.2017.07.034] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/27/2017] [Accepted: 07/30/2017] [Indexed: 10/19/2022]
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Berkman AM, Brewster AM, Jones LW, Yu J, Lee JJ, Peng SA, Crocker A, Ater JL, Gilchrist SC. Racial Differences in 20-Year Cardiovascular Mortality Risk Among Childhood and Young Adult Cancer Survivors. J Adolesc Young Adult Oncol 2017; 6:414-421. [PMID: 28530506 DOI: 10.1089/jayao.2017.0024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Whether cardiovascular disease (CVD) risk differs according to race and cancer type among survivors of childhood or young adulthood cancers is unknown. METHODS Data from the years 1973-2011 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) registries. Cases were categorized by ICD-0-3/WHO 2008 Adolescent and Young Adult classification. CVD death was determined by ICD-10 codes for diseases of the heart, atherosclerosis, cerebrovascular diseases, or other diseases of the arteries. Cox proportional hazards models were fitted to evaluate the hazard ratio (HR) and 95% confidence intervals (CIs) for the effects of race on time-to-event outcomes. RESULTS A total of 164,316 cases of childhood and young adult primary cancers were identified. There were 43,335 total and 1466 CVD deaths among Black and White survivors. Black survivors had higher risks of all-cause mortality (HR: 1.75, 95% CI: 1.70-1.7) and CVD mortality (HR: 2.13, 95% CI: 1.85-2.46) compared to White survivors. The increased risk of CVD for Black survivors compared to White survivors persisted at 5-years (HR: 2.38, 95% CI: 1.83-3.10), 10-years (HR: 2.59, 95% CI: 2.09-3.21), and 20-years (HR: 2.31, 95% CI: 1.95-2.74) postdiagnosis, and varied by cancer type, with the highest HRs for melanoma (HR: 8.16, 95% CI: 1.99-33.45) and thyroid cancer (HR: 3.43, 95% CI: 1.75-6.73). CONCLUSIONS Black survivors of childhood or young adulthood cancers have a higher risk of CVD mortality compared to Whites that varies by cancer type. Knowledge of at-risk populations is important to guide surveillance recommendations and behavioral interventions. Further study is needed to understand the etiology of racial differences in CVD mortality in this population.
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Affiliation(s)
- Amy M Berkman
- 1 Larner College of Medicine, University of Vermont , Burlington, Vermont
| | - Abenaa M Brewster
- 2 Department of Clinical Cancer Prevention, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Lee W Jones
- 3 Department of Medicine, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Jun Yu
- 4 Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - J Jack Lee
- 4 Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - S Andrew Peng
- 4 Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Abigail Crocker
- 5 Department of Mathematics and Statistics, University of Vermont , Burlington, Vermont
| | - Joann L Ater
- 6 Division of Pediatrics, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Susan C Gilchrist
- 2 Department of Clinical Cancer Prevention, The University of Texas M.D. Anderson Cancer Center , Houston, Texas
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Schvartsman G, Peng SA, Bis G, Lee JJ, Benveniste MFK, Zhang J, Rinsurongkawong W, Lewis J, Roarty E, Lacerda L, Roth JA, Swisher S, Heymach J, Fossella FV, William WN. Response to single-agent (SA) chemotherapy (CTx) after immunotherapy exposure in non-small cell lung cancer (NSCLC). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.9083] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9083 Background: Overall response rates (ORR) to 2nd-line SACTx in NSCLC have consistently not exceeded 15%. Exploratory analysis of clinical trials in various tumor types have demonstrated potential improvements in ORR to CTx after exposure to vaccine-based immunotherapy. The objective of this retrospective study was to determine if SACTx (3rd-line or beyond) would yield improved ORR when given after exposure to programmed-death-(ligand)1 inhibitors (PD1i) in metastatic NSCLC. Methods: Eligibility criteria - patients registered in the Thoracic GEMINI database of MD Anderson treated between 06/12 and 11/16 who received at least one SACTx as 3rd-line or beyond, following progression after platinum-based CTx and PD1i. We computed efficacy outcomes to each therapy, including ORR by RECIST v1.1, progression-free survival (PFS) and overall survival (OS). Results: Of 306 PD1i-treated patients registered in the database, 28 met eligibility criteria - 54% were male, median age 66 years, 82% adenocarcinoma, 29% never smokers. The PD1i and SACTx most commonly used were nivolumab (82%) and docetaxel (54%). ORR to SACTx after exposure to PD1i was 39% (11/28 patients, 8 confirmed). In contrast, ORR to 1st-line CTx in this cohort was 30% (Table). Liver metastasis and pembrolizumab as the PD1i of choice were the only factors associated with response to SACTx on univariate analysis (p < 0.05). Conclusions: In NSCLC patients, ORR to SACTx after immunotherapy exposure was higher compared to historical data from the pre-PD1i era, and approached ORR to 1st-line platinum-based CTx. Further investigation of a possible chemosensitization effect by immunotherapy is warranted. [Table: see text]
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Affiliation(s)
| | - S. Andrew Peng
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - J. Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jianjun Zhang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jeff Lewis
