1
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Cosentino F, Ceriello A, Baeres FMM, Fioretto P, Garber A, Stough WG, George JT, Grant PJ, Khunti K, Langkilde AM, Plutzky J, Rydén L, Scheen A, Standl E, Tuomilehto J, Zannad F. Addressing cardiovascular risk in type 2 diabetes mellitus: a report from the European Society of Cardiology Cardiovascular Roundtable. Eur Heart J 2020; 40:2907-2919. [PMID: 30445605 DOI: 10.1093/eurheartj/ehy677] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/20/2018] [Accepted: 10/08/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institute & Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Italy
| | | | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Alan Garber
- Baylor College of Medicine, Houston, Texas, USA
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Cary, North Carolina, USA
| | - Jyothis T George
- Boehringer Ingelheim International, Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Jorge Plutzky
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lars Rydén
- Department of Medicine, K2, Karolinska Institute, Stockholm, Sweden
| | - André Scheen
- Division of Diabetes, Nutrition, and Metabolic Disorders, Division of Clinical Pharmacology, CHU de Liège, University of Liège, Liège, Belgium
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Jaakko Tuomilehto
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116, CHRU, Nancy, France
- Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT, Nancy, France
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2
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Rossignol P, Agarwal R, Canaud B, Charney A, Chatellier G, Craig JC, Cushman WC, Gansevoort RT, Fellström B, Garza D, Guzman N, Holtkamp FA, London GM, Massy ZA, Mebazaa A, Mol PGM, Pfeffer MA, Rosenberg Y, Ruilope LM, Seltzer J, Shah AM, Shah S, Singh B, Stefánsson BV, Stockbridge N, Stough WG, Thygesen K, Walsh M, Wanner C, Warnock DG, Wilcox CS, Wittes J, Pitt B, Thompson A, Zannad F. Cardiovascular outcome trials in patients with chronic kidney disease: challenges associated with selection of patients and endpoints. Eur Heart J 2020; 40:880-886. [PMID: 28431138 DOI: 10.1093/eurheartj/ehx209] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/17/2017] [Accepted: 03/30/2017] [Indexed: 12/11/2022] Open
Abstract
Although cardiovascular disease is a major health burden for patients with chronic kidney disease, most cardiovascular outcome trials have excluded patients with advanced chronic kidney disease. Moreover, the major cardiovascular outcome trials that have been conducted in patients with end-stage renal disease have not demonstrated a treatment benefit. Thus, clinicians have limited evidence to guide the management of cardiovascular disease in patients with chronic kidney disease, particularly those on dialysis. Several factors contribute to both the paucity of trials and the apparent lack of observed treatment effect in completed studies. Challenges associated with conducting trials in this population include patient heterogeneity, complexity of renal pathophysiology and its interaction with cardiovascular disease, and competing risks for death. The Investigator Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), an international organization of academic cardiovascular and renal clinical trialists, held a meeting of regulators and experts in nephrology, cardiology, and clinical trial methodology. The group identified several research priorities, summarized in this paper, that should be pursued to advance the field towards achieving improved cardiovascular outcomes for these patients. Cardiovascular and renal clinical trialists must partner to address the uncertainties in the field through collaborative research and design clinical trials that reflect the specific needs of the chronic and end-stage kidney disease populations, with the shared goal of generating robust evidence to guide the management of cardiovascular disease in patients with kidney disease.
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Affiliation(s)
- Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116; CHRU Nancy; Université de Lorraine; Association Lorraine pour le Traitement de l'Insuffisance Rénale, Institut lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue du Morvan, Nancy, France.,F-CRIN INI-CRCT, Nancy, France
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Bernard Canaud
- Fresenius Medical Care Deutschland and University of Montpellier, UFR Medicine, France
| | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Gilles Chatellier
- AP-HP, Hôpital Européen Georges Pompidou, Unité de Recherche Clinique and INSERM CIC 1418, Paris, France
| | - Jonathan C Craig
- School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Ronald T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bengt Fellström
- Inserm U1018, Université Paris-Saclay, UVSQ, Université. Paris-Sud, Villejuif, France
| | | | | | - Frank A Holtkamp
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerard M London
- F-CRIN INI-CRCT, Nancy, France.,France Centre Hospitalier F.H. Manhès, Fleury-Merogis, France
| | - Ziad A Massy
- F-CRIN INI-CRCT, Nancy, France.,Ambroise Pare University Hospital, APHP, Paris-Ile-de France-Ouest University (UVSQ), and INSERM U1018, Team 5 Boulogne Billancourt, France
| | - Alexandre Mebazaa
- F-CRIN INI-CRCT, Nancy, France.,U942 Inserm, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Peter G M Mol
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Luis M Ruilope
- Institute of Investigation and Hypertension Unit, Hospital 12 de Octubre, Department of Preventive Medicine and Public Health, Universidad Autonoma and School of Doctoral Studies and Research, Universidad Europea de Madrid, Madrid, Spain
| | | | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Salim Shah
- Sarfez Pharmaceuticals, Inc., McLean, VA, USA
| | | | | | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Walsh
- McMaster University and Population Health Research Institute, Hamilton, Canada
| | - Christoph Wanner
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Würzburg and Comprehensive Heart Failure Center, Würzburg, Germany
| | - David G Warnock
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christopher S Wilcox
- Hypertension, Kidney and Vascular Research Center and Division of Nephrology and Hypertension, Department of Medicine, Georgetown University, Washington, DC, USA
| | - Janet Wittes
- Statistics Collaborative, Inc., Washington, District of Columbia, USA
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Aliza Thompson
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116; CHRU Nancy; Université de Lorraine; Association Lorraine pour le Traitement de l'Insuffisance Rénale, Institut lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue du Morvan, Nancy, France.,F-CRIN INI-CRCT, Nancy, France
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3
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Graham I, Shear C, De Graeff P, Boulton C, Catapano AL, Stough WG, Carlsson SC, De Backer G, Emmerich J, Greenfeder S, Kim AM, Lautsch D, Nguyen T, Nissen SE, Prasad K, Ray KK, Robinson JG, Sasiela WJ, Bruins Slot K, Stroes E, Thuren T, Van der Schueren B, Velkovski-Rouyer M, Wasserman SM, Wiklund O, Zouridakis E. New strategies for the development of lipid-lowering therapies to reduce cardiovascular risk. Eur Heart J Cardiovasc Pharmacother 2019; 4:119-127. [PMID: 29194462 DOI: 10.1093/ehjcvp/pvx031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/27/2017] [Indexed: 12/29/2022]
Abstract
The very high occurrence of cardiovascular events presents a major public health issue, because treatment remains suboptimal. Lowering LDL cholesterol (LDL-C) with statins or ezetimibe in combination with a statin reduces major adverse cardiovascular events. The cardiovascular risk reduction in relation to the absolute LDL-C reduction is linear for most interventions without evidence of attenuation or increase in risk at low LDL-C levels. Opportunities for innovation in dyslipidaemia treatment should address the substantial risk of lipid-associated cardiovascular events among patients optimally treated per guidelines but who cannot achieve LDL-C goals and who could benefit from additional LDL-C-lowering therapy or experience side effects of statins. Fresh approaches are needed to identify promising drug targets early and develop them efficiently. The Cardiovascular Round Table of the European Society of Cardiology (ESC) convened a workshop to discuss new lipid-lowering strategies for cardiovascular risk reduction. Opportunities to improve treatment approaches and the efficient study of new therapies were explored. Circulating biomarkers may not be fully reliable proxy indicators of the relationship between treatment effect and clinical outcome. Mendelian randomization studies may better inform development strategies and refine treatment targets before Phase 3. Trials should match the drug to appropriate lipid and patient profile, and guidelines may move towards a precision-based approach to individual patient management. Stakeholder collaboration is needed to ensure continued innovation and better international coordination of both regulatory aspects and guidelines. It should be noted that risk may also be addressed through increased attention to other risk factors such as smoking, hypertension, overweight, and inactivity.
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Affiliation(s)
- Ian Graham
- Trinity College, Adelaide Health Foundation, Tallaght Hospital, Dublin 24, Ireland
| | - Chuck Shear
- Global Product Development/Internal Medicine, Pfizer, Inc., 235 E. 42nd Street, New York, New York 10017, NY, USA
| | - Pieter De Graeff
- Dutch Medicines Evaluation Board (CBG-MEB), Graadt Van Roggenweg 500, 3531 AH Utrecht, The Netherlands.,Department of Pharmacy and Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | | | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences and Multimedica IRCCS, University of Milan, via Balzaretti 9, 20133 Milano, Italy
| | - Wendy Gattis Stough
- Departments of Clinical Research and Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, 217 Main St., Buies Creek, NC 27506, USA
| | - Stefan C Carlsson
- Cardiovascular Pharmacology, AstraZeneca, Pepparredsleden 1, SE-431 83 Mölndal, Sweden
| | - Guy De Backer
- Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, University Hospital, K3, 4th floor, De Pintelaan 185, B9000 Ghent, Belgium
| | - Joseph Emmerich
- Université Paris-Descartes, Cochin-Hôtel Dieu Hospital, French National Agency for Medicines and Health Products Safety, 143/147, Boulevard, Anatole France 93285, Saint-Denis, France
| | - Scott Greenfeder
- Regulatory Affairs, Daiichi-Sankyo, 211 Mt. Airy Road, Basking Ridge, NJ 07920, USA
| | - Albert M Kim
- Internal Medicine Research Unit, Pfizer, Inc., 1 Portland St., 4th floor, Cambridge, MA 02139, USA
| | - Dominik Lautsch
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA
| | - Tu Nguyen
- Sanofi, 55 Corporate Drive, Bridgewater, NJ, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Krishna Prasad
- Licensing Division, United Kingdom Medicines and Healthcare Products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College, 323 Reynolds Building, Room 320, Charing Cross Hospital, London W68RF, UK
| | - Jennifer G Robinson
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Dr S455 CPHB, Iowa City, IA 52242, USA
| | - William J Sasiela
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Karsten Bruins Slot
- Oslo University Hospital, Ullevål, Medical Department, Postboks 4956 Nydalen, 0424 Oslo, Norway
| | - Erik Stroes
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Tom Thuren
- Novartis Pharma AG, Asklepios 8, 4056 Basel, Switzerland
| | - Bart Van der Schueren
- Laboratory of Experimental Medicine and Endocrinology, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | | | - Scott M Wasserman
- Amgen, One Amgen Center Drive, MS 38.2.C, Thousand Oaks, CA 91320, USA
| | - Olov Wiklund
- Wallenberg Laboratory, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Emmanouil Zouridakis
- Licensing Division, United Kingdom Medicines and Healthcare Products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK
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4
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Ferrari R, Bueno H, Chioncel O, Cleland JG, Stough WG, Lettino M, Metra M, Parissis JT, Pinto F, Ponikowski P, Ruschitzka F, Tavazzi L. Acute heart failure: lessons learned, roads ahead. Eur J Heart Fail 2018. [DOI: 10.1002/ejhf.1169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Roberto Ferrari
- Department of Cardiology and LTTA Centre; University Hospital of Ferrara; Ferrara Italy
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
| | - Héctor Bueno
- Department of Cardiology; Hospital 12 de Octubre; Madrid Spain
| | - Ovidiu Chioncel
- University of Medicine Carol Davila Bucuresti; Institutul de Urgente Boli Cardiovasculare CC; Iliescu Romania
| | - John G. Cleland
- National Heart & Lung Institute; Harefield Hospital, Imperial College; London UK
| | - Wendy Gattis Stough
- Departments of Pharmacy Practice and Clinical Research; Campbell University College of Pharmacy and Health Sciences; Cary NC USA
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | | | - Fausto Pinto
- Departamento de Cardiologia, CCUL, CAML, Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Piotr Ponikowski
- Medical University, Centre for Heart Disease; Clinical Military Hospital; Wroclaw Poland
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Zürich Switzerland
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
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5
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Vodovar N, Mebazaa A, Januzzi JL, Murtagh G, Stough WG, Adams KF, Zannad F. Evolution of natriuretic peptide biomarkers in heart failure: Implications for clinical care and clinical trials. Int J Cardiol 2018; 254:215-221. [PMID: 29407093 DOI: 10.1016/j.ijcard.2017.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/27/2017] [Accepted: 11/02/2017] [Indexed: 01/08/2023]
Abstract
Natriuretic peptides (NPs) are recommended by international guidelines to exclude non-heart failure causes of acute dyspnea and to assess prognosis. NPs are commonly used as an entry criterion for clinical trials, to minimize enrollment of misdiagnosed patients, or to ensure enrollment of a sufficiently at-risk population. NP values used to select trial populations to date have been inconsistent across studies. Future trials should consider using standardized thresholds for NP levels, with protocol-specified adaptations appropriate for the specific study and patient population to account for factors that can influence the NP level. NPs have been used as an endpoint for proof-of-concept or phase 2 clinical trials, although it is important to remember that positive results in early phase studies may be unstable due to small numbers and the play of chance, and they are not always reproducible in phase 3 trials. Likewise, failure to reduce NP in phase 2 may not necessarily indicate that a drug will be ineffective on clinical outcomes in phase 3. NP guided therapy has been intensively studied, but the clinical outcome benefits of this approach remain uncertain. Neprilysin inhibitors have stimulated further exploration of the NP system and how it influences, and is potentially influenced by, heart failure therapies. This paper discusses the utility of NPs in the current clinical research and practice environment and addresses areas in need of further research from the perspectives of academic clinical trialists, clinicians, biostatisticians, regulators, and pharmaceutical industry scientists who participated in the 13th Global Cardiovascular Clinical Trialists Forum.
