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Gaba P, Sabik JF, Murphy SA, Bellavia A, O'Gara PT, Smith PK, Serruys PW, Kappetein AP, Park SJ, Park DW, Christiansen EH, Holm NR, Nielsen PH, Sabatine MS, Stone GW, Bergmark BA. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main Disease With and Without Diabetes: Findings From a Pooled Analysis of 4 Randomized Clinical Trials. Circulation 2024; 149:1328-1338. [PMID: 38465592 DOI: 10.1161/circulationaha.123.065571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Diabetes may be associated with differential outcomes in patients undergoing left main coronary revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The aim of this study was to investigate outcomes in patients with left main disease with and without diabetes randomized to PCI versus CABG. METHODS Individual patient data were pooled from 4 trials (SYNTAX [Synergy Between PCI With Taxus and Cardiac Surgery], PRECOMBAT [Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease], NOBLE [Nordic-Baltic-British Left Main Revascularisation Study], and EXCEL [Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization]) that randomized patients with left main disease to PCI or CABG. Patients were considered suitable for either approach. Patients were categorized by diabetes status. Kaplan-Meier event rates, Cox model hazard ratios, and interactions were assessed. RESULTS Among 4393 patients, 1104 (25.1%) had diabetes. Patients with diabetes experienced higher rates of 5-year death (158/1104 [Kaplan-Meier rate, 14.7%] versus 297/3289 [9.3%]; P<0.001), spontaneous myocardial infarction (MI; 67/1104 [6.7%] versus 114/3289 [3.7%]; P<0.001), and repeat revascularization (189/1104 [18.5%] versus 410/3289 [13.2%]; P<0.001). Rates of all-cause mortality did not differ after PCI versus CABG in those with (84/563 [15.3%] versus 74/541 [14.1%]; hazard ratio, 1.11 [95% CI, 0.82-1.52]) or without (155/1634 [9.7%] versus 142/1655 [8.9%]; hazard ratio, 1.08 [95% CI, 0.86-1.36; PintHR=0.87) diabetes. Rates of stroke within 1 year were lower with PCI versus CABG in the entire population, with no heterogeneity based on diabetes status (PintHR=0.51). The 5-year rates of spontaneous MI and repeat coronary revascularization were higher after PCI regardless of diabetes status (spontaneous MI: 45/563 [8.9%] versus 22/541 [4.4%] in diabetes and 82/1634 [5.3%] versus 32/1655 [2.1%] in no diabetes, PintHR=0.47; repeat revascularization: 127/563 [24.5%] versus 62/541 [12.4%] in diabetes and 254/1634 [16.3%] versus 156/1655 [10.1%] in no diabetes, PintHR=0.18). For spontaneous MI and repeat revascularization, there were greater absolute risk differences beyond 1 year in patients with diabetes (4.9% and 9.9%) compared with those without (2.1% and 4.3%; PintARD=0.047 and 0.016). CONCLUSIONS In patients with left main disease considered equally suitable for PCI or CABG and with largely low to intermediate SYNTAX scores, diabetes was associated with higher rates of death and cardiovascular events through 5 years. Compared with CABG, PCI resulted in no difference in the risk of death and a lower risk of early stroke regardless of diabetes status, and a higher risk of spontaneous MI and repeat coronary revascularization, with larger late absolute excess risks in patients with diabetes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01205776, NCT0146651, NCT00422968, and NCT00114972.
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Affiliation(s)
- Prakriti Gaba
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (P.G., S.A.M., A.B., M.S.S., B.A.B.)
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | - Sabina A Murphy
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (P.G., S.A.M., A.B., M.S.S., B.A.B.)
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
| | - Andrea Bellavia
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (P.G., S.A.M., A.B., M.S.S., B.A.B.)
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
| | - Peter K Smith
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC (P.K.S)
| | - Patrick W Serruys
- National Heart and Lung Institute, Imperial College London, UK (P.W.S.)
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands (A.P.K.)
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea (S.-J.P., D.-W.P.,)
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea (S.-J.P., D.-W.P.,)
| | - Evald H Christiansen
- Department of Cardiology, Aarhus, Aarhus University Hospital, Denmark (E.H.C., N.R.H., P.H.N.)
| | - Niels R Holm
- Department of Cardiology, Aarhus, Aarhus University Hospital, Denmark (E.H.C., N.R.H., P.H.N.)
| | - Per H Nielsen
- Department of Cardiology, Aarhus, Aarhus University Hospital, Denmark (E.H.C., N.R.H., P.H.N.)
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (P.G., S.A.M., A.B., M.S.S., B.A.B.)
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
| | - Brian A Bergmark
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA (P.G., S.A.M., A.B., M.S.S., B.A.B.)
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (P.G., S.A.M., A.B., P.T.O., M.S.S., B.A.B.)
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Bellavia A, Murphy SA. Summarizing Primary Results in Clinical Trials With a Time-to-Event End Point: Complementing Different Measures for a Comprehensive Assessment of Treatment Effect. Circulation 2024; 149:1154-1156. [PMID: 38588333 DOI: 10.1161/circulationaha.123.068037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Andrea Bellavia
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Bergmark BA, Marston NA, Prohaska TA, Alexander VJ, Zimerman A, Moura FA, Murphy SA, Goodrich EL, Zhang S, Gaudet D, Karwatowska-Prokopczuk E, Tsimikas S, Giugliano RP, Sabatine MS. Olezarsen for Hypertriglyceridemia in Patients at High Cardiovascular Risk. N Engl J Med 2024. [PMID: 38587249 DOI: 10.1056/nejmoa2402309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Reducing the levels of triglycerides and triglyceride-rich lipoproteins remains an unmet clinical need. Olezarsen is an antisense oligonucleotide targeting messenger RNA for apolipoprotein C-III (APOC3), a genetically validated target for triglyceride lowering. METHODS In this phase 2b, randomized, controlled trial, we assigned adults either with moderate hypertriglyceridemia (triglyceride level, 150 to 499 mg per deciliter) and elevated cardiovascular risk or with severe hypertriglyceridemia (triglyceride level, ≥500 mg per deciliter) in a 1:1 ratio to either a 50-mg or 80-mg cohort. Patients were then assigned in a 3:1 ratio to receive monthly subcutaneous olezarsen or matching placebo within each cohort. The primary outcome was the percent change in the triglyceride level from baseline to 6 months, reported as the difference between each olezarsen group and placebo. Key secondary outcomes were changes in levels of APOC3, apolipoprotein B, non-high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol. RESULTS A total of 154 patients underwent randomization at 24 sites in North America. The median age of the patients was 62 years, and the median triglyceride level was 241.5 mg per deciliter. The 50-mg and 80-mg doses of olezarsen reduced triglyceride levels by 49.3 percentage points and 53.1 percentage points, respectively, as compared with placebo (P<0.001 for both comparisons). As compared with placebo, each dose of olezarsen also significantly reduced the levels of APOC3, apolipoprotein B, and non-HDL cholesterol, with no significant change in the LDL cholesterol level. The risks of adverse events and serious adverse events were similar in the three groups. Clinically meaningful hepatic, renal, or platelet abnormalities were uncommon, with similar risks in the three groups. CONCLUSIONS In patients with predominantly moderate hypertriglyceridemia at elevated cardiovascular risk, olezarsen significantly reduced levels of triglycerides, apolipoprotein B, and non-HDL cholesterol, with no major safety concerns identified. (Funded by Ionis Pharmaceuticals; Bridge-TIMI 73a ClinicalTrials.gov number, NCT05355402.).
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Affiliation(s)
- Brian A Bergmark
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Nicholas A Marston
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Thomas A Prohaska
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Veronica J Alexander
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - André Zimerman
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Filipe A Moura
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Sabina A Murphy
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Erica L Goodrich
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Shuanglu Zhang
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Daniel Gaudet
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Ewa Karwatowska-Prokopczuk
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Sotirios Tsimikas
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Robert P Giugliano
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
| | - Marc S Sabatine
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston (B.A.B., N.A.M., A.Z., F.A.M., S.A.M., E.L.G., S.Z., R.P.G., M.S.S.); Ionis Pharmaceuticals, Carlsbad (T.A.P., V.J.A., E.K.-P., S.T.), and the Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla (S.T.) - both in California; and the Department of Medicine, Université de Montréal and Ecogene-21 Clinical Research Centre, Quebec, QC, Canada (D.G.)
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Bohula EA, Marston NA, Ruzza A, Murphy SA, De Ferrari GM, Diaz R, Leiter LA, Elliott-Davey M, Wang H, Bhatia AK, Giugliano RP, Sabatine MS. Rationale and design of the effect of evolocumab in patients at high cardiovascular risk without prior myocardial infarction or stroke (VESALIUS-CV) trial. Am Heart J 2024; 269:179-190. [PMID: 38160917 DOI: 10.1016/j.ahj.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The reduction of low-density lipoprotein cholesterol (LDL-C) with evolocumab, a fully human monoclonal antibody inhibitor of proprotein convertase subtilisin/kexin type 9 (PCSK9i), reduces the risk of major adverse cardiovascular events in patients with established atherosclerotic cardiovascular disease (ASCVD) with a prior MI, prior stroke, or symptomatic peripheral artery disease, with no offsetting safety concerns. The effect of evolocumab on CV outcomes in lower risk patients without a history of MI or stroke has not been explored. STUDY DESIGN VESALIUS-CV is a randomized, double-blind, placebo-controlled, global clinical trial designed to evaluate the effect of evolocumab on the risk of major cardiovascular events in patients at high cardiovascular risk but without a prior ischemic event. The study population consists of 12,301 patients with atherosclerosis or high-risk diabetes mellitus without a prior MI or stroke; an LDL-C ≥ 90 mg/dL, or non-high-density lipoprotein cholesterol (non-HDL-C) ≥ 120 mg/dL, or apolipoprotein B ≥ 80 mg/dL; and treated with optimized lipid-lowering therapy. Patients were randomized in a 1:1 ratio to evolocumab 140 mg subcutaneously every 2 weeks or matching placebo. The primary efficacy objective is to assess whether evolocumab reduces the risk of the dual primary composite endpoints of coronary heart disease (CHD) death, myocardial infarction (MI), or ischemic stroke (triple primary endpoint) and of CHD death, MI, ischemic stroke, or ischemia-driven arterial revascularization (quadruple primary endpoint). Recruitment began in June 2019 and completed in November 2021. The trial is planned to continue until at least 751 patients experience an adjudicated triple endpoint, at least 1254 experience an adjudicated quadruple endpoint, and the median follow-up is ≥4.5 years. CONCLUSION VESALIUS-CV will determine whether the addition of evolocumab to optimized lipid-lowering therapy reduces cardiovascular events in patients at high cardiovascular risk without a prior MI or stroke. TRIAL REGISTRATION NCT03872401.
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Affiliation(s)
- Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Nicholas A Marston
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gaetano M De Ferrari
- Department of Medical Sciences, University of Turin and Department of Cardiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Rafael Diaz
- Estudios Clínicos Latino America, Santa Fe, Argentina
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Marston NA, Melloni GEM, Murphy SA, Morze J, Kamanu FK, Ellinor PT, Ruff CT, Sabatine MS. Per-Particle Cardiovascular Risk of Lipoprotein(a) vs Non-Lp(a) Apolipoprotein B-Containing Lipoproteins. J Am Coll Cardiol 2024; 83:470-472. [PMID: 38233021 DOI: 10.1016/j.jacc.2023.09.836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/25/2023] [Accepted: 09/13/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Nicholas A Marston
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Giorgio E M Melloni
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sabina A Murphy
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jakub Morze
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; University of Warmia and Mazury, Olsztyn, Poland
| | - Frederick K Kamanu
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian T Ruff
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zimerman A, Wiviott SD, Park JG, Murphy SA, Ran X, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Verma S, Wojakowski W, Terra SG, Sabatine MS, Bergmark BA, Marston NA. Hepatic fat changes with antisense oligonucleotide therapy targeting ANGPTL3. J Clin Lipidol 2023:S1933-2874(23)00351-3. [PMID: 38158248 DOI: 10.1016/j.jacl.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Angiopoietin-like protein 3 (ANGPTL3) is a novel therapeutic target for hyperlipidemia. Vupanorsen, an antisense oligonucleotide targeting ANGPTL3, reduced triglycerides up to 57% in a phase 2b trial, but caused dose-dependent increases in hepatic fat fraction (HFF). OBJECTIVE To determine the degree of HFF progression with escalating doses of vupanorsen, differential HFF increases in key patient subgroups, and the correlation between changes in HFF and liver enzymes. METHODS TRANSLATE-TIMI 70 was a randomized, placebo-controlled trial testing 7 dosing regimens of vupanorsen in 286 adults with hyperlipidemia. A total of 227 patients had HFF measured at baseline and 24 weeks and were included in this analysis. RESULTS The median HFF at baseline was 8.5%. Vupanorsen led to dose-dependent relative increases in HFF of up to 76% at 24 weeks (p < 0.001), corresponding to an absolute increase of up to 7.0% at the highest dose (p < 0.001). Increases in HFF were numerically greater in patients who had elevated baseline HFF, body mass index, triglycerides, or diabetes. Vupanorsen also increased liver enzymes in a dose-dependent manner, and changes in HFF were moderately positively correlated with changes in AST (rho = 0.49, p < 0.001) and ALT (rho = 0.50, p < 0.001). CONCLUSION Vupanorsen, an inhibitor of ANGPTL3 protein synthesis, caused dose-dependent increases in HFF. Increases in HFF were only moderately correlated with elevations in AST and ALT, suggesting that liver enzymes are an imperfect indicator to detect increases in hepatic fat. These results highlight the need to monitor HFF in clinical trials of therapies targeting intracellular ANGPTL3 inhibition, especially those that are targeted to the liver.
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Affiliation(s)
- Andre Zimerman
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Xinhui Ran
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Candace R Bramson
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Madelyn Curto
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Vesper Ramos
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada (Dr. Verma)
| | | | - Steven G Terra
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston).
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Fagundes A, Ruff CT, Morrow DA, Murphy SA, Palazzolo MG, Chen CZ, Jarolim P, Antman EM, Braunwald E, Giugliano RP. Neutrophil-lymphocyte ratio and clinical outcomes in 19,697 patients with atrial fibrillation: Analyses from ENGAGE AF- TIMI 48 trial. Int J Cardiol 2023; 386:118-124. [PMID: 37211048 DOI: 10.1016/j.ijcard.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/30/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) is the ratio between neutrophil and lymphocyte counts measured in peripheral blood. NLR is easily calculable based on a routine blood test available worldwide and may reflect systemic inflammation. However, the relationship between NLR and clinical outcomes in atrial fibrillation (AF) patients is not well-described. METHODS We calculated NLR at baseline in ENGAGE AF-TIMI 48, a randomized trial comparing edoxaban versus warfarin in patients with AF followed for 2.8 years (median). The association of baseline NLR with major bleeding events, major adverse cardiac events (MACE), cardiovascular death, stroke/systemic embolism, and all-cause mortality were calculated. RESULTS The median baseline NLR in 19,697 patients was 2.53 (interquartile range 1.89-3.41). NLR was associated with major bleeding events (HR 1.60; 95% CI 1.41-1.80), stroke/systemic embolism (HR 1.25; 95% CI, 1.09-1.44), MI (HR 1.73; 95% CI 1.41-2.12), MACE (HR 1.70; 95% CI 1.56-1.84), CV (HR 1.93; 95% CI 1.74-2.13) and all-cause mortality (HR 2.00; 95% CI 1.83-2.18). The relationships between NLR and outcomes remained significant after adjustment for risk factors. Edoxaban consistently reduced major bleeding. MACE, and CV death across NLR groups vs. warfarin. CONCLUSIONS NLR represents a widely available, simple, arithmetic calculation that could be immediately and automatically reported during a white blood cell differential measurement to identify patients with AF at increased risk of bleeding, CV events, and mortality.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA; IDOR, D'Or Institute for Research and Education, DFStar Hospital, Brasília, DF, Brazil
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael G Palazzolo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Z Chen
- Daiichi Sankyo Inc., Global Specialty Medical Affairs, Basking Ridge, NJ, USA
| | - Petr Jarolim
- Biomarker Research and Clinical Trials Laboratory, Brigham and Women's Hospital, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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8
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Burton S, Landers T, Wilson M, Ortiz-Gumina C, Persaud A, McNeill Ransom M, Fox L, Murphy SA. Public health infection prevention: An analysis of existing training during the COVID-19 pandemic. Public Health 2023; 222:7-12. [PMID: 37494870 DOI: 10.1016/j.puhe.2023.06.029] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES In response to the COVID-19 pandemic, agencies and organizations required trainings to support the needs of the public health workforce. To better understand the training resources available, this study identified, organized, and classified infection prevention and control (IPC) training and educational opportunities. STUDY DESIGN Environmental scan. METHODS A total of 306 IPC training resources were compiled between January and April 2021. Key themes and topics were identified and compared to the Healthcare Infection Control Practices Advisory Committee's (HICPAC) core IPC practices. RESULTS Three hundred and six training resources, including webinars, fact sheets, module-based learning activities, infographics, and professional practice guidance materials, were identified. Common themes included proper use of personal protective equipment (e.g., masks, gloves), community reopening guidance, and mass vaccination resources. A large proportion (74.9%) of trainings were under 60 min. Using the HICPAC framework, the most frequently addressed content included standard precautions (40%), leadership support (31.6%), and transmission-based precautions (25.8%). Few trainings addressed performance monitoring and feedback (17.1%). CONCLUSIONS A wide range of organizations developed IPC-specific content during the pandemic. However, these resources did not address the breadth of knowledge required to implement IPC concepts effectively. The creation of universally applicable IPC core competencies and the development of high-quality IPC education and trainings for public health and the overall responder workforces should be prioritized. Accessible high-quality online and just-in-time trainings are critical for future pandemic and disaster preparedness.