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emily Roarty
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lara Lacerda
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jack A. Roth
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen Swisher
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Heymach
- The University of Texas MD Anderson Cancer Center, Houston, TX
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William WN, Uraoka N, Peng SA, Lee JJ, El-Naggar AK, Parra Cuentas ER, Rodriguez-Canales J, Gillenwater AM, Lin HY, Wistuba II, Myers J, Gold KA, Hwu P, Heymach J, Papadimitrakopoulou V, Lippman SM. Immune profiling of oral pre-malignant lesions (OPLs): An Erlotinib Prevention of Oral Cancer (EPOC) study biobank analysis. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1545 Background: We previously demonstrated that high-risk loss of heterozygosity (LOH) profiles (i.e., 3p14/9p21 LOH) and EGFR gene copy number gain (CNG) in OPLs were associated with inferior oral cancer-free survival (OCFS) in patients enrolled in the randomized EPOC trial. Herein, we performed comprehensive immune profiling of OPLs and correlated the findings with molecular features and outcomes, using the prospectively collected and clinically annotated EPOC biobank. Methods: We evaluated OPL specimens by multiplex immunofluorescence using the Opal 7-color fIHC Kit and the Vectra multispectral microscope / inForm Cell Analysis software. Markers included AE1/AE3 pancytokeratins, PD-L1 (clone E1L3N), CD3, CD8, and CD68. Wilcoxon rank-sum and Fisher’s exact tests were used to assess the associations between binary markers and continuous and categorical variables, respectively. Cox model was used to investigate associations of markers with OCFS. Results: The cohort included 188 OPL patients with hyperkeratosis/hyperplasia (18%), mild/moderate (44%), or severe dysplasia (5%); 65% had high-risk LOH profiles. The 5-year OCFS was 72.3% (median follow-up of 50 months). PD-L1 expression in > 1% of epithelial cells occurred in 28% of OPLs. Intraepithelial CD3+, CD3+/CD8+, CD68+, and CD68+/PD-L1+ cells were detected in 100%, 88%, 88%, and 54% of the samples, respectively. OPLs with high-risk LOH profiles had increased epithelial PD-L1 expression (P = 0.007), intraepithelial CD68+/PD-L1+ cells (P = 0.002), and a trend towards more CD3+/CD8+ cells in the stroma (P = 0.06) but not in the epithelium (P = 0.97), compared with low-risk LOH OPLs. Increased epithelial PD-L1 expression was associated with inferior OCFS on univariate (P = 0.023), and multivariate analysis including LOH status and EGFR CNG as co-variates (P = 0.018). Conclusions: High-risk OPLs defined by LOH profiles had increased PD-L1 expression in epithelial cells and intraepithelial macrophages, as well as stromal CD3+/CD8+ immune infiltration. Higher PD-L1 expression was associated with increased oral cancer risk. The findings may support evaluation of (PD-1-targeted) immunoprevention strategies in high-risk OPLs.
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Affiliation(s)
| | - Naohiro Uraoka
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S. Andrew Peng
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J. Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Heather Y. Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jeffrey Myers
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathryn A. Gold
- University of California San Diego Moores Cancer Center, La Jolla, CA
| | - Patrick Hwu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Heymach
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Vial MR, Khan KA, O'Connell O, Peng SA, Gomez DR, Chang JY, Rice DC, Mehran R, Jimenez CJ, Grosu HB, Ost DE, Eapen GA. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Nodal Staging of Stereotactic Ablative Body Radiotherapy Patients. Ann Thorac Surg 2016; 103:1600-1605. [PMID: 28027732 DOI: 10.1016/j.athoracsur.2016.09.106] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 06/01/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with non-small cell lung cancer (NSCLC) being evaluated for stereotactic ablative body radiotherapy (SABR) are typically staged noninvasively with positron emission tomography/computed tomography (PET/CT). Incorporating endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) into the staging workup of these patients has not been evaluated. Our primary objective was to compare the performance of PET/CT with EBUS-TBNA for intrathoracic nodal assessment among SABR-eligible patients. METHODS This was a retrospective study consisting of two parts. First, we assessed the concordance for nodal metastasis of PET/CT and EBUS-TBNA. Second, we evaluated clinical outcomes among patients who underwent SABR with and without a prior EBUS-TBNA. RESULTS We identified 246 eligible patients. Compared with PET/CT, EBUS-TBNA led to a stage shift in 48 of 246 patients (19%). Of 174 N0 patients by PET/CT, 6 (3.4%) had nodal metastasis on EBUS-TBNA. Among 72 clinical N1 patients, 36 (50%) were downstaged to N0 after EBUS-TBNA, therefore becoming eligible for SABR. Concordance between PET/CT and EBUS-TBNA for nodal metastasis was 83% (κ = 0.53). Clinical outcomes of patients who underwent SABR with or without a prior EBUS-TBNA did not differ significantly. CONCLUSIONS Concordance of PET/CT and EBUS-TBNA for nodal disease was only moderate. Incorporating EBUS-TBNA into the staging workup was beneficial in identifying occult nodal metastasis that would otherwise be left untreated with SABR and in expanding the pool of potentially SABR-eligible patients.