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Affiliation(s)
| | - Alexandre Mebazaa
- Inserm UMR-S 942, Paris, France; DHU Neurovasc, Paris, France; Department of Anaesthesiology and Intensive Care, Lariboisière Hospital, Paris, France; Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, MA, United States
| | | | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, NC, United States
| | | | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, CHU Nancy, Université de Lorraine, and F-CRIN INI-CRCT, Nancy, France.
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6
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Katus H, Ziegler A, Ekinci O, Giannitsis E, Stough WG, Achenbach S, Blankenberg S, Brueckmann M, Collinson P, Comaniciu D, Crea F, Dinh W, Ducrocq G, Flachskampf FA, Fox KAA, Friedrich MG, Hebert KA, Himmelmann A, Hlatky M, Lautsch D, Lindahl B, Lindholm D, Mills NL, Minotti G, Möckel M, Omland T, Semjonow V. Early diagnosis of acute coronary syndrome. Eur Heart J 2017; 38:3049-3055. [PMID: 29029109 DOI: 10.1093/eurheartj/ehx492] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/21/2017] [Indexed: 01/01/2023] Open
Abstract
The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin <99th percentile; (ii) patients with symptoms and high-sensitivity troponin <99th percentile but above the limit of detection; (iii) patients with symptoms and high-sensitivity troponin >99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research.
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Affiliation(s)
- Hugo Katus
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Okan Ekinci
- Siemens Healthineers, Erlangen, Germany
- University College Dublin, Dublin, Ireland
| | - Evangelos Giannitsis
- Medizinische Klinik III, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Martina Brueckmann
- Boehringer-Ingelheim GmbH & Co. KG, Ingelheim am Rhein, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Paul Collinson
- St. George's University Hospitals NHS Foundation Trust, London, UK
- St. Georges, University of London, London, UK
| | | | - Filippo Crea
- Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Wilfried Dinh
- Bayer AG Pharmaceuticals, Drug Discovery, Wuppertal, Germany
- Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany
| | | | - Frank A Flachskampf
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Canada
- Heidelberg University, Heidelberg, Germany
| | | | | | - Mark Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Bertil Lindahl
- Department of Medical Sciences, Clinical Physiology/Cardiology, Uppsala University, Uppsala, Sweden
| | - Daniel Lindholm
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Nicholas L Mills
- BHF Center for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Torbjørn Omland
- Akershus University Hospital and University of Oslo, Oslo, Norway
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7
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Landray MJ, Bax JJ, Alliot L, Buyse M, Cohen A, Collins R, Hindricks G, James SK, Lane S, Maggioni AP, Meeker-O'Connell A, Olsson G, Pocock SJ, Rawlins M, Sellors J, Shinagawa K, Sipido KR, Smeeth L, Stephens R, Stewart MW, Stough WG, Sweeney F, Van de Werf F, Woods K, Casadei B. Improving public health by improving clinical trial guidelines and their application. Eur Heart J 2017; 38:1632-1637. [PMID: 28329235 PMCID: PMC5837481 DOI: 10.1093/eurheartj/ehx086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/16/2016] [Accepted: 02/10/2017] [Indexed: 11/12/2022] Open
Abstract
Evidence generated from randomized controlled trials forms the foundation of cardiovascular therapeutics and has led to the adoption of numerous drugs and devices that prolong survival and reduce morbidity, as well as the avoidance of interventions that have been shown to be ineffective or even unsafe. Many aspects of cardiovascular research have evolved considerably since the first randomized trials in cardiology were conducted. In order to be large enough to provide reliable evidence about effects on major outcomes, cardiovascular trials may now involve thousands of patients recruited from hundreds of clinical sites in many different countries. Costly infrastructure has developed to meet the increasingly complex organizational and operational requirements of these clinical trials. Concerns have been raised that this approach is unsustainable, inhibiting the reliable evaluation of new and existing treatments, to the detriment of patient care. These issues were considered by patients, regulators, funders, and trialists at a meeting of the European Society of Cardiology Cardiovascular Roundtable in October 2015. This paper summarizes the key insights and discussions from the workshop, highlights subsequent progress, and identifies next steps to produce meaningful change in the conduct of cardiovascular clinical research.
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Affiliation(s)
- Martin J. Landray
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marc Buyse
- IDDI and CluePoints, Louvain-la-Neuve, Belgium
- University of Hasselt, Hasselt, Belgium
| | - Adam Cohen
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Rory Collins
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan K. James
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | | | | | - Gunnar Olsson
- Board Member (advisory) of European Society of Cardiology, Sweden
| | - Stuart J. Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Rawlins
- Medicines and Healthcare products Regulatory Agency, London, UK
| | | | | | - Karin R. Sipido
- Department of Cardiovascular Sciences, Experimental Cardiology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Liam Smeeth
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, North Carolina, USA
| | | | - Frans Van de Werf
- Department of Cardiovascular Sciences, University Hospitals, Leuven, Belgium
| | - Kerrie Woods
- National Institute for Health Research, National Health Service, London, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford, OX3 9DU, UK
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8
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Stough WG, Patterson JH. Role and Value of Clinical Pharmacy in Heart Failure Management. Clin Pharmacol Ther 2017; 102:209-212. [DOI: 10.1002/cpt.687] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/22/2017] [Accepted: 02/27/2017] [Indexed: 11/06/2022]
Affiliation(s)
- WG Stough
- Campbell University College of Pharmacy and Health Sciences; Cary North Carolina USA
| | - JH Patterson
- Eshelman School of Pharmacy; University of North Carolina; Chapel Hill North Carolina USA
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9
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Zannad F, Pfeffer MA, Bhatt DL, Bonds DE, Borer JS, Calvo-Rojas G, Fiore L, Lund LH, Madigan D, Maggioni AP, Meyers CM, Rosenberg Y, Simon T, Stough WG, Zalewski A, Zariffa N, Temple R. Streamlining cardiovascular clinical trials to improve efficiency and generalisability. Heart 2017; 103:1156-1162. [PMID: 28455296 DOI: 10.1136/heartjnl-2017-311191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/07/2017] [Accepted: 03/19/2017] [Indexed: 11/04/2022] Open
Abstract
Controlled trials provide the most valid determination of the efficacy and safety of an intervention, but large cardiovascular clinical trials have become extremely costly and complex, making it difficult to study many important clinical questions. A critical question, and the main objective of this review, is how trials might be simplified while maintaining randomisation to preserve scientific integrity and unbiased efficacy assessments. Experience with alternative approaches is accumulating, specifically with registry-based randomised controlled trials that make use of data already collected. This approach addresses bias concerns while still capitalising on the benefits and efficiencies of a registry. Several completed or ongoing trials illustrate the feasibility of using registry-based controlled trials to answer important questions relevant to daily clinical practice. Randomised trials within healthcare organisation databases may also represent streamlined solutions for some types of investigations, although data quality (endpoint assessment) is likely to be a greater concern in those settings. These approaches are not without challenges, and issues pertaining to informed consent, blinding, data quality and regulatory standards remain to be fully explored. Collaboration among stakeholders is necessary to achieve standards for data management and analysis, to validate large data sources for use in randomised trials, and to re-evaluate ethical standards to encourage research while also ensuring that patients are protected. The rapidly evolving efforts to streamline cardiovascular clinical trials have the potential to lead to major advances in promoting better care and outcomes for patients with cardiovascular disease.
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Affiliation(s)
- Faiez Zannad
- Clinical Investigation Center, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Denise E Bonds
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey S Borer
- The Howard Gilman Institute, New York, New York, USA.,State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Gonzalo Calvo-Rojas
- Department of Clinical Pharmacology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Louis Fiore
- Department of Veterans Affairs, Cooperative Studies Program, Boston, Massachusetts, USA
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institute, Stockholm, Sweden
| | - David Madigan
- Department of Statistics, Columbia University, New York, New York, USA
| | | | - Catherine M Meyers
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Tabassome Simon
- Assistance Publique-Hôpitaux de Paris, Saint Antoine Hospital, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Research Triangle Park, North Carolina, USA
| | | | | | - Robert Temple
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
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10
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Cowie MR, Filippatos GS, Alonso Garcia MDLA, Anker SD, Baczynska A, Bloomfield DM, Borentain M, Bruins Slot K, Cronin M, Doevendans PA, El-Gazayerly A, Gimpelewicz C, Honarpour N, Janmohamed S, Janssen H, Kim AM, Lautsch D, Laws I, Lefkowitz M, Lopez-Sendon J, Lyon AR, Malik FI, McMurray JJV, Metra M, Figueroa Perez S, Pfeffer MA, Pocock SJ, Ponikowski P, Prasad K, Richard-Lordereau I, Roessig L, Rosano GMC, Sherman W, Stough WG, Swedberg K, Tyl B, Zannad F, Boulton C, De Graeff P. New medicinal products for chronic heart failure: advances in clinical trial design and efficacy assessment. Eur J Heart Fail 2017; 19:718-727. [PMID: 28345190 DOI: 10.1002/ejhf.809] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 11/18/2016] [Revised: 01/30/2017] [Accepted: 02/07/2017] [Indexed: 12/13/2022] Open
Abstract
Despite the availability of a number of different classes of therapeutic agents with proven efficacy in heart failure, the clinical course of heart failure patients is characterized by a reduction in life expectancy, a progressive decline in health-related quality of life and functional status, as well as a high risk of hospitalization. New approaches are needed to address the unmet medical needs of this patient population. The European Medicines Agency (EMA) is undertaking a revision of its Guideline on Clinical Investigation of Medicinal Products for the Treatment of Chronic Heart Failure. The draft version of the Guideline was released for public consultation in January 2016. The Cardiovascular Round Table of the European Society of Cardiology (ESC), in partnership with the Heart Failure Association of the ESC, convened a dedicated two-day workshop to discuss three main topic areas of major interest in the field and addressed in this draft EMA guideline: (i) assessment of efficacy (i.e. endpoint selection and statistical analysis); (ii) clinical trial design (i.e. issues pertaining to patient population, optimal medical therapy, run-in period); and (iii) research approaches for testing novel therapeutic principles (i.e. cell therapy). This paper summarizes the key outputs from the workshop, reviews areas of expert consensus, and identifies gaps that require further research or discussion. Collaboration between regulators, industry, clinical trialists, cardiologists, health technology assessment bodies, payers, and patient organizations is critical to address the ongoing challenge of heart failure and to ensure the development and market access of new therapeutics in a scientifically robust, practical and safe way.
