1
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Burger P, Dorresteijn J, Fiolet A, Koudstaal S, Eikelboom J, Nidorf S, Thompson P, Cornel J, Budgeon C, Steg P, Cramer M, Teraa M, Bhatt D, Visseren F, Mosterd A. Individual lifetime benefit from low-dose colchicine in chronic coronary artery disease patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Low-dose colchicine reduces the risk of cardiovascular events in patients with chronic coronary artery disease (CAD), but the absolute benefit may vary between patients. Individual benefit from preventive therapies can be estimated using the guideline-recommended SMART-REACH model.
Purpose
This study aimed to assess the range of individual absolute 10-year and lifetime benefit from low-dose colchicine according to patient risk profile.
Methods
The SMART-REACH model was combined with the relative treatment effect of low-dose colchicine, and applied to all participants from the LoDoCo2 trial (n=5,522), and patients with chronic CAD from the UCC-SMART cohort (n=5,308). Individual treatment benefit was expressed as (i) 10-year absolute risk reductions (ARRs) for myocardial infarction, ischemic stroke, or cardiovascular death (MACE), and (ii) life-years gained free of MACE. Predictions were also performed for MACE plus ischemia-driven coronary revascularization (MACE+), through development of a new competing risk-adjusted lifetime prediction model in data from the REACH registry (n=14,522). Low-dose colchicine was compared to alternative intensive prevention goals, i.e. low density lipoprotein-cholesterol (LDL-c) reduction to <1.4 mmol/L, and systolic blood pressure (SBP) reduction to <130 mmHg.
Results
Median individual 10-year ARR for MACE from low-dose colchicine therapy was 4.6% (interquartile range [IQR] 3.6–6.0%), and median gain in life expectancy free of MACE was 2.0 (IQR 1.6–2.5) years. Median 10-year ARR for MACE+ was 8.6% (IQR 7.6–9.8%), and median gain in MACE+-free life expectancy was 3.4 (IQR 2.6–4.2) years. For intensified LDL-c and SBP reduction respectively, median 10-year ARRs were 3.0% (IQR 1.5–5.1%) and 1.7% (IQR 0.0–5.7%) for MACE, and 5.2% (IQR 2.5–8.7%) and 2.9% (IQR 0.0–9.5%) for MACE+. Median life-years gained from LDL-c and SBP reduction were 1.2 (IQR 0.6–2.1) and 0.7 (IQR 0.0–2.3) years free of MACE, and 1.8 (IQR 0.8–3.3) and 0.9 (IQR 0.0–3.4) years free of MACE+.
Conclusion
The individual absolute benefit from low-dose colchicine varies between patients. In an era where lipid- and blood pressure-lowering therapies are already routinely used, the benefits of low-dose colchicine are expected to be of at least similar magnitude to those of intensified LDL-c and SBP reduction in patients with chronic CAD.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Burger
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - J Dorresteijn
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - A Fiolet
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - S Koudstaal
- Green Heart Hospital , Gouda , The Netherlands
| | | | - S Nidorf
- Sir Charles Gairdner Hospital , Perth , Australia
| | - P Thompson
- Sir Charles Gairdner Hospital , Perth , Australia
| | - J Cornel
- Radboud University Medical Centre , Nijmegen , The Netherlands
| | - C Budgeon
- University of Western Australia , Perth , Australia
| | - P Steg
- University Paris Diderot , Paris , France
| | - M Cramer
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - M Teraa
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - D Bhatt
- Brigham and Women's Hospital , Boston , United States of America
| | - F Visseren
- University Medical Center Utrecht , Utrecht , The Netherlands
| | - A Mosterd
- Meander Medical Center , Amersfoort , The Netherlands
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2
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Steg P, Szarek M, Valgimigli M, Islam S, Zeiher AM, Bhatt DL, Bittner VA, Diaz R, Goodman SG, Harrington RA, Jukema JW, Pordy R, Scemama M, White HD, Schwartz GG. Lipoprotein(a) and the effect of alirocumab on coronary and non-coronary revascularization following acute coronary syndrome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Many patients require arterial revascularization after an index ACS. Lipoprotein(a) is thought to play a pathogenic role in atherothrombosis. In the ODYSSEY OUTCOMES trial, the PCSK9 inhibitor alirocumab reduced major adverse cardiovascular events after ACS, with greater reduction among those with higher lipoprotein(a).
Objectives
We determined whether the risk of first coronary or any (coronary, peripheral artery or carotid) revascularization after ACS was modified by the level of lipoprotein(a) and treatment with alirocumab or placebo.