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Affiliation(s)
- Macarena R Vial
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Kashif A Khan
- Department of Respiratory Medicine, Cork University Hospital/University College Cork, Ireland
| | - Oisin O'Connell
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - S Andrew Peng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David C Rice
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Reza Mehran
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos J Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Papadimitrakopoulou V, Lee JJ, Wistuba II, Tsao AS, Fossella FV, Kalhor N, Gupta S, Byers LA, Izzo JG, Gettinger SN, Goldberg SB, Tang X, Miller VA, Skoulidis F, Gibbons DL, Shen L, Wei C, Diao L, Peng SA, Wang J, Tam AL, Coombes KR, Koo JS, Mauro DJ, Rubin EH, Heymach JV, Hong WK, Herbst RS. The BATTLE-2 Study: A Biomarker-Integrated Targeted Therapy Study in Previously Treated Patients With Advanced Non-Small-Cell Lung Cancer. J Clin Oncol 2016; 34:3638-3647. [PMID: 27480147 DOI: 10.1200/jco.2015.66.0084] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE By applying the principles of real-time biopsy, biomarker-based, adaptively randomized studies in non-small-cell lung cancer (NSCLC) established by the Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) trial, we conducted BATTLE-2 (BATTLE-2 Program: A Biomarker-Integrated Targeted Therapy Study in Previously Treated Patients With Advanced Non-Small Cell Lung Cancer), an umbrella study to evaluate the effects of targeted therapies focusing on KRAS-mutated cancers. PATIENTS AND METHODS Patients with advanced NSCLC (excluding sensitizing EGFR mutations and ALK gene fusions) refractory to more than one prior therapy were randomly assigned, stratified by KRAS status, to four arms: (1) erlotinib, (2) erlotinib plus MK-2206, (3) MK-2206 plus AZD6244, or (4) sorafenib. Tumor gene expression profiling-targeted next-generation sequencing was performed to evaluate predictive and prognostic biomarkers. RESULTS Two hundred patients, 27% with KRAS-mutated (KRAS mut+) tumors, were adaptively randomly assigned to erlotinib (n = 22), erlotinib plus MK-2206 (n = 42), MK-2206 plus AZD6244 (n = 75), or sorafenib (n = 61). In all, 186 patients were evaluable, and the primary end point of an 8-week disease control rate (DCR) was 48% (arm 1, 32%; arm 2, 50%; arm 3, 53%; and arm 4, 46%). For KRAS mut+ patients, DCR was 20%, 25%, 62%, and 44% whereas for KRAS wild-type patients, DCR was 36%, 57%, 49%, and 47% for arms 1, 2, 3, and 4, respectively. Median progression-free survival was 2.0 months, not different by KRAS status, 1.8 months for arm 1, and 2.5 months for arms 2 versus arms 3 and 4 in KRAS mut+ patients (P = .04). Median overall survival was 6.5 months, 9.0 and 5.1 months for arms 1 and 2 versus arms 3 and 4 in KRAS wild-type patients (P = .03). Median overall survival was 7.5 months in mesenchymal versus 5 months in epithelial tumors (P = .02). CONCLUSION Despite improved progression-free survival on therapy that did not contain erlotinib for KRAS mut+ patients and improved prognosis for mesenchymal tumors, better biomarker-driven treatment strategies are still needed.
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Affiliation(s)
- Vassiliki Papadimitrakopoulou
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - J Jack Lee
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Ignacio I Wistuba
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Anne S Tsao
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Frank V Fossella
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Neda Kalhor
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Sanjay Gupta
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Lauren Averett Byers
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Julie G Izzo
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Scott N Gettinger
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Sarah B Goldberg
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Ximing Tang
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Vincent A Miller
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Ferdinandos Skoulidis
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Don L Gibbons
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Li Shen
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Caimiao Wei
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Lixia Diao
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - S Andrew Peng
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Jing Wang
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Alda L Tam
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Kevin R Coombes
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Ja Seok Koo
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - David J Mauro
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Eric H Rubin
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - John V Heymach
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Waun Ki Hong
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
| | - Roy S Herbst
- Vassiliki Papadimitrakopoulou, J. Jack Lee, Ignacio I. Wistuba, Anne S. Tsao, Frank V. Fossella, Neda Kalhor, Sanjay Gupta, Lauren Averett Byers, Julie G. Izzo, Ximing Tang, Ferdinandos Skoulidis, Don L. Gibbons, Li Shen, Caimiao Wei, Lixia Diao, S. Andrew Peng, Jing Wang, Alda L. Tam, John V. Heymach, and Waun Ki Hong, The University of Texas MD Anderson Cancer Center, Houston, TX; Scott N. Gettinger, Sarah B. Goldberg, Ja Seok Koo, and Roy S. Herbst, Yale University, New Haven, CT; Vincent A. Miller, Foundation Medicine, Cambridge, MA; Kevin R. Coombes, Ohio State University College of Medicine, Columbus, OH; and David J. Mauro and Eric H. Rubin, Merck, North Wales, PA
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Anderson LL, French WJ, Peng SA, Vora AN, Henry TD, Roe MT, Kontos MC, Granger CB, Bates ER, Hellkamp A, Wang TY. Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2016; 8:e002477. [PMID: 26338881 DOI: 10.1161/circinterventions.114.002477] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging. METHODS AND RESULTS We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002). CONCLUSIONS Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.
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Affiliation(s)
- Lindsay L Anderson
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - William J French
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - S Andrew Peng
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Amit N Vora
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Timothy D Henry
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Matthew T Roe
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Michael C Kontos
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Christopher B Granger
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Eric R Bates
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Anne Hellkamp
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Tracy Y Wang
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.).
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11
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Hess CN, Hellkamp AS, Roe MT, Thomas L, Scirica BM, Peng SA, Peterson ED, Wang TY. Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization. J Am Heart Assoc 2016; 5:e002784. [PMID: 26976877 PMCID: PMC4943255 DOI: 10.1161/jaha.115.002784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/17/2022]
Abstract
Background While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non–ST‐segment elevation myocardial infarction patients who did not undergo coronary revascularization. Methods and Results We included unrevascularized non–ST‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], Pinteraction=0.20). Conclusions We found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non–ST‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.