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Affiliation(s)
- Martin R Cowie
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK
| | - Gerasimos S Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Maria de Los Angeles Alonso Garcia
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK.,Scientific Advice Working Party European Medicines Agency, Medical Assessor Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen (UMG), Göttingen, Germany.,Division of Homeostasis Research, Dept of Cardiology, Charité Campus CVK, Berlin, Germany
| | | | | | | | | | | | - Pieter A Doevendans
- European Medicines Agency Committee for Advanced Therapy, London, UK.,UMC, Utrecht, the Netherlands
| | | | | | | | | | | | | | | | | | - Martin Lefkowitz
- Novartis Pharmaceuticals, East Hanover, New Jersey, United States
| | - Jose Lopez-Sendon
- Cardiology Department, Hospital Universitario La Paz; IdiPaz, CIBER-CV, Madrid, Spain
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | - Krishna Prasad
- United Kingdom Medicines and Healthcare Products Regulatory Agency, London, UK
| | | | | | - Giuseppe M C Rosano
- IRCCS San Raffaele Hospital Roma, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust, University of London, London, UK
| | | | | | - Karl Swedberg
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK.,Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 1433 and Unité 1116, Université de Lorraine and CHU, Nancy, France
| | | | - Pieter De Graeff
- Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, the Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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11
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Filippatos GS, de Graeff P, Bax JJ, Borg JJ, Cleland JGF, Dargie HJ, Flather M, Ford I, Friede T, Greenberg B, Henon-Goburdhun C, Holcomb R, Horst B, Lekakis J, Mueller-Velten G, Papavassiliou AG, Prasad K, Rosano GMC, Severin T, Sherman W, Stough WG, Swedberg K, Tavazzi L, Tousoulis D, Vardas P, Ruschitzka F, Anker SD. Independent academic Data Monitoring Committees for clinical trials in cardiovascular and cardiometabolic diseases. Eur J Heart Fail 2017; 19:449-456. [PMID: 28271595 DOI: 10.1002/ejhf.761] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/30/2016] [Indexed: 11/06/2022] Open
Abstract
Data Monitoring Committees (DMCs) play a crucial role in the conducting of clinical trials to ensure the safety of study participants and to maintain a trial's scientific integrity. Generally accepted standards exist for DMC composition and operational conduct. However, some relevant issues are not specifically addressed in current guidance documents, resulting in uncertainties regarding optimal approaches for communication between the DMC, steering committee, and sponsors, release of information, and liability protection for DMC members. The Heart Failure Association (HFA) of the European Society of Cardiology (ESC), in collaboration with the Clinical Trials Unit of the European Heart Agency (EHA) of the ESC convened a meeting of international experts in DMCs for cardiovascular and cardiometabolic clinical trials to identify specific issues and develop steps to resolve challenges faced by DMCs.The main recommendations from the meeting relate to methodological consistency, independence, managing conflicts of interest, liability protection, and training of future DMC members. This paper summarizes the key outcomes from this expert meeting, and describes the core set of activities that might be further developed and ultimately implemented by the ESC, HFA, and other interested ESC constituent bodies. The HFA will continue to work with stakeholders in cardiovascular and cardiometabolic clinical research to promote these goals.
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Affiliation(s)
- Gerasimos S Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Pieter de Graeff
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.,Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Henry J Dargie
- Cardiology Department, Western Infirmary, Glasgow, Scotland, UK
| | - Marcus Flather
- Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | | | | | | | | | - John Lekakis
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | | | - Athanasios G Papavassiliou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,National Ethics Committee for Clinical Trials, Athens, Greece
| | - Krishna Prasad
- UK Medicines and Healthcare Products Regulatory Agency, London, UK.,St Thomas' Hospital, London, UK
| | - Giuseppe M C Rosano
- IRCCS San Raffaele Hospital Roma, Rome, Italy.,Cardiovascular and Cell Sciences Institute, St George's University of London, London, UK
| | | | | | | | - Karl Swedberg
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
| | - Luigi Tavazzi
- GVM Care and Research, ES Health Science Foundation, Maria Cecilia Hospital, Cotignola, Italy
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, University of Athens, Athens, Greece
| | - Panagiotis Vardas
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
| | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Centre Zurich, Zurich, Switzerland
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen (UMG), Robert-Koch-Strasse 40, D-37075, Göttingen, Germany
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12
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Bartunek J, Terzic A, Davison BA, Filippatos GS, Radovanovic S, Beleslin B, Merkely B, Musialek P, Wojakowski W, Andreka P, Horvath IG, Katz A, Dolatabadi D, El Nakadi B, Arandjelovic A, Edes I, Seferovic PM, Obradovic S, Vanderheyden M, Jagic N, Petrov I, Atar S, Halabi M, Gelev VL, Shochat MK, Kasprzak JD, Sanz-Ruiz R, Heyndrickx GR, Nyolczas N, Legrand V, Guédès A, Heyse A, Moccetti T, Fernandez-Aviles F, Jimenez-Quevedo P, Bayes-Genis A, Hernandez-Garcia JM, Ribichini F, Gruchala M, Waldman SA, Teerlink JR, Gersh BJ, Povsic TJ, Henry TD, Metra M, Hajjar RJ, Tendera M, Behfar A, Alexandre B, Seron A, Stough WG, Sherman W, Cotter G, Wijns W. Cardiopoietic cell therapy for advanced ischaemic heart failure: results at 39 weeks of the prospective, randomized, double blind, sham-controlled CHART-1 clinical trial. Eur Heart J 2017; 38:648-660. [PMID: 28025189 PMCID: PMC5381596 DOI: 10.1093/eurheartj/ehw543] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/22/2016] [Accepted: 11/02/2016] [Indexed: 12/14/2022] Open
Abstract
AIMS Cardiopoietic cells, produced through cardiogenic conditioning of patients' mesenchymal stem cells, have shown preliminary efficacy. The Congestive Heart Failure Cardiopoietic Regenerative Therapy (CHART-1) trial aimed to validate cardiopoiesis-based biotherapy in a larger heart failure cohort. METHODS AND RESULTS This multinational, randomized, double-blind, sham-controlled study was conducted in 39 hospitals. Patients with symptomatic ischaemic heart failure on guideline-directed therapy (n = 484) were screened; n = 348 underwent bone marrow harvest and mesenchymal stem cell expansion. Those achieving > 24 million mesenchymal stem cells (n = 315) were randomized to cardiopoietic cells delivered endomyocardially with a retention-enhanced catheter (n = 157) or sham procedure (n = 158). Procedures were performed as randomized in 271 patients (n = 120 cardiopoietic cells, n = 151 sham). The primary efficacy endpoint was a Finkelstein-Schoenfeld hierarchical composite (all-cause mortality, worsening heart failure, Minnesota Living with Heart Failure Questionnaire score, 6-min walk distance, left ventricular end-systolic volume, and ejection fraction) at 39 weeks. The primary outcome was neutral (Mann-Whitney estimator 0.54, 95% confidence interval [CI] 0.47-0.61 [value > 0.5 favours cell treatment], P = 0.27). Exploratory analyses suggested a benefit of cell treatment on the primary composite in patients with baseline left ventricular end-diastolic volume 200-370 mL (60% of patients) (Mann-Whitney estimator 0.61, 95% CI 0.52-0.70, P = 0.015). No difference was observed in serious adverse events. One (0.9%) cardiopoietic cell patient and 9 (5.4%) sham patients experienced aborted or sudden cardiac death. CONCLUSION The primary endpoint was neutral, with safety demonstrated across the cohort. Further evaluation of cardiopoietic cell therapy in patients with elevated end-diastolic volume is warranted.
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Affiliation(s)
- Jozef Bartunek
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis OLV Hospital, Moorselbaan 164, Aalst, B-9300, Aalst, Belgium
| | - Andre Terzic
- Mayo Clinic, Center for Regenerative Medicine, Department of Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 550905, USA
| | | | - Gerasimos S. Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | | | - Branko Beleslin
- Cardiology Clinic, Clinical Centre of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Wojciech Wojakowski
- Third Division of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Peter Andreka
- Gottsegen Gyorgy Hungarian Institute of Cardiology, Budapest, Hungary
| | | | - Amos Katz
- Department of Cardiology, Barzilai Medical Center, Israel Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dariouch Dolatabadi
- Division of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Badih El Nakadi
- Division of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Istvan Edes
- Department of Cardiology, University of Debrecen, Debrecen, Hungary
| | - Petar M. Seferovic
- University of Belgrade School of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Slobodan Obradovic
- Clinic of Emergency Medicine, Military Medical Academy, School of Medicine, University of Defense, Belgrade, Serbia
| | - Marc Vanderheyden
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis OLV Hospital, Moorselbaan 164, Aalst, B-9300, Aalst, Belgium
| | | | - Ivo Petrov
- Department of Cardiology, Angiology, and Electrophysiology, City Clinic Heart and Vascular Institute, Sofia University, Sofia, Bulgaria
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Majdi Halabi
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Valeri L. Gelev
- Department of Cardiology, Angiology, and Electrophysiology, City Clinic Heart and Vascular Institute, Sofia University, Sofia, Bulgaria
| | - Michael K. Shochat
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Rappaport School of Medicine, Haifa, Israel, Technion
| | | | | | - Guy R. Heyndrickx
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis OLV Hospital, Moorselbaan 164, Aalst, B-9300, Aalst, Belgium
| | - Noémi Nyolczas
- Medical Centre, Hungarian Defense Forces, Budapest, Hungary
| | - Victor Legrand
- Department of Cardiology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Antoine Guédès
- Department of Cardiology, Universite Catholique de Louvain, CHU UcL Namur, Yvoir, Belgium
| | - Alex Heyse
- Department of Cardiology, AZ Glorieux, Ronse, Belgium
| | | | | | | | - Antoni Bayes-Genis
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma, Barcelona, Spain
| | | | | | - Marcin Gruchala
- Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Scott A. Waldman
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - John R. Teerlink
- School of Medicine, University of California San Francisco and Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Bernard J. Gersh
- Mayo Clinic, Center for Regenerative Medicine, Department of Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 550905, USA
| | - Thomas J. Povsic
- Duke Clinical Research Institute and Duke Medicine, Durham, NC, USA
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Spedali Civili, Brescia, Italy
| | | | - Michal Tendera
- Third Division of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Atta Behfar
- Mayo Clinic, Center for Regenerative Medicine, Department of Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 550905, USA
| | | | | | - Wendy Gattis Stough
- Departments of Clinical Research and Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Cary, NC, USA
| | | | | | - William Wijns
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis OLV Hospital, Moorselbaan 164, Aalst, B-9300, Aalst, Belgium
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway and Saolta University Healthcare Group, Galway, Ireland
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13
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Cowie MR, Blomster JI, Curtis LH, Duclaux S, Ford I, Fritz F, Goldman S, Janmohamed S, Kreuzer J, Leenay M, Michel A, Ong S, Pell JP, Southworth MR, Stough WG, Thoenes M, Zannad F, Zalewski A. Electronic health records to facilitate clinical research. Clin Res Cardiol 2016; 106:1-9. [PMID: 27557678 PMCID: PMC5226988 DOI: 10.1007/s00392-016-1025-6] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/05/2016] [Indexed: 02/07/2023]
Abstract
Electronic health records (EHRs) provide opportunities to enhance patient care, embed performance measures in clinical practice, and facilitate clinical research. Concerns have been raised about the increasing recruitment challenges in trials, burdensome and obtrusive data collection, and uncertain generalizability of the results. Leveraging electronic health records to counterbalance these trends is an area of intense interest. The initial applications of electronic health records, as the primary data source is envisioned for observational studies, embedded pragmatic or post-marketing registry-based randomized studies, or comparative effectiveness studies. Advancing this approach to randomized clinical trials, electronic health records may potentially be used to assess study feasibility, to facilitate patient recruitment, and streamline data collection at baseline and follow-up. Ensuring data security and privacy, overcoming the challenges associated with linking diverse systems and maintaining infrastructure for repeat use of high quality data, are some of the challenges associated with using electronic health records in clinical research. Collaboration between academia, industry, regulatory bodies, policy makers, patients, and electronic health record vendors is critical for the greater use of electronic health records in clinical research. This manuscript identifies the key steps required to advance the role of electronic health records in cardiovascular clinical research.