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Affiliation(s)
- S Burton
- Tulane University, New Orleans, LA, USA
| | - T Landers
- Nationwide Children's Hospital, Columbus, OH, USA
| | - M Wilson
- Tulane University, New Orleans, LA, USA
| | | | | | - M McNeill Ransom
- National Coordinating Center for Public Health Training, NNPHI, USA
| | - L Fox
- National Network of Public Health Institutes, New Orleans, LA, USA
| | - S A Murphy
- Tulane University, New Orleans, LA, USA.
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9
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Gaba P, Christiansen EH, Nielsen PH, Murphy SA, O’Gara PT, Smith PK, Serruys PW, Kappetein AP, Park SJ, Park DW, Stone GW, Sabik JF, Sabatine MS, Holm NR, Bergmark BA. Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes: A Pooled Analysis of 4 Randomized Clinical Trials. JAMA Cardiol 2023; 8:631-639. [PMID: 37256598 PMCID: PMC10233454 DOI: 10.1001/jamacardio.2023.1177] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 06/01/2023]
Abstract
Importance Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis. Objective To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS. Design, Setting, and Participants Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023. Main Outcomes and Measures The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. Results Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P < .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P < .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P < .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status. Conclusion and Relevance Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status. Trial Registration ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776.
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Affiliation(s)
- Prakriti Gaba
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Per H. Nielsen
- Department of Cardiology, Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Sabina A. Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick T. O’Gara
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - Peter K. Smith
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Patrick W. Serruys
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - A. Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph F. Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - Niels R. Holm
- Department of Cardiology, Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Brian A. Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Schechter M, Wiviott SD, Raz I, Goodrich EL, Rozenberg A, Yanuv I, Murphy SA, Zelniker TA, Fredriksson M, Johansson PA, Leiter LA, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Cahn A, Langkilde AM, Sabatine MS, Mosenzon O. Effects of dapagliflozin on hospitalisations in people with type 2 diabetes: post-hoc analyses of the DECLARE-TIMI 58 trial. Lancet Diabetes Endocrinol 2023; 11:233-241. [PMID: 36878239 DOI: 10.1016/s2213-8587(23)00009-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND In people with type 2 diabetes at high risk of cardiovascular or kidney disease, sodium-glucose co-transporter 2 (SGLT2) inhibitors consistently reduce the risk of hospitalisations for heart failure. Less is known about their effects on hospitalisation from any cause, especially in people with type 2 diabetes without atherosclerotic cardiovascular disease, which includes most of the global population of people with type 2 diabetes. We aimed to assess the effect of the SGLT2 inhibitor, dapagliflozin, on the risks of hospitalisations for any cause and for specific causes in people with type 2 diabetes with and without atherosclerotic cardiovascular disease. METHODS The DECLARE-TIMI 58 trial was a double-blind, multicentre, randomised, placebo-controlled study. People with type 2 diabetes and either risk factors for or established atherosclerotic cardiovascular disease were randomly assigned (1:1) to receive oral dapagliflozin 10 mg or placebo once daily. In these post-hoc analyses, the effects of dapagliflozin on risks of first non-elective any-cause and cause-specific hospitalisation were assessed with Cox proportional hazards regression models overall and in the subset of participants without prevalent atherosclerotic cardiovascular disease. The risk of total (first plus subsequent) non-elective hospitalisations was assessed with Lin-Wei-Ying-Yang model. Investigator-reported System Organ Class terms were used to classify cause-specific hospitalisations. The trial is registered with ClinicalTrials.gov, NCT01730534. FINDINGS Between April 25, 2013, and Sept 18, 2018, 17 160 people (6422 [37·4%] women, 10 738 [62·6%] men; mean age 63·9 years [SD 6·8]) were enrolled in the original trial, of whom 10186 (59·4%) had multiple risk factors for but did not have established atherosclerotic cardiovascular disease, and 6835 (39·8%) had both no evidence of atherosclerotic cardiovascular disease and low KDIGO risk. Over a median follow-up of 4·2 years (IQR 3·9-4·4), dapagliflozin was associated with a lower risk of first non-elective hospitalisation for any cause (2779 [32·4%] of 8582 people in the dapagliflozin group vs 3036 [35·4%] of 8578 people in the placebo group; hazard ratio [HR] 0·89 [95% CI 0·85-0·94]) and total (first plus subsequent) non-elective hospitalisations for any cause (risk ratio 0·92 [95% CI 0·86-0·97]). The association between dapagliflozin use and the risk of first non-elective hospitalisation for any cause was consistent in subgroups of participants with (HR 0·92 [95% CI 0·85-0·99] and without (0·87 [0·81-0·94]) atherosclerotic cardiovascular disease at baseline (p interaction=0·31). Compared with the placebo group, the dapagliflozin group had lower risk of first hospitalisations due to cardiac disorders (HR 0·91 [95% CI 0·84-1·00]), metabolism and nutrition disorders (0·73 [0·60-0·89]), renal and urinary disorders (0·61 [0·49-0·77]), and due to any other cause excluding these three causes (0·90 [0·85-0·96]). Treatment with dapagliflozin was also associated with a lower risk of hospitalisations due to musculoskeletal and connective tissue disorders (HR 0·81 [0·67-0·99]) and infections and infastations (HR 0·86 [0·78-0·96]). INTERPRETATION Dapagliflozin reduced the risk of first and total non-elective hospitalisations for any cause in people with type 2 diabetes, regardless of the presence of atherosclerotic cardiovascular disease, including hospitalisations not directly attributed to cardiac, kidney, or metabolic causes. These findings might have implications on health-related quality of life for people with type 2 diabetes and on health-care costs attributable this condition. FUNDING AstraZeneca.
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Affiliation(s)
- Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen D Wiviott
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Fredriksson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Peter A Johansson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Internal Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Marc S Sabatine
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Zimerman A, Ruff CT, Palazzolo M, Murphy SA, Antman EM, Braunwald E, Giugliano RP. EDOXABAN 30 MG VS WARFARIN IN 2,406 PATIENTS AGE ≥80 YEARS: A RANDOMIZED ANALYSIS FROM ENGAGE AF-TIMI 48. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00491-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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12
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Gaba P, O'Donoghue ML, Park JG, Wiviott SD, Atar D, Kuder JF, Im K, Murphy SA, De Ferrari GM, Gaciong ZA, Toth K, Gouni-Berthold I, Lopez-Miranda J, Schiele F, Mach F, Flores-Arredondo JH, López JAG, Elliott-Davey M, Wang B, Monsalvo ML, Abbasi S, Giugliano RP, Sabatine MS. Association Between Achieved Low-Density Lipoprotein Cholesterol Levels and Long-Term Cardiovascular and Safety Outcomes: An Analysis of FOURIER-OLE. Circulation 2023; 147:1192-1203. [PMID: 36779348 DOI: 10.1161/circulationaha.122.063399] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) level is a well-established risk factor for atherosclerotic cardiovascular disease. However, the optimal achieved LDL-C level with regard to efficacy and safety in the long term remains unknown. METHODS In FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk), 27 564 patients with stable atherosclerotic cardiovascular disease were randomized to evolocumab versus placebo, with a median follow-up of 2.2 years. In the open-label extension (FOURIER-OLE), 6635 of these patients were transitioned to open-label evolocumab regardless of initial treatment allocation in the parent trial and were followed up with for an additional median of 5 years. In this prespecified analysis, we examined the relationship between achieved LDL-C levels (an average of the first 2 LDL-C levels measured) in FOURIER-OLE (available in 6559 patients) and the incidence of subsequent cardiovascular and safety outcomes. We also performed sensitivity analyses evaluating cardiovascular and safety outcomes in the entire FOURIER and FOURIER-OLE patient population. Multivariable modeling was used to adjust for baseline factors associated with achieved LDL-C levels. RESULTS In FOURIER-OLE, 1604 (24%), 2627 (40%), 1031 (16%), 486 (7%), and 811 (12%) patients achieved LDL-C levels of <20, 20 to <40, 40 to <55, 55 to <70, and ≥70 mg/dL, respectively. There was a monotonic relationship between lower achieved LDL-C levels-down to very low levels <20 mg/dL-and a lower risk of the trial's primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, or hospital admission for unstable angina or coronary revascularization) and the key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) that persisted after multivariable adjustment (adjusted Ptrend<0.0001 for both end points). No statistically significant associations existed in the primary analyses between lower achieved LDL-C levels and increased risk of the safety outcomes (serious adverse events, new or recurrent cancer, cataract-related adverse events, hemorrhagic stroke, new-onset diabetes, neurocognitive adverse events, muscle-related events, or noncardiovascular death). Similar findings were noted in the entire FOURIER and FOURIER-OLE cohort up to a maximum follow-up of 8.6 years. CONCLUSIONS In patients with atherosclerotic cardiovascular disease, long-term achievement of lower LDL-C levels, down to <20 mg/dL (<0.5 mmol/L), was associated with a lower risk of cardiovascular outcomes with no significant safety concerns. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01764633.
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Affiliation(s)
- Prakriti Gaba
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Michelle L O'Donoghue
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Dan Atar
- Division of Medicine, University of Oslo, Norway (D.A.)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Gaetano M De Ferrari
- Department of Medical Sciences, University of Turin and Department of Cardiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Turin, Italy (G.M.D.)
| | - Zbigniew A Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Poland (Z.A.G.)
| | - Kalman Toth
- 1st Department of Medicine, University of Pécs, Medical School, Hungary (K.T.)
| | - Ioanna Gouni-Berthold
- University of Cologne, Center for Endocrinology, Diabetes, and Preventative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Germany (I.G.-B.)
| | - Jose Lopez-Miranda
- Lipids and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, CIBEROBN, Spain (J.L.-M.)
| | | | - François Mach
- Cardiology Department, Geneva University Hospital, Switzerland (F.M.)
| | | | - J Antonio G López
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Mary Elliott-Davey
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Bei Wang
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | | | - Siddique Abbasi
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
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13
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Pollack R, Raz I, Wiviott SD, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Mosenzon O, Langkilde AM, Gause-Nilsson IAM, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Cahn A. Efficacy and Safety of Dapagliflozin by Baseline Insulin Regimen and Dose: Post Hoc Analyses From DECLARE-TIMI 58. Diabetes Care 2023; 46:156-164. [PMID: 36399721 DOI: 10.2337/dc22-1318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The cardiorenal benefits of adding sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy for patients on insulin, particularly those on intensive regimens that include short-acting (SA) insulin, have not been explored. RESEARCH DESIGN AND METHODS In Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomized to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular (CV), renal, metabolic, and safety outcomes with dapagliflozin versus placebo by insulin dose and regimen were studied with Cox regression models. RESULTS The study included 7,013 insulin users at baseline, with 4,650 (66.3%) patients on regimens including SA insulin. Insulin doses varied, with 2,443 (34.8%) patients receiving <0.5 IU/kg, 2,795 (39.9%) 0.5 to ≤1 IU/kg, and 1,339 (19.1%) >1 IU/kg. Dapagliflozin reduced CV death/hospitalization for heart failure among overall insulin users (hazard ratio [HR] 0.82 [95% CI 0.69-0.97]) and consistently in patients on insulin regimens with or without SA insulin (0.83 [0.67-1.03] and 0.78 [0.57-1.07], respectively, Pinteraction = 0.75). No heterogeneity was observed by insulin dose (Pinteraction = 0.43). The HR for major adverse CV events with dapagliflozin among insulin users (0.84 [0.74-0.97]) was similar irrespective of regimen or dose (Pinteraction = 0.75 and 0.07). Dapagliflozin reduced the rate of adverse renal outcomes overall and consistently across subgroups of insulin users. Decreases in HbA1c, weight, and systolic blood pressure with dapagliflozin were seen regardless of insulin dose or regimen. The known safety profile of dapagliflozin was unchanged in patients on intensive insulin regimens. CONCLUSIONS The benefits and safety of dapagliflozin were maintained in high-risk patients receiving high-dose or intensive insulin regimens including SA insulin.
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Affiliation(s)
- Rena Pollack
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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14
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Patel SM, Palazzolo MG, Murphy SA, Antman EM, Braunwald E, Lanz HJ, Lip GYH, Giugliano RP, Ruff CT. Evaluation of the atrial fibrillation better care pathway in the ENGAGE AF-TIMI 48 trial. Europace 2022; 24:1730-1738. [PMID: 36017608 DOI: 10.1093/europace/euac082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS The Atrial fibrillation Better Care (ABC) pathway is endorsed by guidelines to improve care of patients with atrial fibrillation (AF). However, whether the benefit of ABC pathway-concordant care is consistent across anticoagulants remains unclear. We assessed the association between ABC-concordant care and outcomes in this post hoc analysis from the ENGAGE AF-TIMI 48 trial, which was reported prior to the initial description of the ABC pathway. METHODS AND RESULTS Patients were retrospectively classified as receiving ABC-concordant care based on optimal anticoagulation, adequate rate control, management of co-morbidities and lifestyle measures. Associations between ABC-concordance and outcomes were assessed with adjustment for components of the CHA2DS2-VASc and HAS-BLED scores. Of 20 926 patients, 7915 (37.8%) satisfied criteria of ABC-concordant care, which was associated with significantly lower incidence of stroke or systemic embolic event [stroke/SEE: hazard ratio (HRadj): 0.54; 95% confidence interval (CI): 0.47-0.63], major bleeding (HRadj 0.66; 95% CI: 0.58-0.75), major adverse cardiac events (HRadj 0.53; 95% CI: 0.48-0.58), primary net clinical outcome (composite of stroke/SEE, major bleeding or death; HRadj 0.61; 95% CI: 0.56-0.65), cardiovascular (CV) hospitalization (HRadj 0.78; 95% CI: 0.74-0.83), CV death (HRadj 0.52; 95% CI: 0.46-0.58), and all-cause mortality (HRadj 0.56; 95% CI: 0.51-0.62), P < 0.001 for each. These associations were qualitatively consistent for both edoxaban and warfarin and across patient subgroups. CONCLUSION Atrial fibrillation Better Care pathway-concordant care is associated with reductions across multiple CV endpoints and all-cause mortality, with benefit in edoxaban- and warfarin-treated patients and across patient subgroups. Increasing implementation of ABC-concordant care may improve clinical outcomes of patients with AF irrespective of anticoagulant.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael G Palazzolo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elliot M Antman
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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15
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O'Donoghue ML, Rosenson RS, Gencer B, López JAG, Lepor NE, Baum SJ, Stout E, Gaudet D, Knusel B, Kuder JF, Ran X, Murphy SA, Wang H, Wu Y, Kassahun H, Sabatine MS. Small Interfering RNA to Reduce Lipoprotein(a) in Cardiovascular Disease. N Engl J Med 2022; 387:1855-1864. [PMID: 36342163 DOI: 10.1056/nejmoa2211023] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lipoprotein(a) is a presumed risk factor for atherosclerotic cardiovascular disease. Olpasiran is a small interfering RNA that reduces lipoprotein(a) synthesis in the liver. METHODS We conducted a randomized, double-blind, placebo-controlled, dose-finding trial involving patients with established atherosclerotic cardiovascular disease and a lipoprotein(a) concentration of more than 150 nmol per liter. Patients were randomly assigned to receive one of four doses of olpasiran (10 mg every 12 weeks, 75 mg every 12 weeks, 225 mg every 12 weeks, or 225 mg every 24 weeks) or matching placebo, administered subcutaneously. The primary end point was the percent change in the lipoprotein(a) concentration from baseline to week 36 (reported as the placebo-adjusted mean percent change). Safety was also assessed. RESULTS Among the 281 enrolled patients, the median concentration of lipoprotein(a) at baseline was 260.3 nmol per liter, and the median concentration of low-density lipoprotein cholesterol was 67.5 mg per deciliter. At baseline, 88% of the patients were taking statin therapy, 52% were taking ezetimibe, and 23% were taking a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor. At 36 weeks, the lipoprotein(a) concentration had increased by a mean of 3.6% in the placebo group, whereas olpasiran therapy had significantly and substantially reduced the lipoprotein(a) concentration in a dose-dependent manner, resulting in placebo-adjusted mean percent changes of -70.5% with the 10-mg dose, -97.4% with the 75-mg dose, -101.1% with the 225-mg dose administered every 12 weeks, and -100.5% with the 225-mg dose administered every 24 weeks (P<0.001 for all comparisons with baseline). The overall incidence of adverse events was similar across the trial groups. The most common olpasiran-related adverse events were injection-site reactions, primarily pain. CONCLUSIONS Olpasiran therapy significantly reduced lipoprotein(a) concentrations in patients with established atherosclerotic cardiovascular disease. Longer and larger trials will be necessary to determine the effect of olpasiran therapy on cardiovascular disease. (Funded by Amgen; OCEAN[a]-DOSE ClinicalTrials.gov number, NCT04270760.).