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Affiliation(s)
- Connie N Hess
- University of Colorado School of Medicine, Aurora, CO
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Wang TY, Vora AN, Peng SA, Fonarow GC, Das S, de Lemos JA, Peterson ED. Effectiveness and Safety of Aldosterone Antagonist Therapy Use Among Older Patients With Reduced Ejection Fraction After Acute Myocardial Infarction. J Am Heart Assoc 2016; 5:JAHA.115.002612. [PMID: 26796254 PMCID: PMC4859378 DOI: 10.1161/jaha.115.002612] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background While aldosterone antagonists have proven benefit among post‐myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described. Methods and Results Using ACTION Registry‐GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40% who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11% (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10% of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2‐year follow‐up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39% versus 38%; HR 0.99, 95% CI 0.88–1.33 using inverse probability‐weighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95% CI 0.72–0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3% versus 1.5%; adjusted HR 2.04, 95% CI 1.16–3.60), as was 2‐year risk of acute renal failure (unadjusted 6.7% versus 4.8%; adjusted HR 1.39, 95% CI 1.01–1.92) compared with patients not prescribed aldosterone antagonists. Conclusions Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post‐discharge monitoring of this patient population.
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Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.)
| | - Amit N Vora
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.)
| | - S Andrew Peng
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.)
| | - Gregg C Fonarow
- Ahmanson-University of California Los Angeles Cardiomyopathy Center, Los Angeles, CA (G.C.F.)
| | - Sandeep Das
- University of Texas Southwestern Medical Center, Dallas, TX (S.D., J.A.L.)
| | - James A de Lemos
- University of Texas Southwestern Medical Center, Dallas, TX (S.D., J.A.L.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.)
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13
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Goyal A, de Lemos JA, Peng SA, Thomas L, Amsterdam EA, Hockenberry JM, Peterson ED, Wang TY. Association of Patient Enrollment in Medicare Part D With Outcomes After Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2015; 8:567-75. [DOI: 10.1161/circoutcomes.115.001650] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 09/16/2015] [Indexed: 11/16/2022]
Abstract
Background—
Little is known about whether enrollment versus nonenrollment in Medicare’s prescription drug plan (Part D) is associated with better outcomes after acute myocardial infarction (AMI).
Methods and Results—
Using Medicare records linked to Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines, we identified 59 149 Medicare beneficiaries (age ≥65 years) discharged after AMI between January 2007 and December 2010. We described trends in Medicare Part D enrollment, and compared the following 30-day and 1-year outcomes: all-cause death, all-cause readmissions, and major adverse cardiac events (a composite of all-cause death or readmission for AMI or stroke) between Part D enrollees and nonenrollees, after adjustment for patient and hospital factors. From 2007 to 2010, 29 264 (49.5%) patients with AMI enrolled in Medicare were also participating in Part D by hospital discharge. All-cause 30-day death was more common among enrollees versus nonenrollees (4.0% versus 3.3%), but this difference was not statistically significant after multivariable adjustment (adjusted hazard ratio, 1.06 [95% confidence interval, 0.97–1.17]). Enrollees also had higher unadjusted risks of 30-day all-cause readmissions or major adverse cardiac events, and 1-year mortality, all-cause readmissions, or major adverse cardiac events, but these were attenuated after multivariable adjustment. Adherence to key secondary prevention medications (statins, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and P2Y
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antagonists) remained low (range, 55%–64%) at 1 year post discharge among Part D enrollees.
Conclusions—
Only half of Medicare-insured patients with AMI were enrolled in Part D by hospital discharge, and their 30-day and 1-year adjusted outcomes did not differ substantially from nonenrollees. There remain opportunities for improvement in medication adherence among patients with prescription drug coverage.