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Affiliation(s)
- Martin R Cowie
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK.
| | - Juuso I Blomster
- Astra Zeneca R&D, Molndal, Sweden
- University of Turku, Turku, Finland
| | | | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | | | | | - Jörg Kreuzer
- Boehringer-Ingelheim, Pharma GmbH & Co KG, Ingelheim, Germany
| | | | | | | | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Campbell, NC, USA
| | | | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, Nancy, France
- Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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14
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Adams KF, Butler J, Patterson JH, Gattis Stough W, Bauman JL, van Veldhuisen DJ, Schwartz TA, Sabbah H, Mackowiak JI, Ventura HO, Ghali JK. Dose response characterization of the association of serum digoxin concentration with mortality outcomes in the Digitalis Investigation Group trial. Eur J Heart Fail 2016; 18:1072-81. [DOI: 10.1002/ejhf.584] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 11/12/2015] [Revised: 03/17/2016] [Accepted: 04/19/2016] [Indexed: 12/25/2022] Open
Affiliation(s)
- Kirkwood F. Adams
- Departments of Medicine and Radiology, School of Medicine, Division of Cardiology; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Javed Butler
- Department of Medicine, Division of Cardiology; Emory University; Atlanta GA USA
| | - J. Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics; University of North Carolina at Chapel Hill Eshelman School of Pharmacy; Chapel Hill NC USA
| | - Wendy Gattis Stough
- Departments of Clinical Research and Pharmacy Practice; Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
| | - Jerry L. Bauman
- Departments of Pharmacy Practice and Medicine, Section of Cardiology, Colleges of Pharmacy and Medicine; University of Illinois at Chicago; Chicago IL USA
| | - Dirk J. van Veldhuisen
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Todd A. Schwartz
- Department of Biostatistics, Gillings School of Global Public Health; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Hani Sabbah
- Division of Cardiology, Wayne State University; Henry Ford Health System; Detroit MI USA
| | | | - Hector O. Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School; The University of Queensland School of Medicine; New Orleans LA USA
| | - Jalal K. Ghali
- Division of Cardiology; Mercer University School of Medicine; Macon GA USA
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15
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Bueno H, de Graeff P, Richard-Lordereau I, Emmerich J, Fox KA, Friedman CP, Gaudin C, El-Gazayerly A, Goldman S, Hemmrich M, Henderson RA, Himmelmann A, Irs A, Jackson N, James SK, Katus HA, Laslop A, Laws I, Mehran R, Ong S, Prasad K, Roffi M, Rosano GM, Rose M, Sinnaeve PR, Stough WG, Thygesen K, Van de Werf F, Varin C, Verheugt FW, de Los Angeles Alonso García M. Report of the European Society of Cardiology Cardiovascular Round Table regulatory workshop update of the evaluation of new agents for the treatment of acute coronary syndrome: Executive summary. Eur Heart J Acute Cardiovasc Care 2016; 8:745-754. [PMID: 27357206 DOI: 10.1177/2048872616649859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Regulatory authorities interpret the results of randomized controlled trials according to published principles. The European Medicines Agency (EMA) is planning a revision of the 2000 and 2003 guidance documents on clinical investigation of new medicinal products for the treatment of acute coronary syndrome (ACS) to achieve consistency with current knowledge in the field. This manuscript summarizes the key output from a collaborative workshop, organized by the Cardiovascular Round Table and the European Affairs Committee of the European Society of Cardiology, involving clinicians, academic researchers, trialists, European and US regulators, and pharmaceutical industry researchers. Specific questions in four key areas were selected as priorities for changes in regulatory guidance: patient selection, endpoints, methodologic issues and issues related to the research for novel agents. Patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) should be studied separately for therapies aimed at the specific pathophysiology of either condition, particularly for treatment of the acute phase, but can be studied together for other treatments, especially long-term therapy. Unstable angina patients should be excluded from acute phase ACS trials. In general, cardiovascular death and reinfarction are recommended for primary efficacy endpoints; other endpoints may be considered if specifically relevant for the therapy under study. New agents or interventions should be tested against a background of evidence-based therapy with expanded follow-up for safety assessment. In conclusion, new guidance documents for randomized controlled trials in ACS should consider changes regarding patient and endpoint selection and definitions, and trial designs. Specific requirements for the evaluation of novel pharmacological therapies need further clarification.
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Affiliation(s)
- Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares, Spain.,Cardiology Department, Hospital Universitario 12 de Octubre, Spain.,Universidad Complutense de Madrid, Spain
| | - Pieter de Graeff
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands.,Dutch Medicines Evaluation Board, The Netherlands
| | | | - Joseph Emmerich
- Université Paris-Descartes Cochin-Hôtel Dieu Hospital, French National Agency for Medicines and Health Products Safety, France
| | - Keith Aa Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, UK
| | | | | | | | | | | | | | | | - Alar Irs
- Department of Cardiology, University of Tartu, Estonia.,Estonian State Agency of Medicines, Estonia
| | | | - Stefan K James
- Department of Medical Sciences, Uppsala University, Sweden
| | - Hugo A Katus
- Medizinische Klinik, Universitätsklinikum Heidelberg, Germany
| | | | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, USA
| | | | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, UK.,St Thomas Hospital, University of London, UK
| | - Marco Roffi
- Department of Cardiology, University Hospital, Switzerland
| | - Giuseppe Mc Rosano
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Hospital Roma, Italy.,Cardiovascular and Cell Sciences Institute, University of London, UK
| | | | - Peter R Sinnaeve
- Department of Cardiovascular Sciencies, University of Leuven, Belgium
| | | | | | - Frans Van de Werf
- Department of Cardiovascular Sciencies, University of Leuven, Belgium
| | - Claire Varin
- Institut de Recherches Internationales Servier, France
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16
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Anker SD, Schroeder S, Atar D, Bax JJ, Ceconi C, Cowie MR, Crisp A, Dominjon F, Ford I, Ghofrani HA, Gropper S, Hindricks G, Hlatky MA, Holcomb R, Honarpour N, Jukema JW, Kim AM, Kunz M, Lefkowitz M, Floch CL, Landmesser U, McDonagh TA, McMurray JJ, Merkely B, Packer M, Prasad K, Revkin J, Rosano GMC, Somaratne R, Stough WG, Voors AA, Ruschitzka F. Erratum to "Traditional and new composite endpoints in heart failure clinical trials: facilitating comprehensive efficacy assessments and improving trial efficiency" [Eur J Heart Fail 2016;18:482-489]. Eur J Heart Fail 2016; 18:727. [PMID: 27324688 DOI: 10.1002/ejhf.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Germany
| | | | - Dan Atar
- Department of Cardiology B, Oslo University Hospital Ulleval and University of Oslo, Norway
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Claudio Ceconi
- Unit of Cardiology, Hospital of Desenzano del Garda, Desenzano del Garda, Italy
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, UGMLC [member of the German Center for Lung Research (DZL)], Giessen, Germany.,Kerckhoff-Klinik Bad Nauheim, Germany.,Imperial College London, UK
| | | | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - John J McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Milton Packer
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krishna Prasad
- United Kingdom Medicines and Healthcare Products Regulatory Agency, London, UK
| | | | - Giuseppe M C Rosano
- IRCCS San Raffaele Hospital Roma, Rome, Italy.,Cardiovascular and Cell Sciences Institute, St. George's University of London, London, UK
| | | | | | | | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Center Zurich, Zurich, Switzerland
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17
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Anker SD, Schroeder S, Atar D, Bax JJ, Ceconi C, Cowie MR, Crisp A, Dominjon F, Ford I, Ghofrani HA, Gropper S, Hindricks G, Hlatky MA, Holcomb R, Honarpour N, Jukema JW, Kim AM, Kunz M, Lefkowitz M, Le Floch C, Landmesser U, McDonagh TA, McMurray JJ, Merkely B, Packer M, Prasad K, Revkin J, Rosano GMC, Somaratne R, Stough WG, Voors AA, Ruschitzka F. Traditional and new composite endpoints in heart failure clinical trials: facilitating comprehensive efficacy assessments and improving trial efficiency. Eur J Heart Fail 2016; 18:482-9. [PMID: 27071916 DOI: 10.1002/ejhf.516] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/15/2015] [Accepted: 01/17/2016] [Indexed: 02/05/2023] Open
Abstract
Composite endpoints are commonly used as the primary measure of efficacy in heart failure clinical trials to assess the overall treatment effect and to increase the efficiency of trials. Clinical trials still must enrol large numbers of patients to accrue a sufficient number of outcome events and have adequate power to draw conclusions about the efficacy and safety of new treatments for heart failure. Additionally, the societal and health system perspectives on heart failure have raised interest in ascertaining the effects of therapy on outcomes such as repeat hospitalization and the patient's burden of disease. Thus, novel methods for using composite endpoints in clinical trials (e.g. clinical status composite endpoints, recurrent event analyses) are being applied in current and planned trials. Endpoints that measure functional status or reflect the patient experience are important but used cautiously because heart failure treatments may improve function yet have adverse effects on mortality. This paper discusses the use of traditional and new composite endpoints, identifies qualities of robust composites, and outlines opportunities for future research.