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Affiliation(s)
- Michelle L O'Donoghue
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Robert S Rosenson
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Baris Gencer
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - J Antonio G López
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Norman E Lepor
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Seth J Baum
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Elmer Stout
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Daniel Gaudet
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Beat Knusel
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Julia F Kuder
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Xinhui Ran
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Sabina A Murphy
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Huei Wang
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - You Wu
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Helina Kassahun
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
| | - Marc S Sabatine
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (M.L.O., J.F.K., X.R., S.A.M., M.S.S.); the Icahn School of Medicine, Mount Sinai Hospital, New York (R.S.R.); the Division of Cardiology, Geneva University Hospitals, Geneva, and the Institute of Primary Health Care, University of Bern, Bern - both in Switzerland (B.G.); Global Development, Amgen, Thousand Oaks (J.A.G.L., B.K., H.W., Y.W., H.K.), and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (N.E.L.) - both in California; Flourish Research and the Charles E. Schmidt College of Medicine, Florida Atlantic University - both in Boca Raton (S.J.B.); Crossroads Clinical Research, Mooresville, NC (E.S.); and the Department of Medicine, Université de Montréal, Montreal, and ECOGENE-21, Chicoutimi, QC - both in Canada (D.G.)
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16
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Bergmark B, Dallan LA, Pereira GT, Kuder JF, Murphy SA, Buccola J, Wollmuth J, Lopez J, Spinelli J, Meinen J, West NE, Croce K. Decision-Making During Percutaneous Coronary Intervention Guided by Optical Coherence Tomography: Insights From the LightLab Initiative. Circ Cardiovasc Interv 2022; 15:872-881. [PMID: 36378739 PMCID: PMC9648988 DOI: 10.1161/circinterventions.122.011851] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Use of intracoronary imaging is associated with improved outcomes in patients undergoing percutaneous coronary intervention (PCI). Yet, the impact of intracoronary imaging on real-time physician decision-making during PCI is not fully known. METHODS The LightLab Initiative is a multicenter, prospective, observational study designed to characterize the use of a standardized optical coherence tomography (OCT) workflow during PCI. Participating physicians performed pre-PCI and post-PCI OCT in accordance with this workflow and operator assessments of lesion characteristics and treatment plan were recorded for each lesion based on angiography alone and following OCT. Physicians were categorized as having low (n=15), intermediate (n=13), or high (n=14) OCT use in the year preceding participation. RESULTS Among 925 patients with 1328 lesions undergoing PCI, the prescribed OCT workflow was followed in 773 (84%) of patients with 836 lesions. Operator lesion assessment and decision-making during PCI changed with OCT use in 86% (721/836) of lesions. Pre-PCI OCT use changed operator decision-making in 80% of lesions, including lesion assessment (45%), vessel preparation strategy (27%), stent diameter (37%), and stent length (36%). Post-PCI OCT changed stent optimization decision-making in 31% of lesions. These findings were consistent across strata of physician prior OCT experience. CONCLUSIONS A standardized OCT workflow impacted PCI decision-making in 86% of lesions, with a predominant effect on pre-PCI lesion assessment and planning of treatment strategy. This finding was consistent regardless of operator experience level and provides insight into mechanisms by which intravascular imaging might improve PCI outcomes.
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Affiliation(s)
- Brian Bergmark
- CTO/Complex Coronary Intervention Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (B.B., K.C.).,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston (B.B., J.F.K., S.A.M.)
| | - Luis A.P. Dallan
- University Hospitals Cleveland Medical Center, OH (L.A.P.D., G.T.R.P.)
| | | | - Julia F. Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston (B.B., J.F.K., S.A.M.)
| | - Sabina A. Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston (B.B., J.F.K., S.A.M.)
| | - Jana Buccola
- Abbott Vascular, Santa Clara, CA (J.B., J.S., J.M., N.E.J.W.)
| | | | - John Lopez
- Loyola University Medical Center, Maywood, IL (J.L.)
| | - Joia Spinelli
- Abbott Vascular, Santa Clara, CA (J.B., J.S., J.M., N.E.J.W.)
| | - Jennifer Meinen
- Abbott Vascular, Santa Clara, CA (J.B., J.S., J.M., N.E.J.W.)
| | - Nick E.J. West
- Abbott Vascular, Santa Clara, CA (J.B., J.S., J.M., N.E.J.W.)
| | - Kevin Croce
- CTO/Complex Coronary Intervention Program, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (B.B., K.C.)
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17
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Bohula EA, Berg DD, Lopes MS, Connors JM, Babar I, Barnett CF, Chaudhry SP, Chopra A, Ginete W, Ieong MH, Katz JN, Kim EY, Kuder JF, Mazza E, McLean D, Mosier JM, Moskowitz A, Murphy SA, O’Donoghue ML, Park JG, Prasad R, Ruff CT, Shahrour MN, Sinha SS, Wiviott SD, Van Diepen S, Zainea M, Baird-Zars V, Sabatine MS, Morrow DA. Anticoagulation and Antiplatelet Therapy for Prevention of Venous and Arterial Thrombotic Events in Critically Ill Patients With COVID-19: COVID-PACT. Circulation 2022; 146:1344-1356. [PMID: 36036760 PMCID: PMC9624238 DOI: 10.1161/circulationaha.122.061533] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The efficacy and safety of prophylactic full-dose anticoagulation and antiplatelet therapy in critically ill COVID-19 patients remain uncertain. METHODS COVID-PACT (Prevention of Arteriovenous Thrombotic Events in Critically-ill COVID-19 Patients Trial) was a multicenter, 2×2 factorial, open-label, randomized-controlled trial with blinded end point adjudication in intensive care unit-level patients with COVID-19. Patients were randomly assigned to a strategy of full-dose anticoagulation or standard-dose prophylactic anticoagulation. Absent an indication for antiplatelet therapy, patients were additionally randomly assigned to either clopidogrel or no antiplatelet therapy. The primary efficacy outcome was the hierarchical composite of death attributable to venous or arterial thrombosis, pulmonary embolism, clinically evident deep venous thrombosis, type 1 myocardial infarction, ischemic stroke, systemic embolic event or acute limb ischemia, or clinically silent deep venous thrombosis, through hospital discharge or 28 days. The primary efficacy analyses included an unmatched win ratio and time-to-first event analysis while patients were on treatment. The primary safety outcome was fatal or life-threatening bleeding. The secondary safety outcome was moderate to severe bleeding. Recruitment was stopped early in March 2022 (≈50% planned recruitment) because of waning intensive care unit-level COVID-19 rates. RESULTS At 34 centers in the United States, 390 patients were randomly assigned between anticoagulation strategies and 292 between antiplatelet strategies (382 and 290 in the on-treatment analyses). At randomization, 99% of patients required advanced respiratory therapy, including 15% requiring invasive mechanical ventilation; 40% required invasive ventilation during hospitalization. Comparing anticoagulation strategies, a greater proportion of wins occurred with full-dose anticoagulation (12.3%) versus standard-dose prophylactic anticoagulation (6.4%; win ratio, 1.95 [95% CI, 1.08-3.55]; P=0.028). Results were consistent in time-to-event analysis for the primary efficacy end point (full-dose versus standard-dose incidence 19/191 [9.9%] versus 29/191 [15.2%]; hazard ratio, 0.56 [95% CI, 0.32-0.99]; P=0.046). The primary safety end point occurred in 4 (2.1%) on full dose and in 1 (0.5%) on standard dose (P=0.19); the secondary safety end point occurred in 15 (7.9%) versus 1 (0.5%; P=0.002). There was no difference in all-cause mortality (hazard ratio, 0.91 [95% CI, 0.56-1.48]; P=0.70). There were no differences in the primary efficacy or safety end points with clopidogrel versus no antiplatelet therapy. CONCLUSIONS In critically ill patients with COVID-19, full-dose anticoagulation, but not clopidogrel, reduced thrombotic complications with an increase in bleeding, driven primarily by transfusions in hemodynamically stable patients, and no apparent excess in mortality. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04409834.
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Affiliation(s)
- Erin A. Bohula
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Mathew S. Lopes
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jean M. Connors
- Hematology Division (J.M.C.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Ijlal Babar
- Singing River Health System, Ocean Springs, MS (I.B.)
| | | | | | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, NY (A.C.)
| | - Wilson Ginete
- Essentia Health St. Mary’s Medical Center, Duluth, MN (W.G.)
| | - Michael H. Ieong
- The Pulmonary Center, Boston University School of Medicine, MA (M.H.I.)
| | - Jason N. Katz
- Division of Cardiovascular Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - Edy Y. Kim
- Pulmonary and Critical Care Medicine Division (E.Y.K.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Julia F. Kuder
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Dalton McLean
- Moses H. Cone Memorial Hospital, Greensboro, NC (D.M.)
| | - Jarrod M. Mosier
- Department of Emergency Medicine and Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson (J.M.M.)
| | - Ari Moskowitz
- Beth Israel Deaconess Medical Center, Boston, MA (A.M.)
| | - Sabina A. Murphy
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Christian T. Ruff
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Sean Van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.V.D.)
| | | | - Vivian Baird-Zars
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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18
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O'Donoghue ML, Giugliano RP, Wiviott SD, Atar D, Keech A, Kuder JF, Im K, Murphy SA, Flores-Arredondo JH, López JAG, Elliott-Davey M, Wang B, Monsalvo ML, Abbasi S, Sabatine MS. Long-Term Evolocumab in Patients With Established Atherosclerotic Cardiovascular Disease. Circulation 2022; 146:1109-1119. [PMID: 36031810 DOI: 10.1161/circulationaha.122.061620] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk), the proprotein convertase subtilisin-kexin type 9 inhibitor evolocumab reduced low-density lipoprotein cholesterol (LDL-C) and risk of cardiovascular events and was safe and well tolerated over a median of 2.2 years of follow-up. However, large-scale, long-term data are lacking. METHODS The parent FOURIER trial randomized 27 564 patients with atherosclerotic cardiovascular disease and LDL-C ≥70 mg/dL on statin to evolocumab versus placebo. Patients completing FOURIER at participating sites were eligible to receive evolocumab in 2 open-label extension studies (FOURIER-OLE [FOURIER Open-Label Extension]) in the United States and Europe; primary analyses were pooled across studies. The primary end point was the incidence of adverse events. Lipid values and major adverse cardiovascular events were prospectively collected. RESULTS A total of 6635 patients were enrolled in FOURIER-OLE (3355 randomized to evolocumab and 3280 to placebo in the parent study). Median follow-up in FOURIER-OLE was 5.0 years; maximum exposure to evolocumab in parent plus FOURIER-OLE was 8.4 years. At 12 weeks in FOURIER-OLE, median LDL-C was 30 mg/dL, and 63.2% of patients achieved LDL-C <40 mg/dL on evolocumab. Incidences of serious adverse events, muscle-related events, new-onset diabetes, hemorrhagic stroke, and neurocognitive events with evolocumab long term did not exceed those for placebo-treated patients during the parent study and did not increase over time. During the FOURIER-OLE follow-up period, patients originally randomized in the parent trial to evolocumab versus placebo had a 15% lower risk of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina or coronary revascularization (hazard ratio, 0.85 [95% CI, 0.75-0.96]; P=0.008); a 20% lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80 [95% CI, 0.68-0.93]; P=0.003); and a 23% lower risk of cardiovascular death (hazard ratio, 0.77 [95% CI, 0.60-0.99]; P=0.04). CONCLUSIONS Long-term LDL-C lowering with evolocumab was associated with persistently low rates of adverse events for >8 years that did not exceed those observed in the original placebo arm during the parent study and led to further reductions in cardiovascular events compared with delayed treatment initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT02867813 and NCT03080935.
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Affiliation(s)
- Michelle L O'Donoghue
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Norway (D.A.)