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Affiliation(s)
- Abhinav Goyal
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - James A. de Lemos
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - S. Andrew Peng
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - Laine Thomas
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - Ezra A. Amsterdam
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - Jason M. Hockenberry
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - Eric D. Peterson
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
| | - Tracy Y. Wang
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA (A.G.); Department of Internal Medicine, UT Southwestern Medical School, Dallas, TX (J.A.d.L.); Department of Biostatistics and Bioinformatics (L.T) and Department of Medicine (E.D.P., T.Y.W.), Duke Clinical Research Institute, Durham, NC (S.A.P.); Department of Internal Medicine, University of California, Davis Medical Center, Sacramento (E.A.A.); Department of Health Policy and Management, Emory Rollins School of
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Hess CN, Peterson ED, Peng SA, de Lemos JA, Fosbol EL, Thomas L, Bhatt DL, Saucedo JF, Wang TY. Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocardial Infarction and Atrial Fibrillation. J Am Coll Cardiol 2015; 66:616-27. [DOI: 10.1016/j.jacc.2015.05.062] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Goyal A, de Lemos J, Peng SA, Thomas L, Amsterdam E, Hockenberry J, Peterson E, Wang T. THE ASSOCIATION OF MEDICARE PART D ENROLLMENT WITH OUTCOMES AFTER ACUTE MYOCARDIAL INFARCTION: AN ANALYSIS OF LINKED ACTION REGISTRY-GWTG AND MEDICARE DATA. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Pickering CR, Zhou JH, Lee JJ, Drummond JA, Peng SA, Saade RE, Tsai KY, Curry JL, Tetzlaff MT, Lai SY, Yu J, Muzny DM, Doddapaneni H, Shinbrot E, Covington KR, Zhang J, Seth S, Caulin C, Clayman GL, El-Naggar AK, Gibbs RA, Weber RS, Myers JN, Wheeler DA, Frederick MJ. Mutational landscape of aggressive cutaneous squamous cell carcinoma. Clin Cancer Res 2014; 20:6582-92. [PMID: 25303977 DOI: 10.1158/1078-0432.ccr-14-1768] [Citation(s) in RCA: 421] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Aggressive cutaneous squamous cell carcinoma (cSCC) is often a disfiguring and lethal disease. Very little is currently known about the mutations that drive aggressive cSCC. EXPERIMENTAL DESIGN Whole-exome sequencing was performed on 39 cases of aggressive cSCC to identify driver genes and novel therapeutic targets. Significantly, mutated genes were identified with MutSig or complementary methods developed to specifically identify candidate tumor suppressors based upon their inactivating mutation bias. RESULTS Despite the very high-mutational background caused by UV exposure, 23 candidate drivers were identified, including the well-known cancer-associated genes TP53, CDKN2A, NOTCH1, AJUBA, HRAS, CASP8, FAT1, and KMT2C (MLL3). Three novel candidate tumor suppressors with putative links to cancer or differentiation, NOTCH2, PARD3, and RASA1, were also identified as possible drivers in cSCC. KMT2C mutations were associated with poor outcome and increased bone invasion. CONCLUSIONS The mutational spectrum of cSCC is similar to that of head and neck squamous cell carcinoma and dominated by tumor-suppressor genes. These results improve the foundation for understanding this disease and should aid in identifying and treating aggressive cSCC.
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Affiliation(s)
- Curtis R Pickering
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jane H Zhou
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - S Andrew Peng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rami E Saade
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth Y Tsai
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan L Curry
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Yu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donna M Muzny
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | | | - Eve Shinbrot
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Kyle R Covington
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Jianhua Zhang
- Department of Bioinformatics and Institute for Applied Cancer Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sahil Seth
- Department of Bioinformatics and Institute for Applied Cancer Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos Caulin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gary L Clayman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas. Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David A Wheeler
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas.
| | - Mitchell J Frederick
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Hall HM, de Lemos JA, Enriquez JR, McGuire DK, Peng SA, Alexander KP, Roe MT, Desai N, Wiviott SD, Das SR. Contemporary Patterns of Discharge Aspirin Dosing After Acute Myocardial Infarction in the United States. Circ Cardiovasc Qual Outcomes 2014; 7:701-7. [DOI: 10.1161/circoutcomes.113.000822] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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—
Accumulated data suggest that low-dose aspirin after myocardial infarction (MI) may offer similar efficacy to higher dose aspirin with reduced risk of bleeding. Few data are available on contemporary aspirin dosing patterns after MI in the United States
Methods and Results—
Aspirin dosing from 221 199 patients with MI (40.2% ST-segment–elevation MI) from 525 US hospitals enrolled in the National Cardiovascular Data Registry’s (NCDR’s) Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines were described, overall and in clinically relevant subgroups. High-dose aspirin was defined as 325 mg and low dose as 81 mg. Between January 2007 and March 2011, 60.9% of patients with acute MI were discharged on high-dose aspirin, 35.6% on low-dose aspirin, and 3.5% on other doses. High-dose aspirin was prescribed at discharge to 73.0% of patients treated with percutaneous coronary intervention and 44.6% of patients managed medically. Among 9075 patients discharged on aspirin, thienopyridine, and warfarin, 44.0% were prescribed high-dose aspirin. Patients with an in-hospital major bleeding event were also frequently discharged on high-dose aspirin (56.7%). A 25-fold variation in the proportion prescribed high-dose aspirin at discharge was observed across participating centers.
Conclusions—
Most US patients with MI continue to be discharged on high-dose aspirin. Although aspirin dosing after percutaneous coronary intervention largely reflected prevailing guidelines before 2012, high-dose aspirin was prescribed with similar frequency in medically managed patients and to those in categories expected to be at high risk for bleeding. Wide variability in the proportional use of high-dose aspirin across centers suggests significant influence from local practice habits and uncertainty about appropriate aspirin dosing.
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Affiliation(s)
- Hurst M. Hall
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - James A. de Lemos
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Jonathan R. Enriquez
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Darren K. McGuire
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - S. Andrew Peng
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Karen P. Alexander
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Matthew T. Roe
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Nihar Desai
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Stephen D. Wiviott
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
| | - Sandeep R. Das
- From the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (H.M.H., J.A.d.L., D.K.M., S.R.D.); Division of Cardiology, University of Missouri-Kansas City (J.R.E.); Duke Clinical Research Institute, Durham, NC (S.A.P., K.P.A., M.T.R.); and Division of Cardiology, Brigham and Women’s Hospital, Boston, MA (N.D., S.D.W.)