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Affiliation(s)
- Stefan D Anker
- Innovative Clinical Trials, Depar tment of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Germany
| | | | - Dan Atar
- Department of Cardiology B, Oslo University Hospital Ulleval and University of Oslo, Norway
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Claudio Ceconi
- Unit of Cardiology, Hospital of Desenzano del Garda, Desenzano del Garda, Italy
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, UGMLC [member of the German Center for Lung Research (DZL)], Giessen, Germany.,Kerckhoff-Klinik Bad Nauheim, Germany.,Imperial College London, UK
| | | | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - John J McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Milton Packer
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krishna Prasad
- United Kingdom Medicines and Healthcare Products Regulatory Agency, London, UK
| | | | - Giuseppe M C Rosano
- IRCCS San Raffaele Hospital Roma, Rome, Italy.,Cardiovascular and Cell Sciences Institute, St. George's University of London, London, UK
| | | | | | | | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Center Zurich, Zurich, Switzerland
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18
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Zannad F, Stough WG, Lipicky RJ, Tamargo J, Bakris GL, Borer JS, Alonso García MDLA, Hadjadj S, Koenig W, Kupfer S, McCullough PA, Mosenzon O, Pocock S, Scheen AJ, Sourij H, Van der Schueren B, Stahre C, White WB, Calvo G. Assessment of cardiovascular risk of new drugs for the treatment of diabetes mellitus: risk assessment vs. risk aversion. Eur Heart J Cardiovasc Pharmacother 2016; 2:200-5. [PMID: 27418973 DOI: 10.1093/ehjcvp/pvw007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/25/2016] [Indexed: 01/21/2023]
Abstract
The Food and Drug Administration issued guidance for evaluating the cardiovascular risk of new diabetes mellitus drugs in 2008. Accumulating evidence from several completed trials conducted within this framework raises questions as to whether requiring safety outcome studies for all new diabetes mellitus therapies remains justified. Given the burden of cardiovascular disease in patients with diabetes, the focus should shift towards cardiovascular outcome studies designed to evaluate efficacy (i.e. to determine the efficacy of a drug over placebo or standard care) rather than demonstrating that risk is not increased by a pre-specified safety margin. All stakeholders are responsible for ensuring that new drug approvals occur under conditions of appropriate safety and effectiveness. It is also a shared responsibility to avoid unnecessary hurdles that may compromise access to useful drugs and threaten the sustainability of health systems. It is critical to renew this debate so that stakeholders can collectively determine the optimal approach for developing new drugs to treat type 2 diabetes mellitus.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, CHU Nancy, Université de Lorraine and F-CRIN INI-CRCT, 54500 Nancy, France
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | | | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - George L Bakris
- ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Jeffrey S Borer
- The Howard Gilman Institute, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Maria de Los Angeles Alonso García
- Scientific Advice Working Party, European Medicines Agency, London, UK Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Samy Hadjadj
- CHU de Poitiers, Endocrinologie, Université de Poitiers, INSERM CIC1402, Poitiers, France
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Stuart Kupfer
- Takeda Pharmaceuticals International, Deerfield, IL, USA
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Dallas, TX, USA
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - André J Scheen
- Division of Diabetes, Nutrition, and Metabolic Disorders, Division of Clinical Pharmacology, CHU de Liège, University of Liège, Liège, Belgium
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Medical University of Graz, Centre for Biomarker Research in Medicine, Graz, Austria
| | - Bart Van der Schueren
- Laboratory of Experimental Medicine and Endocrinology, University of Leuven, Leuven, Belgium
| | | | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
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19
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Mebazaa A, Laterre PF, Russell JA, Bergmann A, Gattinoni L, Gayat E, Harhay MO, Hartmann O, Hein F, Kjolbye AL, Legrand M, Lewis RJ, Marshall JC, Marx G, Radermacher P, Schroedter M, Scigalla P, Stough WG, Struck J, Van den Berghe G, Yilmaz MB, Angus DC. Designing phase 3 sepsis trials: application of learned experiences from critical care trials in acute heart failure. J Intensive Care 2016; 4:24. [PMID: 27034779 PMCID: PMC4815117 DOI: 10.1186/s40560-016-0151-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/17/2016] [Indexed: 12/18/2022] Open
Abstract
Substantial attention and resources have been directed to improving outcomes of patients with critical illnesses, in particular sepsis, but all recent clinical trials testing various interventions or strategies have failed to detect a robust benefit on mortality. Acute heart failure is also a critical illness, and although the underlying etiologies differ, acute heart failure and sepsis are critical care illnesses that have a high mortality in which clinical trials have been difficult to conduct and have not yielded effective treatments. Both conditions represent a syndrome that is often difficult to define with a wide variation in patient characteristics, presentation, and standard management across institutions. Referring to past experiences and lessons learned in acute heart failure may be informative and help frame research in the area of sepsis. Academic heart failure investigators and industry have worked closely with regulators for many years to transition acute heart failure trials away from relying on dyspnea assessments and all-cause mortality as the primary measures of efficacy, and recent trials have been designed to assess novel clinical composite endpoints assessing organ dysfunction and mortality while still assessing all-cause mortality as a separate measure of safety. Applying the lessons learned in acute heart failure trials to severe sepsis and septic shock trials might be useful to advance the field. Novel endpoints beyond all-cause mortality should be considered for future sepsis trials.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France ; U942 Inserm, APHP, Paris, France ; APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Pierre François Laterre
- Department of Critical Care Medicine, St. Luc University Hospital, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - James A Russell
- Center for Heart Lung Innovation and the Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | | | - Luciano Gattinoni
- Università di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Etienne Gayat
- Département d'Anesthésie - Réanimation - SMUR, Hôpitaux Universitaires Saint Louis - Lariboisière, INSERM - UMR 942, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Michael O Harhay
- Division of Epidemiology, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | | | | | | | - Matthieu Legrand
- Department of Anesthesiology, Critical Care and Burn Unit, St. Louis Hospital, University Paris 7 Denis Diderot, UMR-S942, Inserm, Paris, France
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA USA
| | - John C Marshall
- Department of Surgery, Interdepartmental Division of Critical Care Medicine, University of Toronto, St. Michael's Hospital, Toronto, Ontario Canada
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | | | | | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC USA
| | | | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Mehmet Birhan Yilmaz
- Department of Cardiology, Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Derek C Angus
- CRISMA Center, Department of Critical Care Medicine, McGowan Institute for Regnerative Medicine, Clinical and Translational Science Institute, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA USA ; Department of Health Policy and Management, McGowan Institute for Regnerative Medicine, Clinical and Translational Science Institute, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA USA
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20
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Colvin M, Sweitzer NK, Albert NM, Krishnamani R, Rich MW, Stough WG, Walsh MN, Westlake Canary CA, Allen LA, Bonnell MR, Carson PE, Chan MC, Dickinson MG, Dries DL, Ewald GA, Fang JC, Hernandez AF, Hershberger RE, Katz SD, Moore S, Rodgers JE, Rogers JG, Vest AR, Whellan DJ, Givertz MM. Heart Failure in Non-Caucasians, Women, and Older Adults: A White Paper on Special Populations From the Heart Failure Society of America Guideline Committee. J Card Fail 2015; 21:674-93. [DOI: 10.1016/j.cardfail.2015.05.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 01/11/2023]
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21
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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22
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Rumsfeld JS, Holmes DR, Stough WG, Edwards FH, Jacques LB, Mack MJ. Insights From the Early Experience of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. JACC Cardiovasc Interv 2015; 8:377-381. [DOI: 10.1016/j.jcin.2014.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 09/15/2014] [Accepted: 09/24/2014] [Indexed: 11/27/2022]
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23
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Zannad F, Stough WG, Mahfoud F, Bakris GL, Kjeldsen SE, Kieval RS, Haller H, Yared N, De Ferrari GM, Piña IL, Stein K, Azizi M. Design Considerations for Clinical Trials of Autonomic Modulation Therapies Targeting Hypertension and Heart Failure. Hypertension 2015; 65:5-15. [DOI: 10.1161/hypertensionaha.114.04057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Faiez Zannad
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Wendy Gattis Stough
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Felix Mahfoud
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - George L. Bakris
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Sverre E. Kjeldsen
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Robert S. Kieval
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Hermann Haller
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Nadim Yared
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Gaetano M. De Ferrari
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Ileana L. Piña
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Kenneth Stein
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
| | - Michel Azizi
- From the Department of Cardiology, INSERM, Center d’Investigation Clinique 9501 and Unité 961, Center Hospitalier Universitaire, Nancy University, Université de Lorraine, Nancy, France (F.Z.); Departments of Pharmacy Practice and Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (W.G.S.); Klinik für Innere Medizin III, Universtitätsklinikum des Saarlandes, Homburg/Saar, Germany (F.M.); Harvard-MIT Biomedical Engineering, Institute of Medical Engineering
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24
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Edelmann F, Holzendorf V, Wachter R, Nolte K, Schmidt AG, Kraigher‐Krainer E, Duvinage A, Unkelbach I, Düngen H, Tschöpe C, Herrmann‐Lingen C, Halle M, Hasenfuss G, Gelbrich G, Stough WG, Pieske BM. Galectin‐3 in patients with heart failure with preserved ejection fraction: results from the Aldo‐
DHF
trial. Eur J Heart Fail 2014; 17:214-23. [DOI: 10.1002/ejhf.203] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [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: 07/22/2014] [Revised: 10/08/2014] [Accepted: 10/10/2014] [Indexed: 12/22/2022] Open
Affiliation(s)
- Frank Edelmann
- Department of Cardiology and Pneumology Heart Center, University of Göttingen Göttingen Germany
- German Center for Cardiovascular Research (DZHK) University of Göttingen Göttingen Germany
| | | | - Rolf Wachter
- Department of Cardiology and Pneumology Heart Center, University of Göttingen Göttingen Germany
- German Center for Cardiovascular Research (DZHK) University of Göttingen Göttingen Germany
| | - Kathleen Nolte
- Department of Cardiology and Pneumology Heart Center, University of Göttingen Göttingen Germany
| | | | - Elisabeth Kraigher‐Krainer
- Department of Cardiology Medical University Graz Graz Austria
- Ludwig‐Boltzmann Institute for Translational Heart Failure Research (LBI) Graz Austria
| | - André Duvinage
- Department of Preventive and Rehabilitative Sports Medicine Technical University Munich Munich Germany
| | - Ines Unkelbach
- Department of Cardiology and Pneumology Heart Center, University of Göttingen Göttingen Germany
| | - Hans‐Dirk Düngen
- Department of Internal Medicine‐Cardiology Charite‐Campus Virchow‐Klinikum, Universitätsmedizin Berlin Berlin Germany
| | - Carsten Tschöpe
- Department of Cardiology and Pneumology Charité‐Campus Benjamin Franklin, Universitätsmedizin Berlin Berlin Germany
| | - Christoph Herrmann‐Lingen
- German Center for Cardiovascular Research (DZHK) University of Göttingen Göttingen Germany
- Department of Psychosomatic Medicine and Psychotherapy University of Göttingen Göttingen Germany
| | - Martin Halle
- Department of Preventive and Rehabilitative Sports Medicine Technical University Munich Munich Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology Heart Center, University of Göttingen Göttingen Germany
- German Center for Cardiovascular Research (DZHK) University of Göttingen Göttingen Germany
| | - Götz Gelbrich
- Institute of Clinical Epidemiology and Biometry University of Würzburg Würzburg Germany
| | - Wendy Gattis Stough
- Departments of Pharmacy Practice and Clinical Research Campbell University College of Pharmacy and Health Sciences Buies Creek NC USA
| | - Burkert M. Pieske
- Department of Cardiology Medical University Graz Graz Austria
- Ludwig‐Boltzmann Institute for Translational Heart Failure Research (LBI) Graz Austria
- Department of Internal Medicine‐Cardiology Charite‐Campus Virchow‐Klinikum, Universitätsmedizin Berlin Berlin Germany
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25
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Senni M, Paulus WJ, Gavazzi A, Fraser AG, Díez J, Solomon SD, Smiseth OA, Guazzi M, Lam CSP, Maggioni AP, Tschöpe C, Metra M, Hummel SL, Edelmann F, Ambrosio G, Stewart Coats AJ, Filippatos GS, Gheorghiade M, Anker SD, Levy D, Pfeffer MA, Stough WG, Pieske BM. New strategies for heart failure with preserved ejection fraction: the importance of targeted therapies for heart failure phenotypes. Eur Heart J 2014; 35:2797-815. [PMID: 25104786 PMCID: PMC4204003 DOI: 10.1093/eurheartj/ehu204] [Citation(s) in RCA: 268] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/01/2014] [Accepted: 04/29/2014] [Indexed: 12/21/2022] Open
Abstract
The management of heart failure with reduced ejection fraction (HF-REF) has improved significantly over the last two decades. In contrast, little or no progress has been made in identifying evidence-based, effective treatments for heart failure with preserved ejection fraction (HF-PEF). Despite the high prevalence, mortality, and cost of HF-PEF, large phase III international clinical trials investigating interventions to improve outcomes in HF-PEF have yielded disappointing results. Therefore, treatment of HF-PEF remains largely empiric, and almost no acknowledged standards exist. There is no single explanation for the negative results of past HF-PEF trials. Potential contributors include an incomplete understanding of HF-PEF pathophysiology, the heterogeneity of the patient population, inadequate diagnostic criteria, recruitment of patients without true heart failure or at early stages of the syndrome, poor matching of therapeutic mechanisms and primary pathophysiological processes, suboptimal study designs, or inadequate statistical power. Many novel agents are in various stages of research and development for potential use in patients with HF-PEF. To maximize the likelihood of identifying effective therapeutics for HF-PEF, lessons learned from the past decade of research should be applied to the design, conduct, and interpretation of future trials. This paper represents a synthesis of a workshop held in Bergamo, Italy, and it examines new and emerging therapies in the context of specific, targeted HF-PEF phenotypes where positive clinical benefit may be detected in clinical trials. Specific considerations related to patient and endpoint selection for future clinical trials design are also discussed.