- Institute of Clinical Medicine, University of Oslo, Norway (D.A.)
| | - Anthony Keech
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Julia F Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | | | - J Antonio G López
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | | | - Bei Wang
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Maria Laura Monsalvo
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Siddique Abbasi
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
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19
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Mosenzon O, Raz I, Wiviott SD, Schechter M, Goodrich EL, Yanuv I, Rozenberg A, Murphy SA, Zelniker TA, Langkilde AM, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Wilding JPH, McGuire DK, Bhatt DL, Leiter LA, Cahn A, Dwyer JP, Heerspink HJL, Sabatine MS. Dapagliflozin and Prevention of Kidney Disease Among Patients With Type 2 Diabetes: Post Hoc Analyses From the DECLARE-TIMI 58 Trial. Diabetes Care 2022; 45:2350-2359. [PMID: 35997319 PMCID: PMC9862307 DOI: 10.2337/dc22-0382] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In patients with moderate to severe albuminuric kidney disease, sodium-glucose cotransporter 2 inhibitors reduce the risk of kidney disease progression. These post hoc analyses assess the effects of dapagliflozin on kidney function decline in patients with type 2 diabetes (T2D), focusing on populations with low kidney risk. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) trial, patients with T2D at high cardiovascular risk were randomly assigned to dapagliflozin versus placebo. Outcomes were analyzed by treatment arms, overall, and by Kidney Disease: Improving Global Outcomes (KDIGO) risk categories. The prespecified kidney-specific composite outcome was a sustained decline ≥40% in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and kidney-related death. Other outcomes included incidence of categorical eGFR decline of different thresholds and chronic (6 month to 4 year) or total (baseline to 4 year) eGFR slopes. RESULTS Most participants were in the low-moderate KDIGO risk categories (n = 15,201 [90.3%]). The hazard for the kidney-specific composite outcome was lower with dapagliflozin across all KDIGO risk categories (P-interaction = 0.97), including those at low risk (hazard ratio [HR] 0.54, 95% CI 0.38-0.77). Risks for categorical eGFR reductions (≥57% [in those with baseline eGFR ≥60 mL/min/1.73 m2], ≥50%, ≥40%, and ≥30%) were lower with dapagliflozin (HRs 0.52, 0.57, 0.55, and 0.70, respectively; P < 0.05). Slopes of eGFR decline favored dapagliflozin across KDIGO risk categories, including the low KDIGO risk (between-arm differences of 0.87 [chronic] and 0.55 [total] mL/min/1.73 m2/year; P < 0.0001). CONCLUSIONS Dapagliflozin mitigated kidney function decline in patients with T2D at high cardiovascular risk, including those with low KDIGO risk, suggesting a role of dapagliflozin in the early prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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20
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Bonaca MP, Antman EM, Cunningham JW, Wiviott SD, Murphy SA, Halperin JL, Weitz JI, Grosso MA, Lanz HJ, Braunwald E, Giugliano RP, Ruff CT. Ischaemic and bleeding risk in atrial fibrillation with and without peripheral artery disease and efficacy and safety of full- and half-dose edoxaban vs. warfarin: insights from ENGAGE AF-TIMI 48. Eur Heart J Cardiovasc Pharmacother 2022; 8:695-706. [PMID: 34962979 DOI: 10.1093/ehjcvp/pvab089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS In patients with atrial fibrillation (AF), peripheral artery disease (PAD) is associated with higher rates of stroke and bleeding. Both higher dose edoxaban (60/30 mg) and lower dose edoxaban (30/15 mg) were non-inferior to warfarin for stroke and systemic embolism (SSE) and significantly reduced major bleeding in AF patients in the global study to assess the safety and effectiveness of edoxaban vs standard practice of dosing with warfarin in patients with atrial fibrillation (ENGAGE AF-TIMI 48) trial. Whether the efficacy and safety of these dosing strategies vs. warfarin are consistent in patients with AF and PAD has not been described. METHODS AND RESULTS Of 21 105 patients with AF randomized to warfarin, edoxaban 60/30 mg, or edoxaban 30/15 mg, 841 were identified with PAD. Endpoints included major adverse cardiovascular events (MACEs), SSE, and major bleeding. Patients with PAD had higher risk of MACEs [adjusted hazard ratio (HRadj) 1.33, 95% confidence interval (CI) 1.12-1.57, P = 0.001] and cardiovascular (CV) death (HRadj 1.49, 95% CI 1.21-1.83, P < 0.001) than those without PAD, but not major bleeding. The efficacy of edoxaban 60/30 mg vs. warfarin was consistent regardless of PAD (SSE HR; PAD 1.16, 95% CI 0.42-3.20; no-PAD 0.86, 95% CI 0.74-1.02, P-interaction 0.57) as was major bleeding (PAD 0.96, 95% CI 0.54-1.70; no-PAD 0.80, 95% CI 0.70-0.91, P-interaction 0.54). Edoxaban 30/15 mg was inferior for SSE, with significant heterogeneity when stratified by PAD status (P-interaction 0.039). CONCLUSION Patients with AF and PAD are at heightened risk of MACEs and CV death vs. those without PAD. The efficacy and safety of edoxaban 60/30 mg vs. warfarin in AF are consistent regardless of PAD; however, edoxaban 30/15 mg is inferior for stroke prevention in AF patients with PAD. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00781391.
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Affiliation(s)
- Marc P Bonaca
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- CPC Clinical Research, University of Colorado School of Medicine, 13199 E. Montview Blvd., Suite 200, Aurora, CO 80045, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan L Halperin
- Cardiovascular Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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21
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Bonaca MP, Morrow DA, Bergmark BA, Berg DD, Lima JAC, Hoffmann U, Kato Y, Lu MT, Kuder J, Murphy SA, Spinar J, Oude Ophuis T, Kiss RG, Lopez-Sendon J, Averkov O, Wheatcroft SB, Kubica J, Carlos Nicolau J, Furtado RHM, Abuhatzira L, Hirshberg B, Omar SA, Vavere AL, Chang YT, George RT, Sabatine MS. Randomized, Placebo-Controlled Phase 2b Study to Evaluate the Safety and Efficacy of Recombinant Human Lecithin Cholesterol Acyltransferase in Acute ST-Segment-Elevation Myocardial Infarction: Results of REAL-TIMI 63B. Circulation 2022; 146:907-916. [PMID: 36039762 DOI: 10.1161/circulationaha.122.059325] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High-density lipoprotein plays a key role in reverse cholesterol transport. In addition, high-density lipoprotein particles may be cardioprotective and reduce infarct size in the setting of myocardial injury. Lecithin-cholesterol acyltransferase is a rate-limiting enzyme in reverse cholesterol transport. MEDI6012 is a recombinant human lecithin-cholesterol acyltransferase that increases high-density lipoprotein cholesterol. Administration of lecithin-cholesterol acyltransferase has the potential to reduce infarct size and regress coronary plaque in acute ST-segment-elevation myocardial infarction. METHODS REAL-TIMI 63B (A Randomized, Placebo‑controlled Phase 2b Study to Evaluate the Safety and Efficacy of MEDI6012 in Acute ST Elevation Myocardial Infarction) was a phase 2B multinational, placebo-controlled, randomized trial. Patients with ST-segment-elevation myocardial infarction within 6 hours of symptom onset and planned for percutaneous intervention were randomly assigned 2:1 to MEDI6012 (2- or 6-dose regimen) or placebo and followed for 12 weeks. The primary outcome was infarct size as a percentage of left ventricular mass by cardiac MRI at 10 to 12 weeks, with the primary analysis in patients with TIMI Flow Grade 0 to 1 before percutaneous intervention who received at least 2 doses of MEDI6012. The secondary outcome was change in noncalcified plaque volume on coronary computed tomographic angiography from baseline to 10 to 12 weeks with the primary analysis in patients who received all 6 doses of MEDI6012. RESULTS A total of 593 patients were randomly assigned. Patients were a median of 62 years old, 77.9% male, and 95.8% statin naive. Median time from symptom onset to randomization was 146 (interquartile range [IQR], 103-221) minutes and from hospitalization to randomization was 12.7 (IQR, 6.6-24.0) minutes, and the first dose of drug was administered a median of 8 (IQR, 3-13) minutes before percutaneous intervention. The index myocardial infarction was anterior in 69.6% and TIMI Flow Grade 0 to 1 in 65.1% of patients. At 12 weeks, infarct size did not differ between treatment groups (MEDI6012: 9.71%, IQR 4.79-16.38; placebo: 10.48%, [IQR, 4.92-16.61], 1-sided P=0.79. There was also no difference in noncalcified plaque volume (geometric mean ratio, 0.96 [95% CI, NA-1.10], 1-sided P=0.30). There was no significant difference in treatment emergent serious adverse events. CONCLUSIONS Administration of MEDI6012 in patients with acute ST-segment-elevation myocardial infarction did not result in a significant reduction in infarct size or noncalcified plaque volume at 12 weeks. MEDI6012 was well tolerated with no excess in overall serious adverse events. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03578809.
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Affiliation(s)
- Marc P Bonaca
- CPC Clinical Research, Department of Medicine, University of Colorado Anschutz School of Medicine, Aurora (M.P.B.)
| | - David A Morrow
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
| | - Brian A Bergmark
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
| | - David D Berg
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
| | - Joao A C Lima
- Division of Cardiology, Johns Hopkins University, Baltimore, MD (J.A.C.L., Y.K.)
| | - Udo Hoffmann
- Internal Cardioangiology Department, St. Ann University Hospital and Masaryk University, Brno, Czechia (J.S.)
| | - Yoko Kato
- Division of Cardiology, Johns Hopkins University, Baltimore, MD (J.A.C.L., Y.K.)
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston (U.H., M.T.L.)
| | - Julia Kuder
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
| | - Sabina A Murphy
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
| | - Jindrich Spinar
- Internal Cardioangiology Department, St. Ann University Hospital and Masaryk University, Brno, Czechia (J.S.)
| | - Ton Oude Ophuis
- Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands (T.O.O.)
| | - Róbert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary (R.G.K.)
| | - Jose Lopez-Sendon
- IdiPaz Research Institute, Hospital Universitario La Paz, UAM, Madrid, Spain (J.L.-S.)
| | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow (O.A.)
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK (S.B.W.)
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J. Kubica)
| | - Jose Carlos Nicolau
- Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil (J.C.N., R.H.M.F.)
| | - Remo H M Furtado
- Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil (J.C.N., R.H.M.F.).,Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil (R.H.M.G.)
| | | | | | - Sami A Omar
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD (S.A.O., A.L.V., Y.-T.C., R.T.G.)
| | - Andrea L Vavere
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD (S.A.O., A.L.V., Y.-T.C., R.T.G.)
| | - Yi-Ting Chang
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD (S.A.O., A.L.V., Y.-T.C., R.T.G.)
| | - Richard T George
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD (S.A.O., A.L.V., Y.-T.C., R.T.G.)
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M., B.A.B., D.D.B., J. Kuder, S.A.M., M.S.S.)
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22
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Späth J, Matschinske J, Kamanu FK, Murphy SA, Zolotareva O, Bakhtiari M, Antman EM, Loscalzo J, Brauneck A, Schmalhorst L, Buchholtz G, Baumbach J. Privacy-aware multi-institutional time-to-event studies. PLOS Digit Health 2022; 1:e0000101. [PMID: 36812603 PMCID: PMC9931301 DOI: 10.1371/journal.pdig.0000101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/06/2022] [Indexed: 11/19/2022]
Abstract
Clinical time-to-event studies are dependent on large sample sizes, often not available at a single institution. However, this is countered by the fact that, particularly in the medical field, individual institutions are often legally unable to share their data, as medical data is subject to strong privacy protection due to its particular sensitivity. But the collection, and especially aggregation into centralized datasets, is also fraught with substantial legal risks and often outright unlawful. Existing solutions using federated learning have already demonstrated considerable potential as an alternative for central data collection. Unfortunately, current approaches are incomplete or not easily applicable in clinical studies owing to the complexity of federated infrastructures. This work presents privacy-aware and federated implementations of the most used time-to-event algorithms (survival curve, cumulative hazard rate, log-rank test, and Cox proportional hazards model) in clinical trials, based on a hybrid approach of federated learning, additive secret sharing, and differential privacy. On several benchmark datasets, we show that all algorithms produce highly similar, or in some cases, even identical results compared to traditional centralized time-to-event algorithms. Furthermore, we were able to reproduce the results of a previous clinical time-to-event study in various federated scenarios. All algorithms are accessible through the intuitive web-app Partea (https://partea.zbh.uni-hamburg.de), offering a graphical user interface for clinicians and non-computational researchers without programming knowledge. Partea removes the high infrastructural hurdles derived from existing federated learning approaches and removes the complexity of execution. Therefore, it is an easy-to-use alternative to central data collection, reducing bureaucratic efforts but also the legal risks associated with the processing of personal data to a minimum.
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Affiliation(s)
- Julian Späth
- Institute for Computational Systems Biology, University of Hamburg, Hamburg, Germany
- * E-mail:
| | - Julian Matschinske
- Institute for Computational Systems Biology, University of Hamburg, Hamburg, Germany
| | - Frederick K. Kamanu
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sabina A. Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Olga Zolotareva
- Institute for Computational Systems Biology, University of Hamburg, Hamburg, Germany
- Chair of Proteomics and Bioanalytics, TUM School of Life Sciences, Technical University of Munich, Munich, Germany
| | - Mohammad Bakhtiari
- Institute for Computational Systems Biology, University of Hamburg, Hamburg, Germany
| | - Elliott M. Antman
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alissa Brauneck
- Faculty of Legal Sciences, University of Hamburg, Hamburg, Germany
| | | | | | - Jan Baumbach
- Institute for Computational Systems Biology, University of Hamburg, Hamburg, Germany
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23
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Fagundes A, Morrow DA, Oyama K, Furtado RHM, Zelniker TA, Tang M, Kuder JF, Murphy SA, Hamer A, Keech AC, Sever P, Giugliano RP, Sabatine MS, Bergmark BA. Biomarker Prediction of Complex Coronary Revascularization Procedures in the FOURIER Trial. J Am Coll Cardiol 2022; 80:887-897. [PMID: 36007987 DOI: 10.1016/j.jacc.2022.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Biomarkers are known to predict major adverse cardiovascular events. However, the association of biomarkers with complex coronary revascularization procedures or high-risk coronary anatomy at the time of revascularization is not understood. OBJECTIVES We examined the associations between baseline biomarkers and major coronary events (MCE) and complex revascularization procedures. METHODS FOURIER was a randomized trial of the proprotein convertase subtilisin-kexin type 9 inhibitor evolocumab vs placebo in 27,564 patients with stable atherosclerosis. We analyzed adjusted associations among the biomarkers, MCE (coronary death, myocardial infarction, or revascularization), and complex revascularization (coronary artery bypass graft or complex percutaneous coronary intervention) using a multimarker score with 1 point assigned for each elevated biomarker (high-sensitivity C-reactive protein ≥2 mg/L; N-terminal pro-B-type natriuretic peptide ≥450 pg/mL; high-sensitivity troponin I ≥6 ng/L; growth-differentiation factor-15 ≥1,800 pg/mL). RESULTS When patients were grouped by the number of elevated biomarkers (0 biomarkers, n = 6,444; 1-2 biomarkers, n = 12,439; ≥3 biomarkers, n = 2,761), there was a significant graded association between biomarker score and the risk of MCE (intermediate score: HRadj: 1.57 [95% CI: 1.38-1.78]; high score: HRadj: 2.90 [95% CI: 2.47-3.40]), and for complex revascularization (intermediate: HRadj: 1.33 [95% CI: 1.06-1.67]; high score: HRadj: 2.07 [95% CI: 1.52-2.83]) and its components (Ptrend <0.05 for each). The number of elevated biomarkers also correlated with the presence of left main disease, multivessel disease, or chronic total occlusion at the time of revascularization (P < 0.05 for each). CONCLUSIONS A biomarker-based strategy identifies stable patients at risk for coronary events, including coronary artery bypass graft surgery and complex percutaneous coronary intervention, and predicts high-risk coronary anatomy at the time of revascularization. These findings provide insight into the relationships between cardiovascular biomarkers, coronary anatomical complexity, and incident clinical events. (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk [FOURIER]; NCT01764633).
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Affiliation(s)
- Antonio Fagundes
- IDOR -D'Or Institute for Research and Education, Sao Paolo, Brazil; Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Morrow
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kazuma Oyama
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Remo H M Furtado
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Hospital Israelita Albert Einstein and Instituto do Coração da Faculdade de Medicina da U.S.P., Sao Paulo, Brazil
| | - Thomas A Zelniker
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Vienna, Austria
| | - Minao Tang
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Sever
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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24
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Scirica BM, Im K, Murphy SA, Kuder JF, Rodriguez DA, Lopes RD, Green JB, Ruff CT, Sabatine MS. Re-adjudication of the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) with study-level meta-analysis of hospitalization for heart failure from cardiovascular outcomes trials with dipeptidyl peptidase-4 (DPP-4) inhibitors. Clin Cardiol 2022; 45:794-801. [PMID: 35715946 PMCID: PMC9286326 DOI: 10.1002/clc.23844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) assessed the cardiovascular (CV) safety of sitagliptin versus placebo on CV outcomes in patients with type 2 diabetes and CV disease and found sitagliptin noninferior to placebo. Subsequently, based on feedback from FDA, the Sponsor of the trial, Merck & Co., Inc., engaged a separate academic research organization, the TIMI Study Group, to re‐adjudicate a prespecified set of originally adjudicated events. Methods TIMI adjudicated in a blinded fashion all potential hospitalization for heart failure (HHF) events, all potential MACE+ events previously adjudicated as not an endpoint event, and a random subset (~10%) of MACE+ events previously adjudicated as an endpoint event. An updated study‐level meta‐analysis of four randomized, placebo‐controlled, CV outcomes trials with dipeptidyl peptidase 4 (DPP‐4) inhibitors was then performed. Results After re‐adjudication of potential HHF events in the intent‐to‐treat population, there were 224 patients with a confirmed event in the sitagliptin arm (1.05/100 person‐years) and 239 patients in the placebo arm (1.13/100 person‐years), corresponding to a hazard ratio (HR) of 0.94 (95% confidence interval [95% CI]: 0.78–1.13, p = .49). Concordance between the outcome of the original adjudication and the re‐adjudication for HHF events was 82.7%. The meta‐analysis of CV outcomes trials with DPP‐4 inhibitors with placebo and involving 43 522 patients yielded an HR of 1.07 (95% CI: 0.83–1.39), with moderate heterogeneity (p = .45, I2 = 62.07%). Conclusion The results of this independent re‐adjudication process and analyses of CV outcomes from TECOS were consistent with the original adjudication results and overall study findings. An updated study‐level meta‐analysis showed no overall significant risk for HHF with DPP‐4 inhibitors, but with statistical heterogeneity.