Methods
The ODYSSEY OUTCOMES trial (NCT01663402) compared alirocumab with placebo in 18,924 patients with ACS and elevated atherogenic lipoproteins despite optimized statin treatment. Treatment effects were summarized by competing-risks proportional hazard models.
Results
A total of 1559 (8.2%) patients had coronary, 204 (1.1%) peripheral artery, and 40 (0.2%) carotid revascularization after randomization. Alirocumab reduced first coronary revascularization (9.6% vs. 11.3% at 4 years; hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80–0.97; p=0.01) and any first revascularization (10.8% vs. 13.0%; HR 0.85, 95% CI 0.78–0.94; p=0.001). Baseline lipoprotein(a) quartile was directly associated with risk of coronary or any revascularization in the placebo arm (ptrend <0.0001) and inversely related to treatment HRs (ptrend <0.001). The greatest benefits of alirocumab on coronary or any revascularization were observed in patients with baseline lipoprotein(a) in the top quartile (≥59.6 mg/dL) (figures).
Conclusions
Alirocumab reduced revascularization after ACS. The risk of revascularization and reduction in that risk with alirocumab were greatest in patients with elevated lipoprotein(a) at baseline.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): SanofiRegeneron Pharmaceuticals
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Affiliation(s)
- P Steg
- Hospital Bichat-Claude Bernard , Paris , France
| | - M Szarek
- State University of New York Downstate Medical Center , New York , United States of America
| | - M Valgimigli
- Cardiocentro Ticino Institute , Lugano , Switzerland
| | - S Islam
- NYU Long Island School of Medicine, Division of Health Services Research , Mineola , United States of America
| | - A M Zeiher
- Goethe University Hospital , Frankfurt , Germany
| | - D L Bhatt
- Brigham and Women's Hospital , Boston , United States of America
| | - V A Bittner
- University of Alabama Birmingham , Birmingham , United States of America
| | - R Diaz
- Estudios Cardiologicos Latinoamerica (ECLA) , Rosario , Argentina
| | | | - R A Harrington
- School of Medicine , Stanford , United States of America
| | - J W Jukema
- Leiden University Medical Center , Leiden , The Netherlands
| | - R Pordy
- Regeneron Pharmaceuticals, Inc. , Tarrytown , United States of America
| | | | - H D White
- Auckland City Hospital , Auckland , New Zealand
| | - G G Schwartz
- University of Colorado , Aurora , United States of America
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3
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Bhatt D, Brinton E, Miller M, Steg P, Jacobson T, Ketchum S, Juliano R, Jiao L, Doyle R, Granowitz C, Busch R, Tardif J, Ballantyne C. SUBSTANTIAL CARDIOVASCULAR RISK REDUCTION WITH ICOSAPENT ETHYL REGARDLESS OF DIABETES STATUS OR BMI: REDUCE-IT BMI. Can J Cardiol 2021. [DOI: 10.1016/j.cjca.2021.07.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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4
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Bhatt D, Miller M, Steg P, Brinton E, Jacobson T, Ketchum S, Doyle R, Juliano R, Jiao L, Granowitz C, Tardif JC, Ballantyne C. REDUCE-IT: outcomes by baseline statin type. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) randomized 8,179 statin-treated patients with elevated triglycerides and increased cardiovascular (CV) risk to either icosapent ethyl (IPE), a pure, stable prescription form of eicosapentaenoic acid, 4g/day or placebo. IPE significantly reduced time to first occurrence of the primary composite endpoint of major adverse CV events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) (HR 0.75, CI 0.68–0.83) and key secondary endpoint events (composite of CV death, nonfatal MI, or nonfatal stroke) (HR 0.74, CI 0.65–0.83) versus placebo (all p<0.0001). A modest reduction in placebo-corrected LDL-C was observed (−6.6%; p<0.0001). The mechanisms for the CV benefit of icosapent ethyl are not fully understood.
Purpose
Explore the impact of statin type and lipophilic/lipophobic category on outcomes, and on LDL-C, to further consider the possible relevance of LDL-C pathways to the observed CV benefit of icosapent ethyl.
Methods
Primary and key secondary endpoint analyses and LDL-C changes from baseline were explored by individual statin type (atorvastatin, simvastatin, rosuvastatin, or pravastatin) at baseline, and then by categorizing these statins into lipophilic (i.e., hydrophobic: atorvastatin, simvastatin) and lipophobic (i.e., hydrophilic: rosuvastatin, pravastatin) statin groups; 96.1% of patients fell within these individual statin groups.