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Affiliation(s)
- Michele Senni
- Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Walter J Paulus
- Institute for Cardiovascular Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Antonello Gavazzi
- Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Alan G Fraser
- Wales Heart Research Institute, Cardiff University, Cardiff, UK
| | - Javier Díez
- Division of Cardiovascular Sciences Centre for Applied Medical Research and Department of Cardiology and Cardiac Surgery, University of Navarra Clinic, University of Navarra, Pamplona, Spain
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Otto A Smiseth
- Institute for Surgical Research, Department of Cardiology, and Center for Cardiological Innovation, University of Oslo, Oslo, Norway
| | - Marco Guazzi
- Heart Failure Unit, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | | | | | - Carsten Tschöpe
- Department of Cardiology and Pneumology, Charité-University Medicine Berlin, Campus Benjamin Franklin, Germany
| | - Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Scott L Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA Section of Cardiology, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI, USA
| | - Frank Edelmann
- Department of Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Gottingen, Gottingen, Germany Applied Cachexia Research, Department of Cardiology, Charite, Campus CVK, Berlin, Germany
| | - Daniel Levy
- Framingham Heart Study, Framingham, MA, USA Division of Cardiology, Boston University School of Medicine, Boston, MA, USA Center for Population Studies, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Wendy Gattis Stough
- Department of Clinical Research, Campbell University College of Pharmacy and Health Sciences, North Carolina, USA
| | - Burkert M Pieske
- Department of Cardiology, Medical University Graz, Ludwig-Boltzmann-Institute for Heart Failure Research, Auenbruggerplatz 15, 8010 Graz, Austria
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26
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Zannad F, Stough WG, Piña IL, Mehran R, Abraham WT, Anker SD, De Ferrari GM, Farb A, Geller NL, Kieval RS, Linde C, Redberg RF, Stein K, Vincent A, Woehrle H, Pocock SJ. Current challenges for clinical trials of cardiovascular medical devices. Int J Cardiol 2014; 175:30-7. [PMID: 24861254 DOI: 10.1016/j.ijcard.2014.05.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/08/2014] [Accepted: 05/11/2014] [Indexed: 01/01/2023]
Abstract
Several features of cardiovascular devices raise considerations for clinical trial conduct. Prospective, randomized, controlled trials remain the highest quality evidence for safety and effectiveness assessments, but, for instance, blinding may be challenging. In order to avoid bias and not confound data interpretation, the use of objective endpoints and blinding patients, study staff, core labs, and clinical endpoint committees to treatment assignment are helpful approaches. Anticipation of potential bias should be considered and planned for prospectively in a cardiovascular device trial. Prospective, single-arm studies (often referred to as registry studies) can provide additional data in some cases. They are subject to selection bias even when carefully designed; thus, they are generally not acceptable as the sole basis for pre-market approval of high risk cardiovascular devices. However, they complement the evidence base and fill the gaps unanswered by randomized trials. Registry studies present device safety and effectiveness in day-to-day clinical practice settings and detect rare adverse events in the post-market period. No single research design will be appropriate for every cardiovascular device or target patient population. The type of trial, appropriate control group, and optimal length of follow-up will depend on the specific device, its potential clinical benefits, the target patient population and the existence (or lack) of effective therapies, and its anticipated risks. Continued efforts on the part of investigators, the device industry, and government regulators are needed to reach the optimal approach for evaluating the safety and performance of innovative devices for the treatment of cardiovascular disease.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 Unité 1116, Centre Hospitalier Universitaire, France; Department of Cardiology, Université de Lorraine, Nancy, France.
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - Ileana L Piña
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Roxana Mehran
- Cardiovascular Research Foundation, New York, NY, USA; Mount Sinai Medical Center, New York, NY, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Stefan D Anker
- Applied Cachexia Research, Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany
| | | | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Nancy L Geller
- National Heart Lung and Blood Institute, Bethesda, MD, USA
| | | | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Holger Woehrle
- ResMed Science Center, ResMed, Martinsried, Germany; Sleep and Ventilation Center Blaubeuren/Lung Center, Ulm, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
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27
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Adams KF, Ghali JK, Herbert Patterson J, Stough WG, Butler J, Bauman JL, Ventura HO, Sabbah H, Mackowiak JI, van Veldhuisen DJ. A perspective on re-evaluating digoxin's role in the current management of patients with chronic systolic heart failure: targeting serum concentration to reduce hospitalization and improve safety profile. Eur J Heart Fail 2014; 16:483-93. [DOI: 10.1002/ejhf.64] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/07/2013] [Accepted: 01/20/2014] [Indexed: 01/11/2023] Open
Affiliation(s)
- Kirkwood F. Adams
- Departments of Medicine and Radiology, School of Medicine, Division of Cardiology; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Jalal K. Ghali
- Division of Cardiology; Mercer University School of Medicine; Macon GA USA
| | - J. Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics; University of North Carolina at Chapel Hill Eshelman School of Pharmacy; Chapel Hill NC USA
| | - Wendy Gattis Stough
- Department of Clinical Research; Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
| | - Javed Butler
- Department of Medicine, Division of Cardiology; Emory University; Atlanta GA USA
| | - Jerry L. Bauman
- Departments of Pharmacy Practice and Medicine, Section of Cardiology, Colleges of Pharmacy and Medicine; University of Illinois at Chicago; Chicago IL USA
| | - Hector O. Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School; The University of Queensland School of Medicine; New Orleans LA USA
| | - Hani Sabbah
- Division of Cardiology; Wayne State University, Henry Ford Health System; Detroit MI USA
| | | | - Dirk J. van Veldhuisen
- Department of Cardiology; University of Groningen, University Medical Center Groningen; Groningen the Netherlands
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28
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Givertz MM, Teerlink JR, Albert NM, Westlake Canary CA, Collins SP, Colvin-Adams M, Ezekowitz JA, Fang JC, Hernandez AF, Katz SD, Krishnamani R, Stough WG, Walsh MN, Butler J, Carson PE, Dimarco JP, Hershberger RE, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Tang WHW, Starling RC. Acute decompensated heart failure: update on new and emerging evidence and directions for future research. J Card Fail 2013; 19:371-89. [PMID: 23743486 DOI: 10.1016/j.cardfail.2013.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 01/10/2023]
Abstract
Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.
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Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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29
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Zannad F, Stough WG, Regnault V, Gheorghiade M, Deliargyris E, Gibson CM, Agewall S, Berkowitz SD, Burton P, Calvo G, Goldstein S, Verheugt FW, Koglin J, O'Connor CM. Is thrombosis a contributor to heart failure pathophysiology? Possible mechanisms, therapeutic opportunities, and clinical investigation challenges. Int J Cardiol 2013; 167:1772-82. [DOI: 10.1016/j.ijcard.2012.12.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 12/06/2012] [Indexed: 12/21/2022]
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30
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Zannad F, Garcia AA, Anker SD, Armstrong PW, Calvo G, Cleland JGF, Cohn JN, Dickstein K, Domanski MJ, Ekman I, Filippatos GS, Gheorghiade M, Hernandez AF, Jaarsma T, Koglin J, Konstam M, Kupfer S, Maggioni AP, Mebazaa A, Metra M, Nowack C, Pieske B, Piña IL, Pocock SJ, Ponikowski P, Rosano G, Ruilope LM, Ruschitzka F, Severin T, Solomon S, Stein K, Stockbridge NL, Stough WG, Swedberg K, Tavazzi L, Voors AA, Wasserman SM, Woehrle H, Zalewski A, McMurray JJV. Clinical outcome endpoints in heart failure trials: a European Society of Cardiology Heart Failure Association consensus document. Eur J Heart Fail 2013; 15:1082-94. [PMID: 23787718 DOI: 10.1093/eurjhf/hft095] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Endpoint selection is a critically important step in clinical trial design. It poses major challenges for investigators, regulators, and study sponsors, and it also has important clinical and practical implications for physicians and patients. Clinical outcomes of interest in heart failure trials include all-cause mortality, cause-specific mortality, relevant non-fatal morbidity (e.g., all-cause and cause-specific hospitalization), composites capturing both morbidity and mortality, safety, symptoms, functional capacity, and patient-reported outcomes. Each of these endpoints has strengths and weaknesses that create controversies regarding which is most appropriate in terms of clinical importance, sensitivity, reliability, and consistency. Not surprisingly, a lack of consensus exists within the scientific community regarding the optimal endpoint(s) for both acute and chronic heart failure trials. In an effort to address these issues, the Heart Failure Association of the European Society of Cardiology (HFA-ESC) convened a group of expert heart failure clinical investigators, biostatisticians, regulators, and pharmaceutical industry scientists (Nice, France, 12-13 February 2012) to evaluate the challenges of defining heart failure endpoints in clinical trials and to develop a consensus framework. This report summarizes the group's recommendations for achieving common views on heart failure endpoints in clinical trials.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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31
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Verheugt FW, Clemmensen P, Mehran R, Agewall S, Pocock SJ, Goldstein S, Torp-Pedersen C, Simoons ML, Borer JS, Khder YM, Burton P, Deliargyris E, McMurray JJ, Berkowitz SD, Stough WG, Zannad F. Antithrombotic outcome trials in acute coronary syndromes: seeking the optimal balance between safety and efficacy†. Eur Heart J 2013; 34:1621-9. [DOI: 10.1093/eurheartj/eht013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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32
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Acker MA, Pagani FD, Stough WG, Mann DL, Jessup M, Kormos R, Slaughter MS, Baldwin T, Stevenson L, Aaronson KD, Miller L, Naftel D, Yancy C, Rogers J, Teuteberg J, Starling RC, Griffith B, Boyce S, Westaby S, Blume E, Wearden P, Higgins R, Mack M. Statement Regarding the Pre and Post Market Assessment of Durable, Implantable Ventricular Assist Devices in the United States. Circ Heart Fail 2013; 6:e1-e11. [DOI: 10.1161/hhf.0b013e318279f6b5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael A. Acker
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Francis D. Pagani
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Wendy Gattis Stough
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Douglas L. Mann
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Mariell Jessup
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Robert Kormos
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Mark S. Slaughter
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Timothy Baldwin
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Lynne Stevenson
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Keith D. Aaronson
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Leslie Miller
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - David Naftel
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Clyde Yancy
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Joseph Rogers
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Jeffrey Teuteberg
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Randall C. Starling
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Bartley Griffith
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Steven Boyce
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Stephen Westaby
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Elizabeth Blume
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Peter Wearden
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Robert Higgins
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
| | - Michael Mack
- From the Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania (MAA); Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan (FDP); Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina (WGS); Cardiovascular Division, Washington University, St. Louis, Missouri (DLM); Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (MJ); Department of Cardiothoracic Surgery,
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Acker MA, Pagani FD, Stough WG, Mann DL, Jessup M, Kormos R, Slaughter MS, Baldwin T, Stevenson L, Aaronson KD, Miller L, Naftel D, Yancy C, Rogers J, Teuteberg J, Starling RC, Griffith B, Boyce S, Westaby S, Blume E, Wearden P, Higgins R, Mack M. Statement Regarding the Pre and Post Market Assessment of Durable, Implantable Ventricular Assist Devices in the United States: Executive Summary. Ann Thorac Surg 2012; 94:e163-8. [DOI: 10.1016/j.athoracsur.2012.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 10/27/2022]
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Acker MA, Pagani FD, Stough WG, Mann DL, Jessup M, Kormos R, Slaughter MS, Baldwin T, Stevenson L, Aaronson KD, Miller L, Naftel D, Yancy C, Rogers J, Teuteberg J, Starling RC, Griffith B, Boyce S, Westaby S, Blume E, Wearden P, Higgins R, Mack M. Statement Regarding the Pre and Post Market Assessment of Durable, Implantable Ventricular Assist Devices in the United States. Ann Thorac Surg 2012; 94:2147-58. [DOI: 10.1016/j.athoracsur.2012.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 11/16/2022]
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Acker MA, Pagani FD, Stough WG, Mann DL, Jessup M, Kormos R, Slaughter MS, Baldwin T, Stevenson L, Aaronson KD, Miller L, Naftel D, Yancy C, Rogers J, Teuteberg J, Starling RC, Griffith B, Boyce S, Westaby S, Blume E, Wearden P, Higgins R, Mack M. Statement regarding the pre and post market assessment of durable, implantable ventricular assist devices in the United States: executive summary. Circ Heart Fail 2012; 6:145-50. [PMID: 23149496 DOI: 10.1161/hhf.0b013e318279f55d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 12/22/2022]
Abstract
The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the US Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients with advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart, Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Interagency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society for Heart and Lung Transplantation, and the Interagency Registry of Mechanically Assisted Circulatory Support.