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Affiliation(s)
- Benjamin M Scirica
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - KyungAh Im
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julia F Kuder
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dolly A Rodriguez
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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25
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Furtado RHM, Raz I, Goodrich EL, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Aylward P, Dalby AJ, Dellborg M, Dimulescu D, Nicolau JC, Oude Ophuis AJM, Cahn A, Mosenzon O, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin in Type 2 Diabetes According to Baseline Blood Pressure: Observations From DECLARE-TIMI 58 Trial. Circulation 2022; 145:1581-1591. [PMID: 35510542 DOI: 10.1161/circulationaha.121.058103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Dapagliflozin improved heart failure and kidney outcomes in patients with type 2 diabetes mellitus (T2DM) with or at high risk for cardiovascular disease in the DECLARE-TIMI 58 trial. Here, the aim was to analyze efficacy and safety of dapagliflozin stratified according to baseline systolic blood pressure (SBP). Methods: The DECLARE-TIMI 58 trial randomized patients with T2DM and either prior atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors to dapagliflozin or placebo. Patients were categorized by baseline SBP levels: < 120, 120-129, 130-139, 140-159 and ≥ 160 mmHg (respectively, normal, elevated, stage 1, stage 2 and severe hypertension). Efficacy outcomes of interest were hospitalization for heart failure (HHF) and a renal-specific composite outcome (sustained decrease in estimated glomerular filtration rate by 40%, progression to end-stage renal disease or renal death). Safety outcomes included symptoms of volume depletion, lower extremity amputations and acute kidney injury. Results: The trial comprised 17,160 patients; mean age of 64.0 ± 6.8 years ; 37.4% women; median duration of T2DM 11 years; 40.6% with prevalent CVD. Overall, dapagliflozin reduced SBP by 2.4 mmHg (95% CI 1.9-2.9; p < 0.0001) compared with placebo at 48 months. The beneficial effects of dapagliflozin on HHF and renal outcomes were consistent across all baseline SBP categories, with no evidence of modification of treatment effect (p-interactions = 0.28 and 0.52, respectively). Among normotensive patients, the HR´s were 0.66 (95% CI 0.42-1.05) and 0.39 (95% CI 0.19-0.78), respectively for HHF and the renal specific outcome. Events of volume depletion, amputation and acute kidney injury did not differ with dapagliflozin overall or within any baseline SBP group. Conclusions: In patients with T2DM with or at high ASCVD risk, dapagliflozin reduced risk for HHF and renal outcomes regardless of baseline systolic blood pressure, with no difference in adverse events of interest at any level of baseline SBP. These results indicate that dapagliflozin provides important cardiorenal benefit in patients with T2DM at high ASCVD risk, independent of baseline blood pressure.
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Affiliation(s)
- Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Philip Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | - Mikael Dellborg
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Doina Dimulescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
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Gencer B, Eisen A, Berger D, Nordio F, Murphy SA, Grip LT, Chen C, Lanz H, Ruff CT, Antman EM, Braunwald E, Giugliano RP. Edoxaban versus Warfarin in high-risk patients with atrial fibrillation: A comprehensive analysis of high-risk subgroups. Am Heart J 2022; 247:24-32. [PMID: 34990581 DOI: 10.1016/j.ahj.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND To compare the efficacy and safety of edoxaban vs warfarin in high-risk subgroups. METHODS ENGAGE AF-TIMI 48 was a multicenter randomized, double-blind, controlled trial in 21,105 patients with atrial fibrillation (AF) within 12 months and CHADS2 score >2 randomized to higher-dose edoxaban regimen (HDER) 60 mg/reduced 30 mg, lower-dose edoxaban regimen (LDER) 30 mg/reduced 15 mg, or warfarin, and followed for 2.8 years (median). The primary outcome for this analysis was the net clinical outcome (NCO), a composite of stroke/systemic embolism events, major bleeding, or death. Multivariable risk-stratification analysis was used to categorize patients by the number of high-risk features. RESULTS The annualized NCO rates in the warfarin arm were highest in patients with malignancy (19.2%), increased fall risk (14.0%), and very-low body weight (13.5%). The NCO rates increased with the numbers of high-risk factors in the warfarin arm: 4.5%, 7.2%, 9.9% and 14.6% in patients with 0 to 1, 2, 3, and >4 risk factors, respectively (Ptrend <0.001). Versus warfarin, HDER was associated with significant reductions of NCO in most of the subgroups: elderly, patients with moderate renal dysfunction, prior stroke/TIA, of Asian race, very-low body weight, concomitant single antiplatelet therapy, and VKA-naïve. With more high-risk features (0->4+), the absolute risk reductions favoring edoxaban over warfarin increased: 0.3%->2.0% for HDER; 0.4%->3.4% for LDER vs warfarin (P = .065 and P < .001, respectively). CONCLUSIONS While underuse of anticoagulation in high-risk patients with AF remains common, substitution of effective and safer alternatives to warfarin, such as edoxaban, represents an opportunity to improve clinical outcomes.
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Affiliation(s)
- Baris Gencer
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA; Cardiology Division, Geneva University Hospitals, Geneva, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Berger
- Cardiology Department, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Francesco Nordio
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Laura T Grip
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Hans Lanz
- Daiichi Sankyo Europe GmbH, Munich, Germany
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, MA.
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Bergmark BA, Marston NA, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Park JG, Murphy SA, Verma S, Wojakowski W, Terra SG, Sabatine MS, Wiviott SD. Effect of Vupanorsen on Non-High-Density Lipoprotein Cholesterol Levels in Statin-Treated Patients With Elevated Cholesterol: TRANSLATE-TIMI 70. Circulation 2022; 145:1377-1386. [PMID: 35369705 PMCID: PMC9047643 DOI: 10.1161/circulationaha.122.059266] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Genetic loss-of-function variants in ANGPTL3 are associated with lower levels of plasma lipids. Vupanorsen is a hepatically targeted antisense oligonucleotide that inhibits Angiopoietin-like 3 (ANGPTL3) protein synthesis.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada
| | | | | | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Cahn A, Wiviott SD, Mosenzon O, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Raz I. Association of Baseline HbA1c With Cardiovascular and Renal Outcomes: Analyses From DECLARE-TIMI 58. Diabetes Care 2022; 45:938-946. [PMID: 35015847 DOI: 10.2337/dc21-1744] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Current guidelines recommend prescribing SGLT2 inhibitors to patients with type 2 diabetes and established or at high risk for atherosclerotic cardiovascular disease (ASCVD), irrespective of HbA1c levels. We studied the association of HbA1c with cardiovascular and renal outcomes and whether the benefit of dapagliflozin varies by baseline HbA1c. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomly assigned to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular and renal outcomes by baseline HbA1c in the overall population and with dapagliflozin versus placebo in HbA1c subgroups were studied by Cox regression models. RESULTS In the overall population, higher baseline HbA1c was associated with a higher risk of cardiovascular death or hospitalization for heart failure (HHF); major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, and ischemic stroke; and cardiorenal outcomes (adjusted hazard ratios 1.12 [95% CI 1.06-1.19], 1.08 [1.04-1.13], and 1.17 [1.11-1.24] per 1% higher level, respectively). Elevated HbA1c was associated with a greater increased risk for MACE and cardiorenal outcomes in patients with multiple risk factors (MRF) than in established ASCVD (P-interaction = 0.0064 and 0.0093, respectively). Compared with placebo, dapagliflozin decreased the risk of cardiovascular death/HHF, HHF, and cardiorenal outcomes, with no heterogeneity by baseline HbA1c (P-interaction > 0.05). CONCLUSIONS Higher HbA1c levels were associated with greater cardiovascular and renal risk, particularly in the MRF population, yet the benefits of dapagliflozin were observed in all subgroups irrespective of baseline HbA1c, including patients with HbA1c <7%.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Furtado RHM, Fagundes AA, Oyama K, Zelniker TA, Tang M, Kuder JF, Murphy SA, Hamer A, Wang H, Keech AC, Giugliano RP, Sabatine MS, Bergmark BA. Effect of Evolocumab in Patients With Prior Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2022; 15:e011382. [PMID: 35209731 DOI: 10.1161/circinterventions.121.011382] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients with prior percutaneous coronary intervention (PCI) are at high residual risk for multiple types of coronary events within and beyond the stented lesion. This risk might be mitigated by more intensive LDL-C (low-density lipoprotein cholesterol)-lowering beyond just with statin therapy. METHODS FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) randomized 27 564 patients with stable atherosclerotic disease on statin to the PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitor evolocumab or placebo with a median follow-up of 2.2 years. The end points of interest were major adverse cardiovascular events (MACE; a composite of cardiovascular death, myocardial infarction, stroke, unstable angina or coronary revascularization), and major coronary events (a composite of coronary heart death, myocardial infarction, or coronary revascularization). We compared the risk of MACE and the magnitude of relative and absolute risk reductions with evolocumab in patients with and without prior PCI. RESULTS Seventeen thousand seventy-three patients had prior PCI. In the placebo arm, those with prior PCI had higher rates of MACE (13.2% versus 8.3%; hazard ratio [HR]adj 1.61 [95% CI, 1.42-1.84]; P<0.0001) and major coronary events (11.5% versus 6.0%; HRadj, 1.72 [95% CI, 1.49-1.99]; P<0.0001). Relative risk reductions with evolocumab were similar in patients with and without prior PCI (MACE: HR, 0.84 [0.77-0.91] versus HR, 0.88 [0.77-1.01]; Pinteraction 0.51; major coronary events: HR, 0.82 [0.75-0.90] versus HR, 0.88 [0.75-1.04]; Pinteraction 0.42). Absolute risk reductions for MACE were 2.0% versus 0.9% (Pinteraction 0.14) and for major coronary events 2.0% versus 0.7% (Pinteraction 0.045). In those with prior PCI, the effect of evolocumab on coronary revascularization (HR, 0.76 [0.69-0.85]) was directionally consistent across types of revascularization procedures: coronary artery bypass grafting (HR, 0.71 [0.54-0.94]); any PCI (HR, 0.77 [0.69-0.86]); PCI for de novo lesions (HR, 0.76 [0.66-0.88]); and PCI for stent failure or graft lesions (HR, 0.76 [0.63-0.91]). CONCLUSIONS Evolocumab reduces the risk of MACE in patients with prior PCI including the risk of coronary revascularization, with directionally consistent effects across several types of revascularization procedures, including coronary artery bypass grafting and PCI for stent or graft failure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01764633.
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Affiliation(s)
- Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil (R.H.M.F.).,Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Brazil (R.H.M.F.).,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Antônio Aurélio Fagundes
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Kazuma Oyama
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.).,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.O.)
| | - Thomas A Zelniker
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.).,Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria (T.A.Z.)
| | - Minao Tang
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Andrew Hamer
- Cardiol Therapeutics, Oakville, ON, Canada (A.H.)
| | | | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, Australia (A.C.K.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
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Fagundes A, Ruff C, Morrow DA, Murphy SA, Palazzolo MG, Chen CZ, Antman EM, Braunwald E, Giugliano RP. NEUTROPHIL-LYMPHOCYTE RATIO AND OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION: ANALYSES FROM ENGAGE AF-TIMI 48 TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01120-2] [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: 10/18/2022]
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31
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Kolkailah AA, Wiviott SD, Raz I, Murphy SA, Mosenzon O, Bhatt DL, Leiter LA, Wilding JPH, Gause-Nilsson I, Sabatine MS, McGuire DK. Effect of Dapagliflozin on Hematocrit in Patients With Type 2 Diabetes at High Cardiovascular Risk: Observations From DECLARE-TIMI 58. Diabetes Care 2022; 45:e27-e29. [PMID: 35020832 PMCID: PMC8914433 DOI: 10.2337/dc21-1668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/01/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Ahmed A Kolkailah
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Itamar Raz
- Department of Medicine, Hadassah Hebrew University, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- La Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
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Sabatine MS, Bergmark BA, Murphy SA, O'Gara PT, Smith PK, Serruys PW, Kappetein AP, Park SJ, Park DW, Christiansen EH, Holm NR, Nielsen PH, Stone GW, Sabik JF, Braunwald E. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis. Lancet 2021; 398:2247-2257. [PMID: 34793745 DOI: 10.1016/s0140-6736(21)02334-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal revascularisation strategy for patients with left main coronary artery disease is uncertain. We therefore aimed to evaluate long-term outcomes for patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). METHODS In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane database using the search terms "left main", "percutaneous coronary intervention" or "stent", and "coronary artery bypass graft*" to identify randomised controlled trials (RCTs) published in English between database inception and Aug 31, 2021, comparing PCI with drug-eluting stents with CABG in patients with left main coronary artery disease that had at least 5 years of patient follow-up for all-cause mortality. Two authors (MSS and BAB) identified studies meeting the criteria. The primary endpoint was 5-year all-cause mortality. Secondary endpoints were cardiovascular death, spontaneous myocardial infarction, procedural myocardial infarction, stroke, and repeat revascularisation. We used a one-stage approach; event rates were calculated by use of the Kaplan-Meier method and treatment group comparisons were made by use of a Cox frailty model, with trial as a random effect. In Bayesian analyses, the probabilities of absolute risk differences in the primary endpoint between PCI and CABG being more than 0·0%, and at least 1·0%, 2·5%, or 5·0%, were calculated. FINDINGS Our literature search yielded 1599 results, of which four RCTs-SYNTAX, PRECOMBAT, NOBLE, and EXCEL-meeting our inclusion criteria were included in our meta-analysis. 4394 patients, with a median SYNTAX score of 25·0 (IQR 18·0-31·0), were randomly assigned to PCI (n=2197) or CABG (n=2197). The Kaplan-Meier estimate of 5-year all-cause death was 11·2% (95% CI 9·9-12·6) with PCI and 10·2% (9·0-11·6) with CABG (hazard ratio 1·10, 95% CI 0·91-1·32; p=0·33), resulting in a non-statistically significant absolute risk difference of 0·9% (95% CI -0·9 to 2·8). In Bayesian analyses, there was an 85·7% probability that death at 5 years was greater with PCI than with CABG; this difference was more likely than not less than 1·0% (<0·2% per year). The numerical difference in mortality was comprised more of non-cardiovascular than cardiovascular death. Spontaneous myocardial infarction (6·2%, 95% CI 5·2-7·3 vs 2·6%, 2·0-3·4; hazard ratio [HR] 2·35, 95% CI 1·71-3·23; p<0·0001) and repeat revascularisation (18·3%, 16·7-20·0 vs 10·7%, 9·4-12·1; HR 1·78, 1·51-2·10; p<0·0001) were more common with PCI than with CABG. Differences in procedural myocardial infarction between strategies depended on the definition used. Overall, there was no difference in the risk of stroke between PCI (2·7%, 2·0-3·5) and CABG (3·1%, 2·4-3·9; HR 0·84, 0·59-1·21; p=0·36), but the risk was lower with PCI in the first year after randomisation (HR 0·37, 0·19-0·69). INTERPRETATION Among patients with left main coronary artery disease and, largely, low or intermediate coronary anatomical complexity, there was no statistically significant difference in 5-year all-cause death between PCI and CABG, although a Bayesian approach suggested a difference probably exists (more likely than not <0·2% per year) favouring CABG. There were trade-offs in terms of the risk of myocardial infarction, stroke, and revascularisation. A heart team approach to communicate expected outcome differences might be useful to assist patients in reaching a treatment decision. FUNDING No external funding.