Results
CV outcomes were similar across statin types (interaction p=0.61) and lipophilic/lipophobic categories (interaction p=0.51) (Figure). Statin type and category had a similar lack of meaningful impact on the modest placebo-corrected median LDL-C changes from baseline to one year, which ranged from −5.8 to −8.4% (all p≤0.0003).
Conclusion
No meaningful treatment differences in the primary or key secondary endpoints across statin type or lipophilic/lipophobic category were observed. A similar lack of treatment difference was observed in LDL-C changes from baseline to one year. Therefore, the LDL-C changes and CV risk reduction in REDUCE-IT appear independent of the type of concomitant statin therapy. These data provide clinicians with additional insight regarding concomitant statin therapy considerations when prescribing icosapent ethyl and suggest there are important mechanisms of action for the substantial CV risk reduction observed with icosapent ethyl that are distinct from the LDL receptor pathway.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.
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Affiliation(s)
- D Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - M Miller
- University of Maryland, Department of Medicine, University of Maryland School of Medicine, Baltimore, United States of America
| | - P.G Steg
- University of Paris, INSERM Unité 1148; FACT Hopital Bichat, Paris, France
| | - E.A Brinton
- Utah Lipid Center, Salt Lake City, United States of America
| | - T.A Jacobson
- Emory University School of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, Atlanta, United States of America
| | - S.B Ketchum
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.T Doyle
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.A Juliano
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - L Jiao
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - C Granowitz
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - J.-C Tardif
- University of Montreal, Montreal Heart Institute, Montreal, Canada
| | - C.M Ballantyne
- Baylor College of Medicine, Department of Medicine, Houston, United States of America
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5
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Steg P, Bhatt D, James S, Darlington O, Hoskin L, Simon T, Fox K, Leiter L, Mehta S, Harrington R, Himmelmann A, Ridderstrale W, Andersson M, Mellstrom C, Mcewan P. Cost-effectiveness of ticagrelor in patients with type 2 diabetes and coronary artery disease with a history of PCI: an economic evaluation of THEMIS-PCI using a Swedish healthcare perpective. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) evaluated ticagrelor compared to placebo for the prevention of myocardial infarction (MI), stroke and cardiovascular (CV) death in 19 220 patients with type 2 diabetes (T2DM) and stable coronary artery disease (CAD) with no prior myocardial infarction (MI) or stroke. THEMIS-PCI was a pre-specified subgroup of 11 154 patients who had a history of percutaneous coronary intervention (PCI) when entering the study. In THEMIS, ticagrelor reduced CV death, MI or stroke, although with an increase in major bleeding compared to aspirin alone, and there was a significant interaction between a prior history of PCI and the net benefit of ticagrelor. In the THEMIS-PCI population, ticagrelor plus aspirin provided a favourable net clinical benefit with a significant 15% reduction in all-cause death, MI, stroke, fatal bleed, or intracranial haemorrhage.
Objective
The objective of this analysis was to estimate the cost-effectiveness of ticagrelor for the prevention of CV events based on the results of the THEMIS-PCI population using a lifetime horizon from a Swedish healthcare perspective.
Methods
A lifetime Markov state transition model was developed with health states aligned to the THEMIS trial endpoints. Health state transitions were informed by parametric survival equations fitted to patient level data from THEMIS-PCI population. Treatment discontinuation rates were informed by the THEMIS-PCI population, with all patients assumed to discontinue treatment with ticagrelor after four years. The incidence of bleeding and dyspnoea were modelled as adverse events. Costs (2019 Euros) and utility data were derived from the published literature and the THEMIS-PCI population, respectively, and discounted at 3.0% annually. Probabilistic (PSA) and deterministic sensitivity analysis (DSA) were conducted to quantify uncertainty of key input parameters.
Results
Treatment with ticagrelor plus aspirin over four years resulted in estimated Quality Adjusted Life Year (QALY) gains of 0.09 at an incremental cost of €1,891 compared to aspirin alone. The estimated incremental cost-effectiveness ratio (ICER) was €19,959/QALY. PSA indicated that ticagrelor was cost-effective in 93% of simulations using a willingness-to-pay threshold of €47,000/QALY and DSA showed that cost-effectiveness was robust to changes in key input parameters (ICER range: €16,504 to €25,012/QALY).