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Affiliation(s)
- Michael A Acker
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Zannad F, Gattis Stough W, Rossignol P, Bauersachs J, McMurray JJV, Swedberg K, Struthers AD, Voors AA, Ruilope LM, Bakris GL, O'Connor CM, Gheorghiade M, Mentz RJ, Cohen-Solal A, Maggioni AP, Beygui F, Filippatos GS, Massy ZA, Pathak A, Piña IL, Sabbah HN, Sica DA, Tavazzi L, Pitt B. Mineralocorticoid receptor antagonists for heart failure with reduced ejection fraction: integrating evidence into clinical practice. Eur Heart J 2012; 33:2782-95. [PMID: 22942339 DOI: 10.1093/eurheartj/ehs257] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Mineralocorticoid receptor antagonists (MRAs) improve survival and reduce morbidity in patients with heart failure, reduced ejection fraction (HF-REF), and mild-to-severe symptoms, and in patients with left ventricular systolic dysfunction and heart failure after acute myocardial infarction. These clinical benefits are observed in addition to those of angiotensin converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers. The morbidity and mortality benefits of MRAs may be mediated by several proposed actions, including antifibrotic mechanisms that slow heart failure progression, prevent or reverse cardiac remodelling, or reduce arrhythmogenesis. Both eplerenone and spironolactone have demonstrated survival benefits in individual clinical trials. Pharmacologic differences exist between the drugs, which may be relevant for therapeutic decision making in individual patients. Although serious hyperkalaemia events were reported in the major MRA clinical trials, these risks can be mitigated through appropriate patient selection, dose selection, patient education, monitoring, and follow-up. When used appropriately, MRAs significantly improve outcomes across the spectrum of patients with HF-REF.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, France.
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Stevenson WG, Hernandez AF, Carson PE, Fang JC, Katz SD, Spertus JA, Sweitzer NK, Tang WHW, Albert NM, Butler J, Westlake Canary CA, Collins SP, Colvin-Adams M, Ezekowitz JA, Givertz MM, Hershberger RE, Rogers JG, Teerlink JR, Walsh MN, Stough WG, Starling RC. Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee. J Card Fail 2012; 18:94-106. [PMID: 22300776 DOI: 10.1016/j.cardfail.2011.12.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/09/2011] [Indexed: 12/14/2022]
Abstract
Cardiac resynchronization therapy (CRT) improves survival, symptoms, quality of life, exercise capacity, and cardiac structure and function in patients with New York Heart Association (NYHA) functional class II or ambulatory class IV heart failure (HF) with wide QRS complex. The totality of evidence supports the use of CRT in patients with less severe HF symptoms. CRT is recommended for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block (RBBB) who have severe left ventricular (LV) systolic dysfunction and persistent NYHA functional class II-III symptoms despite optimal medical therapy (strength of evidence A). CRT may be considered for several other patient groups for whom evidence of benefit is clinically significant but less substantial, including patients with a QRS interval of ≥120 to <150 ms and severe LV systolic dysfunction who have persistent mild to severe HF despite optimal medical therapy (strength of evidence B), some patients with atrial fibrillation, and some with ambulatory class IV HF. Several evidence gaps remain that need to be addressed, including the ideal threshold for QRS duration, QRS morphology, lead placement, degree of myocardial scarring, and the modality for evaluating dyssynchrony. Recommendations will evolve over time as additional data emerge from completed and ongoing clinical trials.
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Affiliation(s)
- William G Stevenson
- Department of Medicine, Division of Cardiology Brigham and Women's Hospital, Boston, Massachusetts, USA
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Butler J, Ezekowitz JA, Collins SP, Givertz MM, Teerlink JR, Walsh MN, Albert NM, Westlake Canary CA, Carson PE, Colvin-Adams M, Fang JC, Hernandez AF, Hershberger RE, Katz SD, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Wilson Tang W, Stough WG, Starling RC. Update on Aldosterone Antagonists Use in Heart Failure With Reduced Left Ventricular Ejection Fraction Heart Failure Society of America Guidelines Committee. J Card Fail 2012; 18:265-81. [DOI: 10.1016/j.cardfail.2012.02.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 02/15/2012] [Indexed: 01/11/2023]
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Zannad F, Stough WG, Pocock SJ, Sleight P, Cushman WC, Cleland JGF, McMurray JJV, Lonn E, Geller NL, Wedel H, Abadie E, Alonso-Garcia A, Pitt B. Diabetes clinical trials: helped or hindered by the current shift in regulatory requirements? Eur Heart J 2012; 33:1049-57. [PMID: 22422830 DOI: 10.1093/eurheartj/ehr437] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Glycaemic control is an inadequate surrogate marker of cardiovascular event reduction in patients with type 2 diabetes. Clinical trials to date have been unsuccessful in identifying a therapeutic approach that addresses the underlying problem in diabetes (glycaemic control) and reduces cardiovascular risk. The potential for some agents to increase the risk of cardiovascular events has led to substantial changes in regulatory requirements for new anti-diabetic therapies. These requirements, while key to ensuring the cardiovascular safety of new agents, fail to emphasize the need to show clinical benefits, such as less visual impairment, less need for dialysis, or fewer cardiovascular events and deaths. Changes in test results such as glycaemic control, serum creatinine, micro-albuminuria, or retinopathy are inadequate surrogates. Regulators should consider the potential advantages of offering extended patent protection in order to encourage companies to conduct long-term trials in diabetes and many other chronic medical conditions. Cooperative efforts among physicians, clinical trialists, regulators, and sponsors are needed to address unresolved issues including re-defining therapeutic targets that are meaningful to patients with diabetes, determining the appropriate length of follow-up for future trials, and considering the ethical and operational challenges of non-inferiority designs.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Hôpital Jeanne d' Arc, 54200 Toul, Nancy, France.
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Zannad F, Gattis Stough W, McMurray JJ, Remme WJ, Pitt B, Borer JS, Geller NL, Pocock SJ. When to Stop a Clinical Trial Early for Benefit: Lessons Learned and Future Approaches. Circ Heart Fail 2012; 5:294-302. [PMID: 22438522 DOI: 10.1161/circheartfailure.111.965707] [Citation(s) in RCA: 18] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Faiez Zannad
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Wendy Gattis Stough
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - John J.V. McMurray
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Willem J. Remme
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Bertram Pitt
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Jeffrey S. Borer
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Nancy L. Geller
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
| | - Stuart J. Pocock
- From INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Nancy, France (F.Z.); Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, and Duke University Medical Center, Durham, NC (W.G.S.); Western Infirmary and the British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Sticares Cardiovascular Research Institute,
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O'Connor CM, Jiang W, Kuchibhatla M, Silva SG, Cuffe MS, Callwood DD, Zakhary B, Stough WG, Arias RM, Rivelli SK, Krishnan R. Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol 2010; 56:692-9. [PMID: 20723799 DOI: 10.1016/j.jacc.2010.03.068] [Citation(s) in RCA: 301] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 03/02/2010] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The objective was to test the hypothesis that heart failure (HF) patients treated with sertraline will have lower depression scores and fewer cardiovascular events compared with placebo. BACKGROUND Depression is common among HF patients. It is associated with increased hospitalization and mortality. METHODS The SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial was a randomized, double-blind, placebo-controlled trial of sertraline 50 to 200 mg/day versus matching placebo for 12 weeks. All participants also received nurse-facilitated support. Eligible patients were age 45 years or older with HF (left ventricular ejection fraction < or =45%, New York Heart Association functional class II to IV) and clinical depression (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for current major depressive disorder). Those with significant cognitive impairment, psychosis, recent alcohol or drug dependence, bipolar or severe personality disorder, active suicidal ideation, and current antipsychotic or antidepressant medications were excluded. Primary end points were change in depression severity (Hamilton Depression Rating Scale total score) and composite cardiovascular status at 12 weeks. RESULTS A total of 469 patients were randomized (n = 234 sertraline, n = 235 placebo). The mean +/- SE change from baseline to 12 weeks in the Hamilton Depression Rating Scale total score was -7.1 +/- 0.5 (sertraline) and -6.8 +/- 0.5 (placebo) (p < 0.001 from baseline, p = 0.89 between groups, mean change between groups -0.4; 95% confidence interval: -1.7 to 0.92). The proportions whose composite cardiovascular score worsened, improved, or was unchanged were 29.9%, 40.6%, and 29.5%, respectively, in the sertraline group and 31.1%, 43.8%, and 25.1%, respectively, in the placebo group (p = 0.78). CONCLUSIONS Sertraline was safe in patients with significant HF. However, treatment with sertraline compared with placebo did not provide greater reduction in depression or improved cardiovascular status among patients with HF and depression. (Antidepressant Medication Treatment for Depression in Individuals With Chronic Heart Failure [SADHART-CHF]; NCT00078286).
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Affiliation(s)
- Christopher M O'Connor
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, O'Connor CM, Reynolds D, Walsh MN, Yancy CW. Improving Evidence-Based Care for Heart Failure in Outpatient Cardiology Practices. Circulation 2010; 122:585-96. [DOI: 10.1161/circulationaha.109.934471] [Citation(s) in RCA: 317] [Impact Index Per Article: 22.6] [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: 01/08/2023]
Abstract
Background—
A treatment gap exists between heart failure (HF) guidelines and the clinical care of patients. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) prospectively tested a multidimensional practice-specific performance improvement intervention on the use of guideline-recommended therapies for HF in outpatient cardiology practices.
Methods and Results—
Performance data were collected in a random sample of HF patients from 167 US outpatient cardiology practices at baseline, longitudinally after intervention at 12 and 24 months, and in single-point-in-time patient cohorts at 6 and 18 months. Participants included 34 810 patients with reduced left ventricular ejection fraction (≤35%) and chronic HF or previous myocardial infarction. To quantify guideline adherence, 7 quality measures were assessed. Interventions included clinical decision support tools, structured improvement strategies, and chart audits with feedback. The performance improvement intervention resulted in significant improvements in 5 of 7 quality measures at the 24-month assessment compared with baseline: β-blocker (92.2% versus 86.0%, +6.2%), aldosterone antagonist (60.3% versus 34.5%, +25.1%), cardiac resynchronization therapy (66.3% versus 37.2%, +29.9%), implantable cardioverter-defibrillator (77.5% versus 50.1%, +27.4%), and HF education (72.1% versus 59.5%, +12.6%) (each
P
<0.001). There were no statistically significant improvements in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use or anticoagulation for atrial fibrillation. Sensitivity analyses at the patient level and limited to patients with both baseline and 24-month quality measure data yielded similar results. Improvements in the single-point-in-time cohorts were smaller, and there were no concurrent control practices.
Conclusions—
The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting, a defined and scalable practice-specific performance improvement intervention, was associated with substantial improvements in the use of guideline-recommended therapies in eligible patients with HF in outpatient cardiology practices.
Clinical Trial Registration—
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00303979.