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Affiliation(s)
- Marc S Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter K Smith
- Department of Surgery (Cardiothoracic), Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC, USA
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands; Medtronic, Maastricht, Netherlands
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | | | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Per H Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Murphy SA, Furger R, Kurpad SN, Arpinar VE, Nencka A, Koch K, Budde MD. Filtered Diffusion-Weighted MRI of the Human Cervical Spinal Cord: Feasibility and Application to Traumatic Spinal Cord Injury. AJNR Am J Neuroradiol 2021; 42:2101-2106. [PMID: 34620590 DOI: 10.3174/ajnr.a7295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In traumatic spinal cord injury, DTI is sensitive to injury but is unable to differentiate multiple pathologies. Axonal damage is a central feature of the underlying cord injury, but prominent edema confounds its detection. The purpose of this study was to examine a filtered DWI technique in patients with acute spinal cord injury. MATERIALS AND METHODS The MR imaging protocol was first evaluated in a cohort of healthy subjects at 3T (n = 3). Subsequently, patients with acute cervical spinal cord injury (n = 8) underwent filtered DWI concurrent with their acute clinical MR imaging examination <24 hours postinjury at 1.5T. DTI was obtained with 25 directions at a b-value of 800 s/mm2. Filtered DWI used spinal cord-optimized diffusion-weighting along 26 directions with a "filter" b-value of 2000 s/mm2 and a "probe" maximum b-value of 1000 s/mm2. Parallel diffusivity metrics obtained from DTI and filtered DWI were compared. RESULTS The high-strength diffusion-weighting perpendicular to the cord suppressed signals from tissues outside of the spinal cord, including muscle and CSF. The parallel ADC acquired from filtered DWI at the level of injury relative to the most cranial region showed a greater decrease (38.71%) compared with the decrease in axial diffusivity acquired by DTI (17.68%). CONCLUSIONS The results demonstrated that filtered DWI is feasible in the acute setting of spinal cord injury and reveals spinal cord diffusion characteristics not evident with conventional DTI.
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Affiliation(s)
- S A Murphy
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
| | - R Furger
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
| | - S N Kurpad
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
| | - V E Arpinar
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Nencka
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - K Koch
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - M D Budde
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
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Ruff CT, Koren MJ, Grimsby J, Rosenbaum AI, Tu X, Karathanasis SK, Falloon J, Hsia J, Guan Y, Conway J, Tsai LF, Hummer BT, Hirshberg B, Kuder JF, Murphy SA, George RT, Sabatine MS. LEGACY: Phase 2a Trial to Evaluate the Safety, Pharmacokinetics, and Pharmacodynamic Effects of the Anti-EL (Endothelial Lipase) Antibody MEDI5884 in Patients With Stable Coronary Artery Disease. Arterioscler Thromb Vasc Biol 2021; 41:3005-3014. [PMID: 34706556 DOI: 10.1161/atvbaha.120.315757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Functional HDL (high-density lipoprotein) particles that facilitate cholesterol efflux may be cardioprotective. EL (endothelial lipase) hydrolyzes phospholipids promoting catabolism of HDL and subsequent renal excretion. MEDI5884 is a selective, humanized, monoclonal, EL-neutralizing antibody. We sought to determine the safety, pharmacokinetics, and pharmacodynamic effects of multiple doses of MEDI5884 in patients with stable coronary artery disease. Approach and Results: LEGACY was a phase 2a, double-blind, placebo-controlled, parallel-design trial that randomized 132 patients with stable coronary artery disease receiving high-intensity statin therapy to 3 monthly doses of 1 of 5 dose levels of MEDI5884 (50, 100, 200, 350, or 500 mg SC) or matching placebo. The primary end point was the safety and tolerability of MEDI5884 through the end of the study (day 151). Additional end points included change in HDL cholesterol and cholesterol efflux from baseline to day 91, hepatic uptake of cholesterol at day 91, changes in various other lipid parameters. The incidence of adverse events was similar between the placebo and MEDI5884 groups. In a dose-dependent manner, MEDI5884 increased HDL cholesterol up to 51.4% (P<0.0001) and global cholesterol efflux up to 26.2% ([95% CI, 14.3-38.0] P<0.0001). MEDI5884 increased HDL particle number up to 14.4%. At the highest dose tested, an increase in LDL (low-density lipoprotein) cholesterol up to 28.7% (P<0.0001) and apoB (apolipoprotein B) up to 13.1% (P=0.04) was observed with MEDI5884. However, at the potential target doses for future studies, there was no meaningful increase in LDL cholesterol or apoB. CONCLUSIONS Inhibition of EL by MEDI5884 increases the quantity and quality of functional HDL in patients with stable coronary artery disease on high-intensity statin therapy without an adverse safety signal at the likely dose to be used. These data support further clinical investigation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03351738.
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Affiliation(s)
- Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., J.F.K., S.A.M., M.S.S.)
| | | | - Joseph Grimsby
- Bioscience, Research and Early Development, Cardiovascular, Renal and Metabolism (J.G., S.K.K.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Anton I Rosenbaum
- Integrated Bioanalysis, Clinical Pharmacology and Quantitative Pharmacology (A.I.R., Y.G.), Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, South San Francisco, CA
| | - Xiao Tu
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (X.T., J.F., B.H., R.T.G.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Sotirios K Karathanasis
- Bioscience, Research and Early Development, Cardiovascular, Renal and Metabolism (J.G., S.K.K.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Judith Falloon
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (X.T., J.F., B.H., R.T.G.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Judith Hsia
- Research and Early Development, Cardiovascular, Renal and Metabolism (J.H.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Ye Guan
- Integrated Bioanalysis, Clinical Pharmacology and Quantitative Pharmacology (A.I.R., Y.G.), Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, South San Francisco, CA
| | - James Conway
- Bioinformatics, Translational Medicine, Research and Early Development, Oncology R&D, AstraZeneca, Gaithersburg, MD (J.C.)
| | - Lan-Feng Tsai
- Early CVRM Biometrics, Research and Early Development, Cardiovascular, Renal and Metabolism (L.-F.T.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - B Timothy Hummer
- Cardiovascular, Renal and Metabolism Safety (B.T.H.), Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, South San Francisco, CA
| | - Boaz Hirshberg
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (X.T., J.F., B.H., R.T.G.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Julia F Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., J.F.K., S.A.M., M.S.S.)
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., J.F.K., S.A.M., M.S.S.)
| | - Richard T George
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (X.T., J.F., B.H., R.T.G.), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., J.F.K., S.A.M., M.S.S.)
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Semco RS, Bergmark BA, Bergmark RW, Murphy SA, Ruff CT, Antman EM, Braunwald E, Giugliano RP. Epistaxis in anticoagulated patients with atrial fibrillation in the ENGAGE AF-TIMI 48 trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Epistaxis is common with antithrombotic therapy yet under-investigated in cardiovascular clinical trials and observational studies. These bleeding events are often troublesome to patients and may lead to anticoagulant discontinuation.
Purpose
To describe the frequency, severity, and outcomes of epistaxis in patients with atrial fibrillation (AF) randomized to edoxaban vs warfarin.
Methods
ENGAGE AF-TIMI 48 randomized 21,105 patients with AF and CHADS2 ≥2 to a higher-dose edoxaban regimen (HDER; 60mg daily), a lower-dose edoxaban regimen (LDER; 30mg daily), or warfarin, with edoxaban doses reduced by 50% in patients meeting dose-reduction criteria. Location and severity of bleeding were adjudicated by a blinded Clinical Events Committee using ISTH criteria. Patients with intracranial hemorrhage were excluded from this analysis. Patients with more than one bleeding event were categorized according to the most severe event. The safety cohort with interval censoring during study drug interruption was analyzed. Proportions were compared using a Pearson's chi-squared test and treatment arms were compared using a Cox proportional hazards model.
Results
5,247 patients with a bleeding event were included in this analysis, including 1,008 (19.2%) with epistaxis and 4,239 (80.8%) with exclusively non-epistaxis bleeding. Baseline characteristics were similar for patients with epistaxis as compared to non-epistaxis bleeding. Epistaxis events were overall less severe than non-epistaxis bleeds (ISTH major: 3.2% vs 20.7%; CRNM: 64.7% vs 60.1%; minor: 32.1% vs 19.2%; p<0.001; Fig. 1, Panel A). Two life-threatening and no fatal epistaxis bleeds occurred. Permanent study drug discontinuation was similar following epistaxis vs non-epistaxis bleeding in patients with major (59.4% vs 53.6%; p=0.52) or CRNM bleeding (32.5% vs 33.3%; p=0.70), but was significantly higher after minor epistaxis versus minor bleeding at other sites (33.3% vs 23.9%; p=0.001; Fig. 1, Panel B). Compared to warfarin, hazard ratios (HR) for epistaxis bleeding were: 1) major: HDER 0.47 (0.19–1.15), LDER 0.65 (0.29–1.45); 2) major/CRNM: HDER 1.00 (0.84–1.19), LDER 0.70 (0.58–0.85); 3) major/CRNM/minor: HDER 1.09 (0.95–1.26), LDER 0.73 (0.62–0.86) (Fig. 1, Panel C).
Conclusion
Epistaxis was frequent in patients with atrial fibrillation on anticoagulation. When compared to warfarin, LDER reduced the risk of epistaxis by 27–30% while HDER neither increased nor decreased these events. There were significantly higher rates of permanent drug discontinuation following minor epistaxis as compared to minor bleeding at other sites. These findings suggest that epistaxis is symptomatically important, may cause disproportionate interruption in antithrombotic therapy, and deserves increased attention in cardiovascular studies.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Pharma Development Figure 1
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Affiliation(s)
- R S Semco
- Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, United States of America
| | - B A Bergmark
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - R W Bergmark
- Brigham and Women's Hospital and Harvard Medical School, Center for Surgery and Public Health and Department of Otolaryngology-Head and Neck Surgery, Boston, United States of America
| | - S A Murphy
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - C T Ruff
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - E M Antman
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - E Braunwald
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - R P Giugliano
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
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Oyama K, Giugliano RP, Tang M, Bonaca MP, Saver JL, Murphy SA, Ruzza A, Keech AC, Sever PS, Sabatine MS, Bergmark BA. Effect of evolocumab on acute arterial events across all vascular territories : results from the FOURIER trial. Eur Heart J 2021; 42:4821-4829. [PMID: 34537830 DOI: 10.1093/eurheartj/ehab604] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 12/31/2022] Open
Abstract
AIMS We assessed the impact of the proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor evolocumab on acute arterial events across all vascular territories, including coronary, cerebrovascular, and peripheral vascular beds, in patients with established atherosclerotic cardiovascular disease (ASCVD). METHODS AND RESULTS In the FOURIER trial, 27 564 patients with stable ASCVD on statin therapy were randomly assigned to evolocumab or placebo. Acute arterial events were a composite of acute coronary (coronary heart disease death, myocardial infarction, or urgent coronary revascularization), cerebrovascular (ischaemic stroke, transient ischaemic attack, or urgent cerebral revascularization), or peripheral vascular (acute limb ischaemia, major amputation, or urgent peripheral revascularization) events. Of the 2210 first acute arterial events, 74% were coronary, 22% were cerebrovascular, and 4% were peripheral vascular. Evolocumab reduced first acute arterial events by 19% (hazard ratio [HR] 0.81 [95% confidence interval 0.74-0.88]; P < 0.001), with significant individual reductions in acute coronary (HR 0.83 [0.75-0.91]), cerebrovascular (HR 0.77 [0.65-0.92]), and peripheral vascular (HR 0.58 [0.38-0.88]) events. There were 3437 total events (first plus recurrent), with evolocumab reducing total events by 24% (incidence rate ratio 0.76 [0.69-0.85]). The magnitude of reduction in acute arterial events with evolocumab numerically increased over time, with a 16% reduction (HR 0.84 [0.75-0.95]) in the first year followed by a 24% reduction (HR 0.76 [0.67-0.85]) thereafter. CONCLUSION The addition of the PCSK9 inhibitor evolocumab to statin therapy reduced acute arterial events across all vascular territories with a robust effect over time, indicating a pan-vascular impact of aggressive lipid-lowering therapy on these acute and clinically meaningful events. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01764633.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Minao Tang
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Marc P Bonaca
- CPC Clinical Research, Department of Medicine, University of Colorado Anschutz School of Medicine, 2115 N. Scranton St., Suite 2040 Aurora, CO 80045, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, 710 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Andrea Ruzza
- Amgen, 1 Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, Level 6, Medical Foundation Building, 92-94 Parramatta Road, Camperdown, NSW 2050, Australia
| | - Peter S Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59 North Wharf Road, London W2 1LA, UK
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Brian A Bergmark
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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37
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Oyama K, Raz I, Cahn A, Kuder J, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Park KS, Goudev A, Diaz R, Špinar J, Gause-Nilsson IAM, Mosenzon O, Sabatine MS, Wiviott SD. Obesity and effects of dapagliflozin on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021; 43:2958-2967. [PMID: 34427295 DOI: 10.1093/eurheartj/ehab530] [Citation(s) in RCA: 23] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/11/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS We investigated the associations between obesity, cardiorenal events, and benefits of dapagliflozin in patients with type 2 diabetes mellitus (T2DM). METHODS AND RESULTS DECLARE-TIMI 58 randomized patients with T2DM and either atherosclerotic cardiovascular (CV) disease or multiple risk factors to dapagliflozin vs. placebo. Patients were stratified by body mass index (BMI, kg/m2): normal (18.5 to <25), overweight (25 to <30), moderately obese (30 to <35), severely obese (35 to <40), and very-severely obese (≥40). Outcomes analysed were CV death, hospitalization for heart failure (HHF), renal-specific composite outcome, and atrial fibrillation or flutter (AF/AFL). Of 17 134 patients, 9.0% had a normal BMI, 31.5% were overweight, 32.4% were moderately, 17.2% severely, and 9.8% were very-severely obese. Higher BMI was associated with a higher adjusted risk of HHF and AF/AFL (hazard ratio 1.30 and 1.28, respectively, per 5 kg/m2; P < 0.001 for all). Dapagliflozin reduced body weight by similar relative amounts consistently across BMI categories (percent difference: -1.9 to -2.4%). Although relative risk reductions in CV and renal-specific composite outcomes with dapagliflozin did not significantly differ across the range of BMI (P for interaction ≥0.20 for all outcomes), obese patients (BMI ≥ 30 kg/m2) tended to derive greater absolute risk reduction in HHF and AF/AFL (P for interaction 0.02 and 0.09, respectively) than non-obese patients. CONCLUSIONS In DECLARE-TIMI 58, patients with T2DM and higher BMI were more likely to have HHF and AF/AFL. Whereas relative risk reductions in CV and renal outcomes with dapagliflozin were generally consistent across the range of BMI, absolute risk reduction in obesity-related outcomes including HHF and AF/AFL tended to be larger in obese patients with T2DM. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01730534.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Julia Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 36 Queen St. East, Toronto, ON M5B 1W8, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Kyong-Soo Park
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu Seoul 03080, Republic of Korea
| | - Assen Goudev
- Department of Cardiology, Queen Giovanna University Hospital, 8# Bialo More street, Sofia 1527, Bulgaria
| | - Rafael Diaz
- Estudios Clínicos Latino America, Paraguay 160, Rosario, Santa Fe 2000, Argentina
| | - Jindřich Špinar
- Internal Cardiology Department, St. Ann University Hospital, Masaryk University, Pekařská 53 Brno 65691, Czech Republic
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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Mosenzon O, Wiviott SD, Heerspink HJL, Dwyer JP, Cahn A, Goodrich EL, Rozenberg A, Schechter M, Yanuv I, Murphy SA, Zelniker TA, Gause-Nilsson IAM, Langkilde AM, Fredriksson M, Johansson PA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Raz I. The Effect of Dapagliflozin on Albuminuria in DECLARE-TIMI 58. Diabetes Care 2021; 44:1805-1815. [PMID: 34233928 PMCID: PMC8385472 DOI: 10.2337/dc21-0076] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/14/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve albuminuria in patients with high cardiorenal risk. We report albuminuria change in the Dapagliflozin Effect on Cardiovascular Events (DECLARE-TIMI 58) cardiovascular outcome trial, which included populations with lower cardiorenal risk. RESEARCH DESIGN AND METHODS DECLARE-TIMI 58 randomized 17,160 patients with type 2 diabetes, creatinine clearance >60 mL/min, and either atherosclerotic cardiovascular disease (CVD; 40.6%) or risk-factors for CVD (59.4%) to dapagliflozin or placebo. Urinary albumin-to-creatinine ratio (UACR) was tested at baseline, 6 months, 12 months, and yearly thereafter. The change in UACR over time was measured as a continuous and categorical variable (≤15, >15 to <30, ≥30 to ≤300, and >300 mg/g) by treatment arm. The composite cardiorenal outcome was a ≥40% sustained decline in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and cardiovascular or renal death; specific renal outcome included all except cardiovascular death. RESULTS Baseline UACR was available for 16,843 (98.15%) participants: 9,067 (53.83%) with ≤15 mg/g, 2,577 (15.30%) with >15 to <30 mg/g, 4,030 (23.93%) with 30-300 mg/g, and 1,169 (6.94%) with >300 mg/g. Measured as a continuous variable, UACR improved from baseline to 4.0 years with dapagliflozin, compared with placebo, across all UACR and eGFR categories (all P < 0.0001). Sustained confirmed ≥1 category improvement in UACR was more common in dapagliflozin versus placebo (hazard ratio 1.45 [95% CI 1.35-1.56], P < 0.0001). Cardiorenal outcome was reduced with dapagliflozin for subgroups of UACR ≥30 mg/g (P < 0.0125, P interaction = 0.033), and the renal-specific outcome was reduced for all UACR subgroups (P < 0.05, P interaction = 0.480). CONCLUSIONS In DECLARE-TIMI 58, dapagliflozin demonstrated a favorable effect on UACR and renal-specific outcome across baseline UACR categories, including patients with normal albumin excretion. The results suggest a role for SGLT2i also in the primary prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel .,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Hiddo J L Heerspink
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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O'Donoghue ML, Kato ET, Mosenzon O, Murphy SA, Cahn A, Herrera M, Tankova T, Šmahelová A, Merlini P, Gause-Nilsson I, Langkilde AM, McGuire DK, Wilding JPH, Leiter LA, Bhatt DL, Raz I, Sabatine MS, Wiviott SD. The efficacy and safety of dapagliflozin in women and men with type 2 diabetes mellitus. Diabetologia 2021; 64:1226-1234. [PMID: 33611623 DOI: 10.1007/s00125-021-05399-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/09/2020] [Indexed: 01/24/2023]
Abstract
AIMS/HYPOTHESIS Women remain underrepresented in clinical trials and those with type 2 diabetes mellitus are at high risk for cardiovascular (CV) events. The sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin reduces the risk of CV death or heart failure hospitalisations in individuals with type 2 diabetes. Here, we performed a pre-specified analysis to examine whether sex modifies these effects. METHODS The DECLARE-TIMI 58 trial randomised 17,160 patients with type 2 diabetes with or at risk for atherosclerotic disease to dapagliflozin or placebo (median follow-up 4.2 years). The dual efficacy outcomes were CV death or heart failure hospitalisations, and major adverse cardiovascular events (MACE; CV death, myocardial infarction or ischaemic stroke). The renal-specific composite outcome was a sustained ≥40% drop in eGFR to <60 ml min-1 [1.73 m]-2, new end-stage renal disease or renal death. Cox models were run separately by sex with treatment-by-sex interaction testing for each outcome. RESULTS At baseline, women (n = 6422, 37.4%) had higher HbA1c, longer type 2 diabetes duration, and were on fewer glucose-lowering medications. There was no evidence of modification of the effect of dapagliflozin by sex for (1) CV death or heart failure hospitalisations: women (3.8% vs 4.5%; HR 0.84, 95% CI 0.66, 1.07) and men (5.3% vs 6.4%; HR 0.83, 95% CI 0.71, 0.96; pinteraction = 0.90); (2) MACE: women (6.3% vs 6.8%; HR 0.93, 95% CI 0.77, 1.12) and men (10.0% vs 10.7%; HR 0.93, 95% CI 0.83, 1.05; pinteraction = 0.99); or (3) renal-specific composite: women (1.4% vs 2.8%; HR 0.50, 95% CI 0.35, 0.70) and men (1.5% vs 2.5%; HR 0.55, 95% CI 0.42, 0.73; pinteraction = 0.64). The overall safety profile of dapagliflozin was similar for women and men. CONCLUSIONS/INTERPRETATION Dapagliflozin offers comparable CV and renal benefits and a comparable safety profile in women and men. FUNDING AstraZeneca. TRIAL REGISTRATION clinicaltrials.gov NCT01730534.