Conclusion
Based on the results of the THEMIS trial, dual antiplatelet therapy with ticagrelor plus aspirin is likely to be a cost-effective treatment compared with aspirin alone for the prevention of CV events in patients with T2DM and CAD with a history of PCI.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): AstraZeneca
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Affiliation(s)
- P Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - D.L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - S.K James
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - O Darlington
- Health Economics and Outcomes Research Ltd, Cardiff, United Kingdom
| | - L Hoskin
- Health Economics and Outcomes Research Ltd, Cardiff, United Kingdom
| | - T Simon
- Hôpital Saint Antoine, Sorbonne-Université, Paris, France
| | - K Fox
- Royal Brompton Hospital Imperial College London, London, United Kingdom
| | | | - S Mehta
- McMaster University, Hamilton, Canada
| | | | | | | | | | | | - P Mcewan
- Health Economics and Outcomes Research Ltd, Cardiff, United Kingdom
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6
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Olshansky B, Bhatt D, Miller M, Steg P, Brinton E, Jacobson T, Ketchum S, Doyle R, Juliano R, Jiao L, Granowitz C, Tardif JC, Mehta C, Ballantyne C, Chung M. REDUCE-IT: accumulation of data across prespecified interim analyses to final results. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), an event-driven trial, randomized 8,179 statin-treated patients with elevated triglycerides (TGs) and increased cardiovascular (CV) risk to icosapent ethyl (IPE); pure, stable prescription eicosapentaenoic acid, 4g/day or placebo. 1,612 primary endpoint events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) projected 90% power to detect 15% relative risk reduction (5% 2-sided alpha). The key secondary composite endpoint was CV death, nonfatal MI, or nonfatal stroke. An independent data and safety monitoring committee (DMC) performed prespecified interim analyses (IAs) at ∼60% (IA1 31 May 2016 data cutoff; 2.9 y median primary endpoint follow-up) and ∼80% (IA2 01 May 2017; 3.7 y) of events; final analysis included 1,606 events (06 Sep 2018; 4.9 y median study follow-up).
Purpose
Explore REDUCE-IT efficacy and safety across prespecified IAs for insight into progression of robustness and consistency of conclusions.
Methods
The interim statistical analysis plan guided study continuation decisions by a prespecified decision-making process, including assessment of safety, treatment arm performance, primary composite endpoint formal analyses, and informal robustness analyses, with no futility or efficacy stopping requirements. Prior to DMC IA study continuation decisions, the need for a mature dataset to support the robustness of final efficacy and safety findings was discussed. Sponsor, Steering Committee, and Clinical Endpoint Committee were blinded throughout.
Results
Primary and key secondary endpoints achieved statistical significance at IA1 and IA2 that persisted at final analyses (p-value below final adjusted 2-sided alpha of 0.0437); hazard ratios also remained consistent and similar robustness was observed across individual endpoint components; clarity of findings across endpoints and subgroups improved with more events. Stopping for overwhelming efficacy was discussed at each IA; prior to IA study continuation recommendations, the DMC considered historical examples of failed CV outcome studies for TG-lowering and mixed omega-3 therapies, reflected on the potential for overestimating final demonstrated benefit using incomplete data, and weighed societal impacts of fuller datasets relative to patient therapy access.
Conclusions
Consistent, potent efficacy emerged early and persisted across the two prespecified interim and final analyses. The mature dataset demonstrated highly statistically significant reductions in the primary (25%; p=0.00000001) and key secondary (26%; p=0.0000006) endpoints and allowed robust analyses to support overall efficacy and safety conclusions. Allowing the REDUCE-IT dataset to fully mature provided clinicians with robust, consistent, and reliable data upon which to base clinical decisions for IPE in CV risk reduction.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.
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Affiliation(s)
- B Olshansky
- University of Iowa College of Medicine, Iowa city, United States of America
| | - D Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - M Miller
- University of Maryland, Department of Medicine, University of Maryland School of Medicine, Baltimore, United States of America
| | - P.G Steg
- University of Paris, INSERM Unité 1148; FACT Hopital Bichat, Paris, France
| | - E.A Brinton
- Utah Lipid Center, Salt Lake City, United States of America
| | - T.A Jacobson
- Emory University School of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, Atlanta, United States of America
| | - S.B Ketchum
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.T Doyle
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.A Juliano
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - L Jiao
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - C Granowitz
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - J.-C Tardif
- University of Montreal, Montreal Heart Institute, Montreal, Canada
| | - C Mehta
- Cytel Inc., Waltham, United States of America
| | - C.M Ballantyne
- Baylor College of Medicine, Houston, United States of America
| | - M.K Chung
- Cleveland Clinic, Cleveland, United States of America
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7
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Balagny P, Wiernik E, Matta J, Frija-Masson J, Vidal-Petiot E, Steg P, Ribet C, Goldberg M, D'Ortho M, Zins M. Sleep disordered breathing: prevalence and association with cardiovascular disease in the French general population. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Sleep Disordered Breathing (SDB) is highly prevalent and associated with cardiovascular disease (CVD) but many studies have a limited sample size or uncertain generalizability.