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Mumma BE, Kontos MC, Peng SA, Diercks DB. Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry. Am Heart J 2014; 167:915-20. [PMID: 24890543 DOI: 10.1016/j.ahj.2014.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current guidelines recommend ≤90 minutes from first medical contact to percutaneous coronary intervention (FMC2B) for ST-segment-elevation myocardial infarction (STEMI) patients. We evaluated the relationship between patient home distance from a percutaneous coronary intervention (PCI) center, prehospital electrocardiogram (ECG) use, and FMC2B time among patients with STEMI. METHODS We performed a retrospective cohort study including all STEMI patients in the ACTION-Get With The Guidelines registry from July 1, 2008, to September 30, 2012, who were transported by ambulance to a PCI center. Patient home distance was defined as the driving distance from the patient's home zip code to the PCI center address. Distance was classified into tertiles, and linear regression was used to characterize the interaction between prehospital ECG use and patient home distance with respect to FMC2B time. RESULTS Of the 29,506 STEMI patients, 19,690 (67%) received a prehospital ECG. The median patient home distance to the PCI center was 11.0 miles among patients with and 9.9 miles among those without a prehospital ECG. Prehospital ECGs were associated with a 10-minute reduction in the FMC2B time (P < .0001), which was consistent across distance tertiles (11 vs 11 vs 10 minutes). The association between prehospital ECGs and shorter FMC2B was attenuated by 0.8 minute for every 10-mile increase in distance (interaction P = .0002). CONCLUSIONS Prehospital ECGs are associated with a 10-minute reduction in the FMC2B time. However, patient home distance from a PCI center does not substantially change this association.
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Sherwood MW, Wiviott SD, Peng SA, Roe MT, Delemos J, Peterson ED, Wang TY. Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry. J Am Heart Assoc 2014; 3:e000849. [PMID: 24732921 PMCID: PMC4187510 DOI: 10.1161/jaha.114.000849] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [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: 01/10/2023]
Abstract
Background P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices. Methods and Results Using ACTION Registry‐GWTG (Get‐with‐the‐Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non‐ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients. Conclusions With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.
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Affiliation(s)
- Matthew W Sherwood
- Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC
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20
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Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Response to letter regarding article, "Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline Program". Circulation 2014; 129:e372. [PMID: 24589703 DOI: 10.1161/circulationaha.113.008027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akshay Bagai
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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21
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O'Brien EC, Fosbol EL, Peng SA, Alexander KP, Roe MT, Peterson ED. Association of body mass index and long-term outcomes in older patients with non-ST-segment-elevation myocardial infarction: results from the CRUSADE Registry. Circ Cardiovasc Qual Outcomes 2013; 7:102-9. [PMID: 24326936 DOI: 10.1161/circoutcomes.113.000421] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prior studies have found that obese patients have paradoxically lower in-hospital mortality after non-ST-segment-elevation myocardial infarction than their normal-weight counterparts, yet whether these associations persist long term is unknown. METHODS AND RESULTS We linked detailed clinical data for patients with non-ST-segment-elevation myocardial infarction aged ≥65 years in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Registry to Medicare claims data to obtain longitudinal outcomes. Using height and weight measured on admission, patients were categorized into 6 body mass index (BMI [kilograms per meter squared]) groups. Multivariable Cox proportional hazards models were used to estimate the association between BMI and (1) all-cause mortality, (2) all-cause readmission, (3) cardiovascular readmission, and (4) noncardiovascular readmission for 3 years after hospital discharge. Among older patients with non-ST-segment-elevation myocardial infarction (n=34,465), 36.3% were overweight and 27.7% were obese. Obese patients were younger and more likely to have hypertension, diabetes mellitus, and dyslipidemia than normal or underweight patients. Relative to normal-weight patients, long-term mortality was lower for patients classified as overweight (BMI, 25.0-29.9), obese class I (BMI, 30.0-34.9), and obese class II (BMI, 35.0-39.9), but not obese class III (BMI ≥40.0). In contrast, 3-year all-cause and cardiovascular readmission were similar across BMI categories. Relative to normal-weight patients, noncardiovascular readmissions were similar for obese class I but higher for obese class II and obese class III. CONCLUSIONS All-cause long-term mortality was generally lower for overweight and obese older patients after non-ST-segment-elevation myocardial infarction relative to those with normal weight. Longitudinal readmissions were similar or higher with increasing BMI.
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Affiliation(s)
- Emily C O'Brien
- Departments of Clinical Pharmacology and Outcomes Research Duke Clinical Research Institute, Durham, NC; and Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
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22
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Anderson ML, Peterson ED, Peng SA, Wang TY, Ohman EM, Bhatt DL, Saucedo JF, Roe MT. Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR. Circ Cardiovasc Qual Outcomes 2013; 6:708-15. [PMID: 24221834 DOI: 10.1161/circoutcomes.113.000262] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiogenic shock is a deadly complication of an acute myocardial infarction (MI). We sought to characterize differences in patient features, treatments, and outcomes of cardiogenic shock by MI classification: ST-segment-elevation MI (STEMI) versus non-ST-segment elevation MI (NSTEMI). METHODS AND RESULTS We compared differences in care by the shock status of 235 541 patients with STEMI and NSTEMI treated at 392 US hospitals from 2007 to 2011. Cardiogenic shock occurred in 12.2% of patients with STEMI versus 4.3% of patients with NSTEMI. Compared with STEMI shock, NSTEMI shock was more likely in patients who were older and predominantly women; had diabetes mellitus, hypertension, previous heart failure, MI, or peripheral arterial disease; and who received coronary artery bypass grafting (11.6% versus 21.2%; P<0.0001) but less likely to have received percutaneous coronary intervention (84.2% versus 35.3%; P<0.0001). Compared with patients with STEMI presenting with shock at admission, patients with NSTEMI presenting with shock had longer delays to percutaneous coronary intervention (1.2 versus 3.2 hours) and coronary artery bypass grafting (7.9 versus 55.9 hours). Cardiogenic shock in patients with STEMI was associated with a lower mortality risk (33.1% shock versus 2.0% no shock; adjusted odds ratio, 14.1; 95% confidence interval, 13.0-15.4; interaction P value <0.0001) compared with patients with NSTEMI (40.8% shock versus 2.3% no shock, odds ratio, 19.0; 95% confidence interval, 17.1-21.2). CONCLUSIONS Cardiogenic shock is associated with high mortality in patients with STEMI and NSTEMI. However, urgent revascularization is more commonly pursued in patients with STEMI presenting with shock than in patients with NSTEMI. More research is needed to improve the outcomes for patients with MI presenting with shock, particularly those presenting with NSTEMI.