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Affiliation(s)
- Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.
| | - Eri T Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Avivit Cahn
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | | | - Alena Šmahelová
- Faculty Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Piera Merlini
- 2nd Division of Cardiology, Ca' Granda Niguarda Hospital, Milan, Italy
| | | | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Larry A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Oyama K, Giugliano RP, Berg DD, Ruff CT, Jarolim P, Tang M, Murphy SA, Lanz HJ, Grosso MA, Antman EM, Braunwald E, Morrow DA. Serial assessment of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in the ENGAGE AF-TIMI 48 trial. Eur Heart J 2021; 42:1698-1706. [PMID: 33760027 DOI: 10.1093/eurheartj/ehab141] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/26/2020] [Accepted: 02/19/2021] [Indexed: 01/26/2023] Open
Abstract
AIMS We investigated whether patients with atrial fibrillation (AF) demonstrate detectable changes in biomarkers including high-sensitivity troponin T (hsTnT), N-terminal B-type natriuretic peptide (NT-proBNP), and growth differentiation factor-15 (GDF-15) over 12 months and whether such changes from baseline to 12 months are associated with the subsequent risk of stroke or systemic embolic events (S/SEE) and bleeding. METHODS AND RESULTS ENGAGE AF-TIMI 48 was a randomized trial of the oral factor Xa inhibitor edoxaban in patients with AF and a CHADS2 score of ≥2. We performed a nested prospective biomarker study in 6308 patients, analysing hsTnT, NT-proBNP, and GDF-15 at baseline and 12 months. hsTnT was dynamic in 46.9% (≥2 ng/L change), NT-proBNP in 51.9% (≥200 pg/mL change), GDF-15 in 45.6% (≥300 pg/mL change) during 12 months. In a Cox regression model, upward changes in log2-transformed hsTnT and NT-proBNP were associated with increased risk of S/SEE [adjusted hazard ratio (adj-HR) 1.74; 95% confidence interval (CI) 1.36-2.23 and adj-HR 1.27; 95% CI 1.07-1.50, respectively] and log2-transformed GDF-15 with bleeding (adj-HR 1.40; 95% CI 1.02-1.92). Reassessment of ABC-stroke (age, prior stroke/transient ischaemic attack, hsTnT, and NT-proBNP) and ABC-bleeding (age, prior bleeding, haemoglobin, hsTnT, and GDF-15) risk scores at 12 months accurately reclassified a significant proportion of patients compared with their baseline risk [net reclassification improvement (NRI) 0.50; 95% CI 0.36-0.65; NRI 0.42; 95% CI 0.33-0.51, respectively]. CONCLUSION Serial assessment of hsTnT, NT-proBNP, and GDF-15 revealed that a substantial proportion of patients with AF had dynamic values. Greater increases in these biomarkers measured over 1 year are associated with important clinical outcomes in anticoagulated patients with AF.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Petr Jarolim
- Division of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Minao Tang
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Hans J Lanz
- Daiichi Sankyo, Zielstattstraße 48, München 81379, Germany
| | | | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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41
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Keech AC, Oyama K, Sever PS, Tang M, Murphy SA, Hirayama A, Lu C, Tay L, Deedwania PC, Siu CW, Lira Pineda A, Choi D, Charng MJ, Amerena J, Wan Ahmad WA, Chopra VK, Pedersen TR, Giugliano RP, Sabatine MS. Efficacy and Safety of Long-Term Evolocumab Use Among Asian Subjects - A Subgroup Analysis of the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) Trial. Circ J 2021; 85:2063-2070. [PMID: 33980763 DOI: 10.1253/circj.cj-20-1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are concerns that Asian patients respond differently to some medications. This study evaluated the efficacy and safety of evolocumab among Asian vs. other subjects in the FOURIER trial, which randomized stable atherosclerosis patients to receive either evolocumab or placebo.Methods and Results:Effects of adding evolocumab vs. placebo to background statin therapy on low-density lipoprotein cholesterol (LDL-C) reductions, cardiovascular outcomes, and adverse events were compared among 27,564 participants with atherosclerotic disease, according to self-reported Asian (n=2,723) vs. other (n=24,841) races followed for a median of 2.2 years in the FOURIER trial. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. At randomization, Asians had slightly lower LDL-C (median 89 [IQR 78-104] mg/dL vs. 92 [80-109] mg/dL; P<0.001) and were much less likely to be on a high-intensity statin (33.3% vs. 73.3%; P<0.001). Evolocumab lowered LDL-C more in Asians than in others (66% vs. 58%; P<0.001). The effect of evolocumab on the primary endpoint was similar in Asians (HR, 0.79; 95% CI, 0.61-1.03) and others (HR, 0.86; 95% CI, 0.79-0.93; P interaction=0.55). There was no excess of serious adverse events with evolocumab among Asians over others. CONCLUSIONS Use of evolocumab robustly lowers LDL-C and is equally efficacious in lowering the risk of cardiovascular events and safe in Asians as it is in others.
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Affiliation(s)
- Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney
| | - Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Peter S Sever
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London
| | - Minao Tang
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | | | - Leslie Tay
- Cardiology Department, Changi General Hospital
| | | | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR
| | | | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Min-Ji Charng
- Division of Cardiology, Taipei Veterans General Hospital.,Faculty of Medicine, School of Medicine, National Yang Ming University
| | | | | | | | | | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School
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de Groot JR, Ruff CT, Murphy SA, Hamershock RA, Vehmeijer JT, Oude Ophuis AJ, Grip L, Lanz H, Mercuri MF, Antman EM, Giugliano RP. Edoxaban versus warfarin in patients with atrial fibrillation in relation to the risk of stroke: A secondary analysis of the ENGAGE AF-TIMI 48 study. Am Heart J 2021; 235:132-139. [PMID: 33493453 DOI: 10.1016/j.ahj.2021.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The efficacy and safety of the oral factor Xa inhibitor edoxaban compared to warfarin stratified by CHA2DS2VASc scores have not been described. METHODS The ENGAGE AF-TIMI 48 trial randomized patients with atrial fibrillation to once-daily edoxaban or warfarin. We classified patients based on CHA2DS2VASc score and compared pharmacokinetics (edoxaban concentration), pharmacodynamics (anti-factor Xa [FXa] with edoxaban, time-in-therapeutic range for warfarin), efficacy (stroke or systemic embolism [SSE]), safety (major bleeding [MB], intracranial hemorrhage), and cardiovascular mortality, for the approved edoxaban regimen vs warfarin. RESULTS The distribution CHA2DS2VASc score were:≤3, N = 4159 (29.6%); 4, N = 4066 (28.9%); 5, N = 3165 (22.5%); and ≥6, N = 2681 (19.1%). Increasing rates of SSE (1.05 to 2.99%/year) and MB (2.27 to 4.66%/year) were observed in the warfarin arm as the CHA2DS2VASc score increased. The hazard ratios per unit increase of CHA2DS2VASc score were 1.29 (1.21-1.38) and 1.26 (1.17-1.36) for SSE, and 1.20 (1.13-1.27) and 1.19 (1.12-1.27) for MB, with warfarin and edoxaban, respectively. Time-in-therapeutic range in warfarin-treated patients was similar and high (median 68%-69%) across CHA2DS2VASc scores, whereas edoxaban trough concentration, exogenous anti-FXa activity and %inhibition of endogenous FXa were higher at increasing CHA2DS2VASc scores. Edoxaban reduced SSE, MB, intracranial hemorrhage, and cardiovascular mortality vs warfarin to a similar degree across the range of CHA2DS2VASc scores (P-int = 0.90, 0.96, 0.21, and 0.37, respectively). Because of higher event rates the number of events prevented with edoxaban tended to be greater in patients with higher CHA2DS2VASc scores. CONCLUSION The benefit and safety of edoxaban versus warfarin is maintained across CHA2DS2VASc scores. While the relative risk reductions remain similar, edoxaban provides incrementally larger absolute reductions in outcomes over warfarin in patients with higher CHA2DS2VASc scores.