Purpose
The aim of this study was to obtain contemporary data on SDB prevalence and to assess its impact on CVD occurrence in a large French population-based sample.
Methods
Data came from participants of the French population-based CONSTANCES cohort, included between 2012 and 2016, with clinical interview, examination and standard biology at inclusion and who were screened for SDB in 2017 using the Berlin Questionnaire (BQ). Follow-up was performed through yearly CONSTANCES questionnaires. CVD occurrence was defined by self-declared myocardial infarction or stroke between 2013 and 2017. Exposure variables were SDB diagnosis on the basis on BQ and its related sleeping symptoms (snoring, apnea and sleepiness). Odds Ratios (OR) were computed with their 95% Confidence Interval (95% CI) and adjusted for age, sex, smoking, dyslipidemia, diabetes, hypertension and body mass index (except for SDB since BQ considers these variables).
Results
Among 54 228 participants, SDB prevalence was 16.1%. Over four years of follow-up, CVD occurred in 2.23% of SDB participants vs 0.72% in non SDB (OR=1.72, 95% CI [1.41–2.09]). CVD occurrence did not increase significantly with snoring (OR=0.95, 95% CI [0.78; 1.17]), but with apnea (OR=1.34, 95% CI [1.05; 1.71]) and with sleepiness (OR=1.42, 95% CI [1.18–1.72] when fatigue occurred after-sleep and OR=1.62, 95% CI [1.33–1.97] during waking time). These associations remained non-significant for snoring regardless of its frequency or noise, were significant for sleepiness as soon as it happened at least once a week and tended to increase with its frequency whenever fatigue occurred (p for trend<0.001). Subgroups analysis in hypertensive and non-hypertensive participants found similar results concerning snoring and sleepiness.
Conclusions
These results confirm that SDB is highly prevalent in the general French population and is associated with a higher occurrence of CVD particularly in sleepy and apneic subjects. Screen for SDB and its symptoms should be relevant to identify high cardiovascular risk people who would benefit from preventive measures.
Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Plan d'Investissement d'Avenir-3 (PIA3-RHU, Ministry of Health)
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Affiliation(s)
- P Balagny
- Hôpital Bichat AP-HP, INSERM Population-based Epidemiological Cohorts Unit, UMS 011,, Paris, France
| | - E Wiernik
- INSERM, Population-based Epidemiological Cohorts Unit, UMS 011, Paris, France
| | - J Matta
- INSERM, Population-based Epidemiological Cohorts Unit, UMS 011, Paris, France
| | - J Frija-Masson
- Université de Paris, UFR de Médecine, Physiologie Explorations Fonctionnelles, Hôpital Bichat, AP-HP, Paris, France
| | - E Vidal-Petiot
- Université de Paris, UFR de Médecine, Physiologie Explorations Fonctionnelles, Hôpital Bichat, AP-HP, Paris, France
| | - P.G Steg
- Université de Paris UFR de Médecine, Département de Cardiologie Hôpital Bichat AP-HP, INSERM U1148, Paris, France
| | - C Ribet
- INSERM, Population-based Epidemiological Cohorts Unit, UMS 011, Paris, France
| | - M Goldberg
- INSERM, Population-based Epidemiological Cohorts Unit, UMS 011, Paris, France
| | - M.P D'Ortho
- Université de Paris, UFR de Médecine, Physiologie Explorations Fonctionnelles, Hôpital Bichat, AP-HP, Paris, France
| | - M Zins
- Université de Paris UFR de Médecine, INSERM Population-based Epidemiological Cohorts Unit, UMS 011, Paris, France
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8
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Bhatt D, Scheiman J, Angiolillo D, Steg P, Dangas G, Fan W, Prats J, Deliargyris E. Reduced gastric injury with a novel, liquid lipid-aspirin formulation: results from a pooled, patient level analysis of two randomized endoscopy studies In healthy volunteers. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Gastrointestinal (GI) toxicity from aspirin is high at the time of initiation of therapy.
Objective
The current analysis aimed to determine rates of endoscopically detected gastroduodenal erosions and ulcers after 7 days of either immediate release aspirin (IR-ASA) or a novel, pharmaceutical lipid-aspirin complex (PL-ASA) liquid formulation that has an antiplatelet effect similar to IR-ASA.