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Affiliation(s)
- Gregg C. Fonarow
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Nancy M. Albert
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Anne B. Curtis
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Wendy Gattis Stough
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Mihai Gheorghiade
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - J. Thomas Heywood
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Mark L. McBride
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Patches Johnson Inge
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Mandeep R. Mehra
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Christopher M. O'Connor
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Dwight Reynolds
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Mary Norine Walsh
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
| | - Clyde W. Yancy
- From the Department of Medicine, Ahmanson–UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif (G.C.F.); Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio (N.M.A.); Division of Cardiology, University of South Florida College of Medicine, Tampa (A.B.C.); Department of Clinical Research, Campbell University School of Pharmacy, Research Triangle Park, and Department of Medicine, Duke University Medical Center,
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Albert NM, Fonarow GC, Yancy CW, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride M, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Outpatient cardiology practices with advanced practice nurses and physician assistants provide similar delivery of recommended therapies (findings from IMPROVE HF). Am J Cardiol 2010; 105:1773-9. [PMID: 20538129 DOI: 10.1016/j.amjcard.2010.01.360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/20/2010] [Accepted: 01/20/2010] [Indexed: 10/19/2022]
Abstract
National guidelines recommend a team model of care to facilitate adherence to evidence-based practices; however, previous studies suggesting benefit may have limited generalizability. The aim of this study was to examine the influence of advanced practice nurse (APN) and physician assistant (PA) staffing on the delivery of guideline-recommended therapies for outpatients with heart failure (HF). The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF), a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic HF and left ventricular ejection fractions < or =35%. Adherence to guideline-recommended HF therapies was recorded, and the presence of APN and PA staffing was assessed by survey. Multivariate models identified contributions to the delivery of guideline-recommended HF therapies. Of cardiology outpatient practices, 66.0% had APNs and PAs. Practices with 0, >0 to <2, and > or =2.0 APN and PA staffing had similar adherence to the 7 guideline-recommended HF therapies. After adjustment, staffing with > or =2 APNs or PAs was associated with greater conformity with 2 of 7 measures (implantable cardioverter-defibrillator therapy and delivery of HF education, p < or =0.01 for both) and similar conformity to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, beta-blocker therapy, aldosterone antagonist therapy, anticoagulation for atrial fibrillation, and cardiac resynchronization therapy. In conclusion, staffing with APNs and PAs varied in cardiology outpatient practices. Compared to no APNs or PAs, > or =2.0 APNs or PAs per cardiology practice was associated with the greater use of implantable cardioverter-defibrillator therapy and delivery of HF education and equivalent use of drug and cardiac resynchronization therapies.
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Allen LA, Turer AT, Dewald T, Stough WG, Cotter G, O'Connor CM. Continuous versus bolus dosing of Furosemide for patients hospitalized for heart failure. Am J Cardiol 2010; 105:1794-7. [PMID: 20538132 DOI: 10.1016/j.amjcard.2010.01.355] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 01/20/2010] [Accepted: 01/20/2010] [Indexed: 11/12/2022]
Abstract
Intravenous diuretics are the cornerstone of management for patients hospitalized for heart failure. Physiologic data suggest that intermittent high-dose furosemide promotes neurohormonal activation, which a slow continuous infusion might remediate. However, the limited clinical data comparing dosing schemes are confounded. This study was a randomized, open-label, single-center trial of twice-daily bolus injection versus continuous infusion furosemide in patients hospitalized with heart failure and volume overload. The primary outcome was change in creatinine from admission to hospital day 3 or discharge. Twenty-one patients were randomized to bolus injection and 20 patients to continuous infusion. Baseline characteristics were balanced between study arms except for gender, with a mean age of 60 +/- 15 years, a mean ejection fraction of 35 +/- 19%, and a mean creatinine level of 1.9 +/- 1.2 mg/dl. The mean doses of furosemide were similar between arms over the first 48 hours (162 +/- 48 and 162 +/- 52 mg/24 hours). None of the outcomes differed significantly between bolus and continuous dosing from admission to hospital day 3 or discharge (mean change in creatinine -0.02 vs 0.13 mg/dl, p = 0.18; urine output 5,113 vs 4,894 ml, p = 0.78; length of stay 8.8 vs 9.9 days, p = 0.69). All patients survived to discharge. In conclusion, there were no substantial differences between bolus injection and continuous infusion of equal doses of furosemide for the treatment of patients hospitalized with heart failure. Given the high prevalence of heart failure hospitalization and the disparate results of small studies regarding optimal dosing of loop diuretics to treat these patients, larger multicenter blinded studies are needed.
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Affiliation(s)
- Larry A Allen
- Colorado Cardiovascular Outcomes Research Group, University of Colorado Denver, Aurora, CO, USA.
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Heywood JT, Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Influence of renal function on the use of guideline-recommended therapies for patients with heart failure. Am J Cardiol 2010; 105:1140-6. [PMID: 20381667 DOI: 10.1016/j.amjcard.2009.12.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/03/2009] [Accepted: 12/03/2009] [Indexed: 12/20/2022]
Abstract
Guidelines have been established for the treatment of patients with heart failure (HF) and left ventricular dysfunction, but renal dysfunction might limit adherence to these guidelines. Few data have characterized the use of guideline-recommended therapy for patients with HF, left ventricular dysfunction, and renal dysfunction who are treated in outpatient settings. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) was a prospective study of patients receiving treatment as outpatients in cardiology practices in the United States. The rates of adherence to 7 guideline-recommended therapies were evaluated for patients with a left ventricular ejection fraction of < or = 35%. The estimated glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula for 13,164 patients who were categorized as having stage 1 through stage 4/5 chronic kidney disease (CKD). More than 1/2 (52.2%) of the patients had stage 3 or 4/5 CKD. Older patients and women were at increased risk of higher stage CKD, and the rates of co-morbid health conditions were significantly greater among patients with more severe CKD. The patients with more severe CKD were significantly less likely to receive all interventions except cardiac resynchronization therapy. However, multivariate analysis controlling for patient characteristics revealed that the severity of CKD was an independent predictor of adherence to angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy but not to any of the 6 other guideline-recommended measures. In conclusion, these results confirm that CKD is common in patients with HF and left ventricular dysfunction but is not independently associated with adherence to guideline-recommended therapy in outpatient cardiology practices, with the exception of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy.
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Walsh MN, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Fonarow GC. Electronic health records and quality of care for heart failure. Am Heart J 2010; 159:635-642.e1. [PMID: 20362723 DOI: 10.1016/j.ahj.2010.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [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: 06/30/2009] [Accepted: 01/07/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Electronic health records (EHRs) are considered an important technology to improve the quality of health care, yet few data exist regarding their effect on delivery of evidence-based care in the outpatient setting. METHODS IMPROVE HF is a prospective cohort study of 15,381 patients with HF or post myocardial infarction and left ventricular ejection fraction < or =35% cared for in 167 US outpatient cardiology practices. Baseline patient characteristics and quality data were collected by chart abstraction. To quantify care, 7 HF quality measures were assessed; practices with and without EHR were compared. RESULTS Among practices, 52% had EHR systems (30% EHR-only; 22% both EHR and paper) and 48% paper-only systems. Conformity with indicated care for practices with EHR systems was modestly higher for 2 of 7 quality measures compared to those without. After controlling for patient and site characteristics, use of EHR was associated with improved delivery of 3 of 7 quality measures (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, aldosterone antagonist, and HF education), similar care for 3 measures (beta-blocker, anticoagulation for atrial fibrillation, and cardiac resynchronization therapy), and worse for 1 measure (implantable cardioverter-defibrillator). CONCLUSIONS These data are among the first to assess the potential influence of EHR on conformity with HF guidelines in the outpatient setting and suggest that EHR systems as currently deployed are associated with only modest differences in some, but not other, quality measures provided to HF patients compared with use of paper-only systems.
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Walsh MN, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, O’Connor CM, Inge PJ, Mehra MR, Reynolds D, Yancy CW. EQUITABLE IMPROVEMENT FOR WOMEN AND MEN IN THE USE OF GUIDELINE-RECOMMENDED THERAPIES FOR HEART FAILURE: FINDINGS FROM IMPROVE HF. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61331-9] [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: 11/16/2022]
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O’Connor CM, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, Reynolds D, Walsh MN, Yancy CW. RELATIONSHIP BETWEEN CARDIOLOGY PRACTICE TEACHING STATUS AND IMPROVEMENT IN THE USE OF EVIDENCE-BASED THERAPY FOR HEART FAILURE: FINDINGS FROM IMPROVE HF. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61213-2] [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: 11/29/2022]
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Albert NM, Fonarow GC, Yancy CW, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride M, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF). Am Heart J 2010; 159:238-44. [PMID: 20152222 DOI: 10.1016/j.ahj.2009.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 11/24/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND National guidelines recommend heart failure (HF) disease management programs to facilitate adherence to evidence-based practices. This study examined the influence of dedicated HF clinics on delivery of guideline-recommended therapies for cardiology practice outpatients with HF and reduced left ventricular ejection fraction. METHODS IMPROVE HF, a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic systolic HF. Adherence to guideline-recommended HF therapies was recorded, and the presence of a dedicated HF clinic was assessed by survey. Multivariate models identified contributions to delivery of guideline-recommended HF therapies. RESULTS Of practices, 41.3% had a dedicated HF clinic. Practices with a dedicated HF clinic had greater adherence to 3 of 7 guideline-recommended HF therapy measures: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (P = .02), beta-blocker (P = .025), and HF education (P = .009). After adjustment, use of a dedicated HF clinic was associated with greater conformity in 2 of 7 measures: cardiac resynchronization therapy (P = .036) and HF education (P = .005) but not angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aldosterone antagonist, implantable cardioverter-defibrillator therapy, and anticoagulation for atrial fibrillation. CONCLUSIONS Use of dedicated HF clinics varied in cardiology outpatient practices and was associated with greater use of cardiac resynchronization therapy and HF education but not other guideline-recommended therapies.
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Yancy CW, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Adherence to guideline-recommended adjunctive heart failure therapies among outpatient cardiology practices (findings from IMPROVE HF). Am J Cardiol 2010; 105:255-60. [PMID: 20102928 DOI: 10.1016/j.amjcard.2009.08.681] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 08/25/2009] [Accepted: 08/25/2009] [Indexed: 11/25/2022]
Abstract
Although previous studies have documented adherence with certain established heart failure (HF) quality metrics in outpatient cardiology practices, the extent to which there is conformity with other evidence-based, guideline-driven quality metrics in outpatients with HF is unknown. IMPROVE HF is a prospective cohort study designed to characterize the current management of patients with chronic HF and left ventricular ejection fraction <or=35% in outpatient cardiology practices. We evaluated baseline data for conformity with adjunctive HF therapies including pneumococcal vaccinization, hydralazine/isosorbide dinitrate (HYD/ISDN) for Black patients, statin therapy, antiplatelet therapy, smoking-cessation counseling, low-density lipoprotein cholesterol levels (<100 mg/dl), and systolic blood pressure decrease (all patients <140 mm Hg or [optimal] <130 mm Hg). Baseline data were available for 15,381 patients attending 167 cardiology practices. Patient characteristics included a median age 70 years, 71.0% men, 9.1% Black patients, 65.2% with ischemic HF cause, and 61.7% with a history of hypertension. Mean adherences or documentations of adherence were only 7.3% for HYD/ISDN and 1.0% for pneumococcal vaccination. Adherence to other adjunctive therapies ranged from 27.4% to 82.0% but none of the adjunctive treatment interventions were associated with high levels of adherence. Conformity with guideline-recommended, adjunctive HF therapies is deficient in the management of outpatients with HF. Critical gaps in documentation or delivery of care exist, especially for the use of pneumococcal vaccination and HYD/ISDN. In conclusion, improved processes of care, better documentation, and/or increased measures to promote adherence to all primary and adjunctive therapies for HF are needed.
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