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Affiliation(s)
- Monique L Anderson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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23
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Hess CN, Shah BR, Peng SA, Thomas L, Roe MT, Peterson ED. Association of early physician follow-up and 30-day readmission after non-ST-segment-elevation myocardial infarction among older patients. Circulation 2013; 128:1206-13. [PMID: 23946265 DOI: 10.1161/circulationaha.113.004569] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hospital readmission rates within 30 days after acute myocardial infarction are a national performance metric. Previous data suggest that early physician follow-up after heart failure hospitalizations can reduce readmissions; whether these results can be extended to acute myocardial infarction is unclear. METHODS AND RESULTS We analyzed data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) Registry linked with Medicare claims from 2003 to 2006 for 25 872 non-ST-segment-elevation myocardial infarction patients ≥65 years of age discharged home from 228 hospitals with >25 patients and full revascularization capabilities. After adjusting for patient, treatment, and hospital characteristics, we examined the relationship between hospital-level physician follow-up within 7 days of discharge and 30-day all-cause readmission using logistic regression. The median hospital-level percentage of patients receiving early physician follow-up was 23.3% (interquartile range, 17.1%-29.1%). Among 24 165 patients with Medicare fee-for-service eligibility 30 days after discharge, 18.5% of patients were readmitted within 30 days of index hospitalization. Unadjusted and adjusted rates of 30-day readmission did not differ among quartiles of hospital-level early physician follow-up. Similarly, each 5% increase in hospital early follow-up was associated with an insignificant change in risk for readmission (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02; P=0.60). Sensitivity analyses extended these null findings to 30-day cardiovascular readmissions, high-risk subgroups, and early cardiology follow-up. CONCLUSIONS Although rates of early physician follow-up after acute myocardial infarction varied among US hospitals, hospitals with higher early follow-up rates did not have lower 30-day readmission rates. Targeting strategies other than early physician follow-up may be necessary to reduce readmissions in this population.
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Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram. Circulation 2013; 128:352-9. [DOI: 10.1161/circulationaha.113.002339] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Akshay Bagai
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - James G. Jollis
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Harold L. Dauerman
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - S. Andrew Peng
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Ivan C. Rokos
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Eric R. Bates
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - William J. French
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Christopher B. Granger
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Matthew T. Roe
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
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25
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Riley RF, Newby LK, Don CW, Alexander KP, Peterson ED, Peng SA, Gandhi SK, Kutcher MA, Amsterdam EA, Herrington DM. Guidelines-based treatment of anaemic STEMI patients: practice patterns and effects on in-hospital mortality: a retrospective analysis from the NCDR. Eur Heart J Acute Cardiovasc Care 2013; 2:35-43. [PMID: 24062932 PMCID: PMC3760583 DOI: 10.1177/2048872612471216] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/25/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anaemia is associated with an increased risk for morbidity and mortality in ST-elevation myocardial infarction (STEMI) patients. While several physiological mechanisms have been proposed to explain this association, decreased receipt of guidelines-based care may also contribute. We examined the relationship between admission haemoglobin (Hgb) level, receipt of ACC/AHA guidelines-based treatments, and in-hospital outcomes among STEMI patients. We also evaluated whether administration of these treatments modified the association between anaemia and in-hospital mortality in this group. METHODS AND RESULTS We analysed data from 92,686 patients diagnosed with STEMI included in the NCDR ACTION Registry-GWTG database from January 2007 to March 2011. Patients were stratified by initial Hgb value: 83.1% (n=77,035) were classified as non-anaemic (Hgb >13.0 g/dl for men, >12.0 g/dl for women), 11.6% (n=10,710) as mildly anaemic (11.1-13.0 g/dl for men, 11.1-12.0 g/dl for women), 4.4% (n=4059) as moderately anaemic (9.1-11.0 g/dl), and 1.0% (n=882) as severely anaemic (<9.0 g/dl). Anaemia was associated with a significantly increased prevalence of other baseline comorbidities and decreased odds of receiving several class I recommended pharmacological treatments (heparin, beta-blockers, and angiotensin-converting enzyme inhibitors, p<0.01). The overall use of reperfusion therapy (fibrinolytic therapy and/or percutaneous coronary intervention) was also lower in anaemic vs. non-anaemic patients (p<0.01). Anaemia was associated higher in-hospital mortality risk, which remained significant after adjustment for use of guidelines-recommended therapies and interventions (p<0.01). CONCLUSIONS In a national sample of STEMI patients, anaemia on presentation was associated with decreased receipt of ACC/AHA guidelines-based care and higher in-hospital mortality. However, the higher mortality rates could not be fully explained by differences in in-hospital treatment.