Methods
Two randomized, single blind, multicenter active control studies comparing upper GI damage after 7 days of 325 mg PL-ASA or IR-ASA in healthy volunteers not taking a gastroprotectant and who had a negative baseline endoscopy were pooled at the patient level. The primary outcome was the composite of >5 erosions and/or ≥1 ulcer (≥3 mm deep) assessed by a treatment-blinded reviewer at repeat endoscopy on day 7.
Results
Out of 451 randomized subjects (mean age 57 years, 47% males), 441 completed the 7-day endoscopy and represent the full analysis set. PL-ASA significantly reduced the primary outcome by 34% compared with IR-ASA (25.7% vs. 39%, p=0.0032) (figure). Notably, for ulcers there was a 61% reduction with PL-ASA (6.0% vs. 14.8%, p=0.0018) (Figure 1). The mean number of gastric erosions per patient was also reduced with PL-ASA (2.8±7.3 vs. 4.2±7.5, p<0.0001), while erosions in the duodenum were not different (1.4±7.1 vs. 0.9±2.3, p=0.45).
Conclusion
The novel PL-ASA liquid capsules reduced rates of GI injury compared with IR-ASA tablets. The combination of reliable platelet inhibition with less GI injury makes PL-ASA an attractive new aspirin therapy option.
Figure 1
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): PLx Pharma
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Affiliation(s)
- D.L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - J Scheiman
- University of Virginia, Charlottesville, United States of America
| | - D.J Angiolillo
- University of Florida College of Medicine, Jacksonville, United States of America
| | - P.G Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - G.D Dangas
- Mount Sinai Medical Center, New York, United States of America
| | - W Fan
- PLx Pharma, Sparta, United States of America
| | - J Prats
- Elysis LLC, Carlisle, United States of America
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Bhatt D, Miller M, Steg P, Brinton E, Jacobson T, Ketchum S, Doyle R, Juliano R, Jiao L, Granowitz C, Gregson J, Pocock S, Tardif JC, Ballantyne C. REDUCE-IT: total ischemic events reduced across the full range of baseline LDL cholesterol and other key subgroups. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), a study of 8,179 randomized statin-treated patients with elevated triglycerides (TG) and increased cardiovascular (CV) risk followed for a median of 4.9 years, demonstrated robust results. Icosapent ethyl (IPE), a pure and stable prescription form of eicosapentaenoic acid, 4g/day reduced both time-to-first and total primary endpoint ischemic events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) by 25% (HR 0.75; 95% CI 0.68–0.83; p<0.0001) and 30% (rate ratio 0.70; 95% CI 0.62–0.78; p<0.0001), respectively. Similar substantial reductions in first and total key secondary endpoint ischemic events (composite of CV death, nonfatal MI, or nonfatal stroke) were also observed. Demographic and baseline disease characteristics were generally balanced across treatment groups. Time-to-first event analyses showed robust and generally consistent benefit across subgroups. Previous total event analyses by baseline TG demonstrated large, consistent, statistically significant reductions across tertiles, suggesting the CV benefit of IPE is tied primarily to non-TG factors.
Purpose
Further explore the extent to which IPE reduced total primary and key secondary events across prespecified baseline demographic, disease, treatment, and lipid/lipoprotein/inflammatory biomarker subgroups.
Methods
Total events across subgroups were assessed with the prespecified negative binomial regression method. Main outcomes were total (first and subsequent) primary and key secondary composite endpoint events.
Results
Median baseline LDL-C levels in ascending tertiles were 58, 76, and 96 mg/dL; there were large, significant relative reductions in total primary endpoint events with IPE across tertiles (35%, 28%, and 27%, respectively; interaction p=0.62), with parallel substantial absolute risk reductions. Similar, significant relative reductions of 33%, 28%, and 24% in total key secondary endpoint events were observed, along with substantial absolute risk reductions. Total events analyses of prespecified subgroups also demonstrated robust and generally consistent findings for the primary and key secondary composite endpoints.
Conclusion
REDUCE-IT demonstrated substantial reductions in first and total primary and key secondary endpoint ischemic events, with robust and generally consistent results across baseline TG and LDL-C levels, as well as other prespecified baseline biomarker, demographic, disease, and treatment subgroups. These analyses provide useful insights for clinicians considering the range of patients who may benefit from IPE therapy and suggest that mechanisms beyond the lipid/lipoprotein/inflammatory pathways tested, including mechanisms beyond the LDL receptor pathways, may contribute to the observed substantial reductions in total ischemic burden with IPE therapy.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.