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Cahn A, Raz I, Leiter LA, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Wiviott SD. Cardiovascular, Renal, and Metabolic Outcomes of Dapagliflozin Versus Placebo in a Primary Cardiovascular Prevention Cohort: Analyses From DECLARE-TIMI 58. Diabetes Care 2021; 44:1159-1167. [PMID: 33653824 DOI: 10.2337/dc20-2492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE International guidelines propose prescribing sodium-glucose cotransporter 2 (SGLT2) inhibitors to patients with type 2 diabetes (T2D) as secondary prevention in patients with established atherosclerotic cardiovascular disease (ASCVD) or for primary prevention of cardiovascular events in high-risk patients with multiple risk factors (MRF) for ASCVD. The current analyses expand on the cardiovascular renal and metabolic effects of SGLT2 inhibitors in MRF patients. RESEARCH DESIGN AND METHODS In DECLARE-TIMI 58, 17,160 patients with T2D and MRF (59.4%) or established ASCVD (40.6%) were randomized to dapagliflozin versus placebo; patients were followed for a median of 4.2 years. The cardiovascular and renal outcomes in the MRF cohort were studied across clinically relevant subgroups for treatment effect and subgroup-based treatment interaction. RESULTS Among patients with MRF, the reduction with dapagliflozin in risk of cardiovascular death or hospitalization for heart failure (CVD/HHF) (hazard ratio [HR] 0.84, 95% CI 0.67-1.04) and the renal-specific outcome (HR 0.51, 95% CI 0.37-0.69) did not differ from that for patients with ASCVD (P interaction 0.99 and 0.72, respectively). The effect on CVD/HHF was entirely driven by a reduction in HHF (HR 0.64, 95% CI 0.46-0.88). The benefits of dapagliflozin on HHF and on the renal-specific outcome, among the subset with MRF, were directionally consistent across clinically relevant subgroups. At 48 months, HbA1c, weight, systolic blood pressure, and urinary albumin-to-creatinine ratio were lower with dapagliflozin versus placebo and estimated glomerular filtration rate was higher (P < 0.001). CONCLUSIONS In patients with T2D and MRF, dapagliflozin reduced the risk of HHF and adverse renal outcomes regardless of baseline characteristics. These analyses support the benefit of dapagliflozin for important outcomes in a broad primary prevention population.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Fagundes A, Morrow D, Oyama K, Furtado R, Zelniker T, Tang M, Kuder J, Murphy SA, Hamer A, Keech A, Sever P, Giugliano R, Sabatine M, Bergmark B. BIOMARKER PREDICTION OF MAJOR CORONARY EVENTS AND COMPLEX REVASCULARIZATION PROCEDURES IN PATIENTS WITH STABLE ATHEROSCLEROSIS. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01361-9] [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: 10/21/2022]
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Bonaca MP, Morrow DA, Bergmark BA, Lima JA, Hoffmann U, Kato Y, Lu MT, Kuder J, Murphy SA, Omar SA, Vavere AL, Chang YT, George RT, Sabatine MS. CARDIOPROTECTION AND PLAQUE REGRESSION WITH MEDI6012 IN ACUTE ST ELEVATION MYOCARDIAL INFARCTION - PRIMARY RESULTS OF THE REAL-TIMI 63B RANDOMIZED CLINICAL TRIAL. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01382-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Berg DD, Jhund PS, Docherty KF, Murphy SA, Verma S, Inzucchi SE, Køber L, Kosiborod MN, Langkilde AM, Martinez FA, Bengtsson O, Ponikowski P, Sjöstrand M, Solomon SD, McMurray JJV, Sabatine MS. Time to Clinical Benefit of Dapagliflozin and Significance of Prior Heart Failure Hospitalization in Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:499-507. [PMID: 33595593 DOI: 10.1001/jamacardio.2020.7585] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Dapagliflozin has been shown to reduce the risk of cardiovascular death or worsening heart failure (HF) in patients with chronic HF and reduced ejection fraction (HFrEF). However, clinical inertia often underlies deferred initiation of effective therapies. Objective To examine timing of onset of clinical benefit with dapagliflozin and magnitude as a function of proximity to prior HF hospitalization. Design, Setting, and Participants This is a secondary analysis of a completed multinational trial. The Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure trial was a double-blind, placebo-controlled randomized clinical trial of dapagliflozin in patients with chronic HFrEF (n = 4744). From February 2017 to August 2018, the study enrolled patients in New York Heart Association classes II through IV and with left ventricular ejection fraction of 40% or less; the median (range) follow-up time was 18.2 (0-27.8) months. Hazard ratios (HRs) were calculated for the primary efficacy outcome with dapagliflozin vs placebo by time following randomization. Efficacy and safety of dapagliflozin were assessed according to the timing of the most recent HF hospitalization prior to trial enrollment. Exposures None. Main Outcomes and Measures Composite of cardiovascular death or worsening HF. Results A total of 4744 patients were included (1109 women [23.4%]; mean [SD] age, 66.3 [10.9] years). The reduction in the primary outcome with dapagliflozin was rapidly apparent, with a sustained statistically significant benefit by 28 days after randomization (HR at 28 days, 0.51 [95% CI, 0.28-0.94]; P = .03). A total of 2251 patients (47.4%) had been previously hospitalized for HF, and 1301 (27.4%) had been hospitalized within 12 months prior to enrollment. Among patients treated with placebo, there was a stepwise gradient of risk for the primary outcome according to timing of most recent HF hospitalization, with 2-year Kaplan-Meier rates of 21.1%, 25.3%, and 33.8% (adjusted P = .003) for patients with a prior HF hospitalization never, more than 12 months ago, and 12 or fewer months ago, respectively. Across these subgroups, dapagliflozin reduced the relative risk of the primary outcome by 16% (HR, 0.84 [95% CI, 0.69-1.01]), 27% (HR, 0.73 [95% CI, 0.54-0.99]), and 36% (HR, 0.64 [95% CI, 0.51-0.80]), respectively (P = .07 for trend). Accordingly, patients with a more recent HF hospitalization tended to experience greater absolute risk reductions with dapagliflozin at 2 years: 2.1% (95% CI, -1.9% to 6.1%), 4.1% (95% CI, -3.6% to 11.7%), and 9.9% (95% CI, 3.3%-16.5%), respectively (P = .05 for trend). Conclusions and Relevance In this study, treatment with dapagliflozin was associated with rapid reduction in the risk of cardiovascular death or worsening HF, with a sustained statistically significant benefit emerging very early after randomization. Patients with a more recent HF hospitalization were at particularly high risk and experienced greater relative and absolute risk reductions with dapagliflozin. Trial Registration ClinicalTrials.gov Identifier NCT03036124.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | | | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wrocław Medical University, Poland
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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47
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Steffel J, Ruff CT, Yin O, Braunwald E, Park JG, Murphy SA, Connolly S, Antman EM, Giugliano RP. Randomized, Double-Blind Comparison of Half-Dose Versus Full-Dose Edoxaban in 14,014 Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:1197-1207. [PMID: 33663737 DOI: 10.1016/j.jacc.2020.12.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the ENGAGE AF-TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48) trial, the lower dose edoxaban regimen (LDER) and the higher dose edoxaban regimen (HDER) were noninferior to well-managed warfarin for stroke prevention in atrial fibrillation. OBJECTIVES The objective of the present analysis of the ENGAGE AF TIMI-48 trial was to comprehensively compare the net clinical outcome (NCO) of LDER (30 mg once daily, dose reduced to 15 mg in selective patients) versus HDER (60 mg once daily, dose reduced to 30 mg in selective patients). METHODS This study performed a pre-specified analysis of the ENGAGE AF-TIMI 48 trial, comparing patients on LDER versus HDER. RESULTS The pre-defined primary NCO (stroke/systemic embolism [SEE], major bleeding, death) was less frequent with LDER (7.26% vs. 8.01%; hazard ratio: 0.90; 95% confidence interval: 0.84 to 0.98; p = 0.014). The secondary (disabling stroke, life-threatening bleeding, or all-cause mortality) and tertiary pre-defined NCOs (stroke, SEE, life-threatening bleeding, or all-cause mortality) were similar between the 2 dosing regimens. Patients randomized to LDER versus HDER had a significantly higher risk of stroke/SEE (2.04% vs. 1.56%; hazard ratio: 1.31; 95% confidence interval: 1.12 to 1.52; p < 0.001). Conversely, major bleeding, intracranial hemorrhage, major gastrointestinal bleeding, and life-threatening bleeding occurred significantly less frequently with LDER compared with those of HDER. These findings were supported by multiple pharmacokinetic findings. CONCLUSIONS In the ENGAGE AF-TIMI 48 trial, the primary NCO was reduced with LDER versus HDER, whereas the secondary and tertiary NCOs were similar between the 2 dosing regimens. These results may aid physicians in evidence-based individualization of edoxaban dosing. However, the approved HDER remains the standard therapy among the available edoxaban dosing regimens for stroke prevention in atrial fibrillation. (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48 [ENGAGE AF-TIMI 48]; NCT00781391).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland. https://twitter.com/SteffelJ
| | - Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ophelia Yin
- Daiichi-Sankyo, Inc., Basking Ridge, New Jersey, USA
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sabina A Murphy
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Elliott M Antman
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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48
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Zelniker TA, Ardissino M, Andreotti F, O'Donoghue ML, Yin O, Park JG, Murphy SA, Ruff CT, Lanz HJ, Antman EM, Braunwald E, Giugliano RP, Merlini PA. Comparison of the Efficacy and Safety Outcomes of Edoxaban in 8040 Women Versus 13 065 Men With Atrial Fibrillation in the ENGAGE AF-TIMI 48 Trial. Circulation 2021; 143:673-684. [PMID: 33587659 PMCID: PMC7884089 DOI: 10.1161/circulationaha.120.052216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Female sex is an independent risk factor for stroke and systemic embolic events in patients with atrial fibrillation. This study aimed to examine the efficacy and safety profile of edoxaban in women versus men. Methods: The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) randomly assigned 21 105 patients (8040 women) with atrial fibrillation and CHADS2 score ≥2 either to a higher-dose edoxaban regimen, a lower-dose edoxaban regimen, or warfarin. The primary end points of the trial were the composite of stroke or systemic embolic events (efficacy), and International Society on Thrombosis and Haemostasis–defined major bleeding (safety). Results: In comparison with men, women were older, had lower body weight, were more likely to have hypertension and renal dysfunction, but less likely to smoke, drink alcohol, or have diabetes or coronary artery disease. Pretreatment endogenous factor Xa activity was significantly higher in women than in men (92.5% versus 86.1%, P<0.001). Treatment with edoxaban in women resulted in greater peak edoxaban concentration and inhibition of endogenous factor Xa in comparison with men, resulting in similar endogenous factor Xa activity between the sexes 2 to 4 hours after dose. Treatment with higher-dose edoxaban regimen (versus warfarin) resulted in similar reduction in the risk of stroke/systemic embolic events (women: hazard ratio [HR], 0.87 [0.69–1.11], men: HR, 0.87 [0.71–1.06]; P-interaction=0.97) and major bleeding (women: HR, 0.74 [0.59–0.92], men: HR, 0.84 [0.72–0.99]; P-interaction=0.34) in women and men. However, women assigned to higher-dose edoxaban regimen experienced greater reductions in hemorrhagic stroke (HR, 0.30 [95% CI, 0.15–0.59] versus HR, 0.70 [95% CI, 0.46–1.06]), intracranial bleeding (HR, 0.20 [95% CI, 0.10–0.39] versus HR, 0.63 [95% CI, 0.44–0.89]), and life-threatening or fatal bleeding (HR, 0.25 [95% CI, 0.15–0.42] versus HR, 0.72 [95% CI, 0.54–0.96]) than men (each P-interaction<0.05). Conclusions: Despite many differences in baseline characteristics between women and men and higher baseline endogenous factor Xa levels in women, the intensity of anticoagulation achieved with edoxaban between the sexes was similar. Treatment with higher-dose edoxaban regimen resulted in an even greater reduction in hemorrhagic stroke and several serious bleeding outcomes in women than in men, whereas the efficacy profile was similar between sexes.
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Affiliation(s)
- Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Austria (T.A.Z.)
| | | | - Felicita Andreotti
- Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy (F.A.).,Institute of Cardiology, Catholic University Medical School, Rome, Italy (F.A.)
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Ophelia Yin
- Daiichi Sankyo Inc, Basking Ridge, NJ (O.Y.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Hans J Lanz
- Daiichi Sankyo Europe GmbH, Munich, Germany (H.J.L.)
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
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49
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Deedwania P, Murphy SA, Scheen A, Badariene J, Pineda AL, Honarpour N, Keech AC, Sever PS, Pedersen TR, Sabatine MS, Giugliano RP. Efficacy and Safety of PCSK9 Inhibition With Evolocumab in Reducing Cardiovascular Events in Patients With Metabolic Syndrome Receiving Statin Therapy: Secondary Analysis From the FOURIER Randomized Clinical Trial. JAMA Cardiol 2021; 6:139-147. [PMID: 32785614 DOI: 10.1001/jamacardio.2020.3151] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The PCSK9 inhibitor evolocumab reduced low-density lipoprotein cholesterol and cardiovascular events in the FOURIER randomized clinical trial. Patients with metabolic syndrome (MetS) are at increased cardiovascular risk. Objective To investigate outcomes with evolocumab in patients with and without MetS. Design, Setting, and Participants The FOURIER trial randomized patients worldwide with stable atherosclerotic cardiovascular disease receiving statin to evolocumab vs placebo with follow-up for a median of 2.2 years. Data were collected February 2013 to November 2016. For this prespecified analysis, patients with the requisite data were stratified based on the National Cholesterol Education Program Adult Treatment Panel III MetS criteria; in secondary analyses, patients were further substratified by diabetes at baseline. Analysis was intention to treat. Analysis began March 2018 and ended April 2020. Interventions Patients were randomized to evolocumab or placebo. Main Outcomes and Measures The primary end point was cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. The key secondary end point was cardiovascular death, myocardial infarction, or stroke. Results Of 27 342 patients (mean [SD] age, 63 [9] years; 20 623 men [75.4%]) included in this analysis, 16 361 (59.8%) with baseline MetS were, when compared with patients without MetS, at higher risk of cardiovascular events (adjusted hazard ratio [95% CI], 1.31 [1.18-1.46]; P < .001 for the primary and 1.38 [1.20-1.57]; P < .001 for the key secondary end point). Evolocumab reduced low-density lipoprotein cholesterol similarly in patients with MetS (median [interquartile range], 92 [79-109] mg/dL vs 30 [19-48] mg/dL; P < .001) and without MetS (median [interquartile range], 92 [81-108] mg/dL vs 29 [18-44] mg/dl; P < .001). For the primary end point, the hazard ratios (95% CI) with evolocumab vs placebo were 0.83 (0.76-0.91) and 0.89 (0.79-1.01) in patients with and without MetS (P for interaction = .39). For the key secondary end point, the corresponding hazard ratios (95% CIs) were 0.76 (0.68-0.86) and 0.86 (0.74-1.01) (P for interaction = .23), respectively. Evolocumab did not increase the risk of new-onset diabetes or other major safety outcomes including worsening glycemic control, compared with placebo in patients with MetS. Conclusions and Relevance Patients with atherosclerotic cardiovascular disease and MetS have substantial residual risk of cardiovascular events despite statin therapy. Evolocumab significantly reduced low-density lipoprotein cholesterol and cardiovascular risk in patients with MetS without increasing new-onset diabetes, worsening glycemic control, or other major safety events. These data suggest the addition of evolocumab to statin therapy in patients with atherosclerotic cardiovascular disease and MetS is safe and efficacious to reduce residual cardiovascular risk. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andre Scheen
- Department of Medicine, CHU Liège, Liège University, Liège, Belgium
| | - Jolita Badariene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | - Anthony C Keech
- Sydney Medical School, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Peter S Sever
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Norway
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Deputy Editor, JAMA Cardiology
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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50
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Bergmark BA, O'Donoghue ML, Murphy SA, Kuder JF, Ezhov MV, Ceška R, Gouni-Berthold I, Jensen HK, Tokgozoglu SL, Mach F, Huber K, Gaciong Z, Lewis BS, Schiele F, Jukema JW, Pedersen TR, Giugliano RP, Sabatine MS. An Exploratory Analysis of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibition and Aortic Stenosis in the FOURIER Trial. JAMA Cardiol 2021; 5:709-713. [PMID: 32347887 DOI: 10.1001/jamacardio.2020.0728] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [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: 01/24/2023]
Abstract
Importance Despite recent advances in treatment of severe aortic valve stenosis (AS), AS remains a life-threatening condition with no proven disease-modifying therapy. Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp[a]) have been implicated in the pathobiology of AS. The proprotein convertase subtilisin/kexin type 9 inhibitor evolocumab reduces circulating LDL-C concentrations by 50% to 60% and Lp(a) by 20% to 30%. Objective To determine whether evolocumab reduces the risk of AS events in patients with atherosclerotic cardiovascular disease. Interventions Patients were randomized 1:1 to evolocumab or placebo. Design, Setting, and Participants Exploratory analysis of the FOURIER trial, which enrolled 27 564 patients with stable atherosclerotic cardiovascular disease who were taking statin therapy at 1242 sites in 49 countries from February 2013 to November 2016. Patients were randomized to evolocumab or placebo and followed up for a median (interquartile range) of 2.2 (1.8-2.5) years. This post hoc analysis was performed from September 2019 to February 2020. Main Outcomes and Measures Site-reported adverse events of new or worsening AS or aortic valve replacement (termed AS events). The adjusted risk of AS events was calculated with a multivariable model including concentrations of Lp(a) and LDL-C corrected for Lp(a) content, plus age, sex, diabetes, hypertension, current smoking, and estimated glomerular filtration rate. Evolocumab efficacy was tested using a Cox proportional hazards model. Results Aortic stenosis events occurred in 63 patients (48 men [76%]; mean [SD] age, 69 [9] years) over a median of 2.2 years. Elevated Lp(a) concentration was associated with higher rates of AS events (adjusted hazard ratio [aHR], 1.55 [95% CI, 1.17-2.05] per SD; P = .002), including aortic valve replacement (aHR, 2.22 [95% CI, 1.38-3.58] per SD; P = .001), after multivariable adjustment. The corrected LDL-C concentration was not significantly associated with AS events (aHR, 1.23 [95% CI, 0.93-1.61] per SD; P = .14). The overall HR for AS events with evolocumab was 0.66 (95% CI, 0.40-1.09), with no apparent association in the first year (HR, 1.09 [95% CI, 0.48-2.47]) but an HR of 0.48 (95% CI, 0.25-0.93) after the first year of treatment. Conclusions and Relevance In this exploratory analysis of the FOURIER trial, higher Lp(a) levels, but not Lp(a)-corrected LDL-C levels, were associated with a higher risk of subsequent AS events, including aortic valve replacement. Long-term therapy with evolocumab may reduce AS events, and this raises the possibility that specific pharmacologic lipid-lowering therapy could offer a means to prevent or slow the progression of AS. These exploratory findings merit further investigation with a dedicated randomized clinical trial. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
- Brian A Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julia F Kuder
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marat V Ezhov
- National Medical Research Center of Cardiology, Moscow, Russia
| | - Richard Ceška
- Third Internal Medicine Clinic, Center for Preventive Cardiology, University General Hospital, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | | | - François Mach
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Kurt Huber
- Cardiology and Intensive Care Medicine, Wilhelminenhospital, Third Department of Medicine, Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Disease, the Medical University of Warsaw, Warsaw, Poland
| | - Basil S Lewis
- The Ruth and Bruce Rappaport School of Medicine, Lady Davis Carmel Medical Center, Technion-IIT, Haifa, Israel
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, the Netherlands.,Netherlands Heart Institute, Utrecht, the Netherlands
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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