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Affiliation(s)
- Robert F Riley
- Wake Forest University Health Sciences, Winston-Salem, USA
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, USA
- Duke University Medical Center, Durham, USA
| | | | - Karen P Alexander
- Duke Clinical Research Institute, Durham, USA
- Duke University Medical Center, Durham, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, USA
- Duke University Medical Center, Durham, USA
| | | | | | | | - Ezra A Amsterdam
- University of California (Davis) Medical Center, Sacramento, USA
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Enriquez JR, de Lemos JA, Parikh SV, Peng SA, Spertus JA, Holper EM, Roe MT, Rohatgi A, Das SR. Association of chronic lung disease with treatments and outcomes patients with acute myocardial infarction. Am Heart J 2013; 165:43-9. [PMID: 23237132 DOI: 10.1016/j.ahj.2012.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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: 07/25/2012] [Accepted: 09/19/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although chronic lung disease (CLD) is common among patients with myocardial infarction (MI), little is known about the influence of CLD on patient management and outcomes following MI. METHODS Using the National Cardiovascular Data Registry's ACTION Registry-GWTG, demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after acute MI were compared between patients with (n = 22,624) and without (n = 136,266) CLD. Multivariable adjustment was performed to determine the independent association of CLD with treatments and adverse events. RESULTS CLD (17.0% of non-ST-elevation MI [NSTEMI] and 10.1% of ST-elevation MI [STEMI] patients) was associated with older age, female sex, and a greater burden of comorbidities. Among NSTEMI patients, those with CLD were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft compared to those without; in contrast, no differences were seen in invasive therapies for STEMI patients with or without CLD. Multivariable-adjusted risk of major bleeding was significantly increased in CLD patients with NSTEMI (13.0% vs 8.1%, OR(adj) = 1.27, 95% CI = 1.20-1.34, P < .001) and STEMI (16.0% vs 10.5%, OR(adj) = 1.19, 95% CI = 1.10-1.29, P < .001). In NSTEMI, CLD was associated with a higher risk of inhospital mortality (OR(adj) = 1.21, 95% CI = 1.11-1.33); in STEMI no association between CLD and mortality was seen (OR(adj) = 1.05, 95% CI = 0.95-1.17). CONCLUSIONS CLD is common among patients with MI and is independently associated with an increased risk for major bleeding. In NSTEMI, CLD is also associated with receiving less revascularization and with increased in-hospital mortality. Special attention should be given to this high-risk subgroup for the prevention and management of complications after MI.
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Maddox TM, Ho PM, Tsai TT, Wang TY, Li S, Peng SA, Wiviott SD, Masoudi FA, Rumsfeld JS. Clopidogrel Use and Hospital Quality in Medically Managed Patients With Non–ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2012; 5:523-31. [DOI: 10.1161/circoutcomes.112.965285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [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] [Indexed: 11/16/2022]
Abstract
Background—
Clopidogrel prescription is a class I guideline recommendation for medically managed patients with non–ST-segment–elevation myocardial infarction (NSTEMI). However, clopidogrel has historically been underused in this population. We evaluated contemporary rates of its use and evaluated associated factors, with a particular focus on hospital quality of myocardial infarction (MI) care.
Methods and Results—
We examined clopidogrel prescription rates among 23 186 patients with NSTEMI discharged from 382 US hospitals between October 2009 and March 2011. Associations between clopidogrel prescription and various patient and hospital factors, including hospital quality of MI care, were determined with regression modeling. Of the sample, 54.9% of eligible patients with NSTEMI received clopidogrel prescription at hospital discharge. Variation in rate by hospital was large, ranging from 22% to 97%. A variety of patient and hospital factors were associated with clopidogrel prescription. Hospital quality of MI care demonstrated modest association with clopidogrel prescription (odds ratio, 0.68; 95% CI, 0.54–0.85) between the lowest and highest hospital quality quartile) and accounted for 5.7% of the variation in prescription rates.
Conclusions—
Clopidogrel prescription is significantly underused in the medically managed NSTEMI population and demonstrates wide variability by hospital. Although hospital quality of MI care is associated with its use, the findings suggest that it only has a modest effect. Therefore, efforts to improve clopidogrel use likely will require measures beyond improving the overall hospital quality of MI care.
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Affiliation(s)
- Thomas M. Maddox
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - P. Michael Ho
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - Thomas T. Tsai
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - Tracy Y. Wang
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - Shuang Li
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - S. Andrew Peng
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - Stephen D. Wiviott
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - Fredrick A. Masoudi
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
| | - John S. Rumsfeld
- From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., P.M.H., T.T.T., J.S.R.); University of Colorado Denver, Aurora, CO (T.M.M., P.M.H., T.T.T, F.A.M.); Duke Clinical Research Institute, Durham, NC (T.Y.W., S.L., S.A.P.); and TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medicine School, Boston, MA (S.D.W.)
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Riley RF, Newby LK, Don C, Gandhi S, Alexander K, Peng SA, Kutcher M, Amsterdam E, Herrington D. ASSOCIATION BETWEEN ADMISSION HEMOGLOBIN LEVEL AND GUIDELINE-BASED THERAPY IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: AN ANALYSIS FROM THE NCDR®. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)61818-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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