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Affiliation(s)
- D Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - M Miller
- University of Maryland, Department of Medicine, University of Maryland School of Medicine, Baltimore, United States of America
| | - P.G Steg
- University of Paris, INSERM Unité 1148; FACT Hopital Bichat, Paris, France
| | - E.A Brinton
- Utah Lipid Center, Utah, United States of America
| | - T.A Jacobson
- Emory University School of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, Atlanta, United States of America
| | - S.B Ketchum
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.T Doyle
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - R.A Juliano
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - L Jiao
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - C Granowitz
- Amarin Pharma, Inc., Bridgewater, United States of America
| | - J Gregson
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics, London, United Kingdom
| | - S.J Pocock
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics, London, United Kingdom
| | - J.-C Tardif
- University of Montreal, Montreal Heart Institute, Montreal, Canada
| | - C.M Ballantyne
- Baylor College of Medicine, Houston, United States of America
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10
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Gautier A, Ducrocq G, Elbez Y, Ferrari R, Ford I, Fox K, Tardif J, Tendera M, Steg P. CCS patients with polyvascular disease are a high risk but heterogenous subset of patients: insights from the CLARIFY registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Polyvascular disease constitutes a powerful predictor of cardiovascular events, is found in 10 to 15% of chronic coronary syndromes (CCS) patient. Smoking and diabetes mellitus are strongly associated with polyvascular disease. Risk stratification is key to select the most appropriate therapeutic strategy for a given patient.
Purpose
We aimed to describe 5-year ischaemic risk of CCS patients according to vascular disease phenotype and diabetic or smoking status.
Method
We analyzed data from 32 703 consecutive CCS outpatients (45 countries) enrolled between November 2009 to June 2010 in the prospective observational CLARIFY registry. Three mutually exclusive groups were compared: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD+1), CAD with CVD and PAD (CAD+2). Primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted on age, sex and geographic origin at 5 years.
Results
At baseline, 26440 (80.8%) patients were diagnosed with CAD alone, 4967 (15.2%) had CAD+1, 1296 (4%) had CAD+2. Overall, 9501 (29%) patients were diabetics, 19184 (58.7%) were smokers or ex-smokers and only 9220 (28.2%) were free of these two major cardiovascular risk factors. Primary outcome increasing gradually according to the number of arterial diseases locations from 8.4% (95% CI 8.09–8.73) in patients with CAD alone to 17.4% (95% CI 16.95–17.83) of CAD+2 patients (p<0.001). Subgroup analysis according to diabetes or smoking status further enriched risk stratification from 7% (95% CI 6.48–7.59) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.08–21.44) in diabetics and smokers CAD+ 2 patients (Figure 1). Diabetic CAD alone patients had a comparable risk to that of non-diabetic and non-smoking polyvascular patients, 9.8% (95% CI 8.82–10.68) vs 10.3% (95% CI 9.61–10.96), p=0.38. Outcome was similar between polyvascular diabetic patients, regardless of the number of arterial diseases, 15.5% (95% CI 14.31–16.60) for CAD+1 and 15.0 (95% CI 13.88–16.13) for CAD+2, p=0.83. Smoking increased 5-year risk proportionally to the number of symptomatic arterial bed, 8.2% (95% CI 7.72–8.68) vs 11.8% (95% CI 11.18–12.31) vs 17.9% (95% CI 17.18–18.54), respectively for CAD alone, CAD+1 and CAD+2.
Conclusion
CCS patients with polyvascular disease remain at high risk of ischaemic events in the contemporary practice with widespread secondary prevention therapies. Polyvascular is a very heterogenous subset of patients with ischaemic risk varying not only according to the number of vascular bed diseased but also according to smoking and diabetes status, two conditions present in the vast majority of CCS patients. Diabetes confers upfront a maximal increased risk. Identification of higher risk subsets in polyvascular patients can potentially identify those that could derived the greatest benefit from new secondary prevention strategies.
Figure 1
Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique-Hôpitaux de Paris
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Affiliation(s)
- A Gautier
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
| | - G Ducrocq
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
| | - Y Elbez
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
| | - R Ferrari
- Maria Cecilia Hospital, Cotignola, Italy
| | - I Ford
- University of Glasgow, Glasgow, United Kingdom
| | - K.M Fox
- Royal Brompton Hospital Imperial College London, London, United Kingdom
| | - J.C Tardif
- Montreal Heart Institute, Montreal, Canada
| | - M Tendera
- School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - P.G Steg
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
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11
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Lopes R, Steg P, Bhatt D, Bittner V, Dauchy A, Diaz R, Goodman S, Harrington R, Jukema J, Pordy R, Sourdille T, Szarek M, White H, Zeiher A, Schwartz G. Effect of alirocumab on incidence of atrial fibrillation after acute coronary syndromes: insights from ODYSSEY OUTCOMES. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) is a marker of risk in patients presenting with acute coronary syndromes (ACS). The potential effect of inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) on the incidence of AF is unknown.
Methods
The ODYSSEY OUTCOMES trial compared randomized treatment with the PCSK9 inhibitor alirocumab or placebo in patients with recent ACS and residual dyslipidaemia despite optimal statin therapy. The current analysis determined: 1) whether alirocumab treatment influenced incident AF; 2) whether a history of AF influenced the risk of major adverse cardiovascular events (MACE); and 3) whether there was interaction between AF at baseline and randomized treatment on MACE. AF was determined from the medical history and investigator reports of adverse events.
Results
Of 18,924 participants, 662 (3.5%) had a history of AF at randomization and 18,262 (96.5%) had no history of AF. Of the latter category, 499 (2.7%) had incident AF. Older age, randomization in South America or Eastern Europe, history of heart failure or myocardial infarction, and higher body mass index were factors associated with incident AF. Treatment with alirocumab or placebo did not influence incident AF (2.2% vs 2.6%, respectively; hazard ratio 0.90, 95% confidence interval 0.75–1.08; Figure). Patients with a history of AF had a greater burden of comorbidities, including cerebrovascular disease, peripheral artery disease, hypertension and heart failure; they also had higher rates of MACE (Table). There was no significant interaction between AF and randomized treatment on risk of MACE (P interaction=0.78)
Conclusions
Although treatment with alirocumab did not significantly modify the risk of incident AF after ACS in this analysis, future studies with more sensitive and systematic methods of ascertainment may be warranted. History of AF is a strong predictor of risk of recurrent MACE after ACS.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Sanofi, Regeneron Pharmaceuticals, Inc
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Affiliation(s)
- R Lopes
- Duke University Medical Center, Duke Clinical Research Institute, Durham, United States of America
| | - P.G Steg
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
| | - D.L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - V.A Bittner
- University of Alabama Birmingham, Birmingham, United States of America
| | | | - R Diaz
- Estudios Cardiologicos Latinoamerica (ECLA), Rosario, Argentina
| | | | - R.A Harrington
- Stanford University, Department of Medicine, Stanford, United States of America
| | - J.W Jukema
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - R Pordy
- Regeneron Pharmaceuticals, Tarrytown, United States of America
| | - T Sourdille
- Sanofi, Bridgewater, United States of America
| | - M Szarek
- State University of New York Downstate Medical Center, New York, United States of America
| | - H.D White
- Auckland City Hospital, Auckland, New Zealand
| | - A.M Zeiher
- Goethe University, Frankfurt am Main, Germany
| | - G.G Schwartz
- University of Colorado, Aurora, United States of America
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12
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Danchin N, Steg P, Hanon O, Mahe I, Falissard B, Belhassen M, Dalon F, Gollety S, Cotte F, Van-Ganse E. Naxos study: risk of bleeding with oral anticoagulants in non-valvular atrial fibrillation patients in France. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulants reduce the risk of stroke and systemic embolism, at the expense of an increased risk of bleeding.
Purpose
To compare the risk of bleeding and sites of bleeding according to the type of oral anticoagulant used in NVAF patients.
Methods
NAXOS is a population-based, historical cohort study including all patients aged ≥18 years with NVAF and newly initiating one of the OACs available in France between 2014 and 2016, aiming to compare safety, effectiveness, and all-cause mortality, according to the type of oral anticoagulant used. The French national health insurance reimbursement database, cross-linked with the hospitalisation database and civil status registry (SNIIRAM) was used to identify first users of oral anticoagulants and outcomes over their follow-up.
Major bleeding events were identified through main diagnoses of hospital stays, with a specific focus on bleeding site. Apixaban was used as the reference treatment.
Analyses were performed on crude data and with adjustment on propensity scores calculated separately for each of the comparators (VKAs, rivaroxaban and dabigatran).
Results
Overall, 321,501 NVAF patients were included: 87,565 (27.2%), 112,628 (35.0%), 100,063 (31.1%), and 21,245 (6.6%) initiated apixaban, VKAs, rivaroxaban, and dabigatran, respectively. The crude risks of intracranial bleeding were 0.45 [0.40–0.50], 1.23 [1.16–1.30], 0.48 [0.44–0.53], and 0.26 [0.19–0.34] per 100 patient-year, for apixaban, VKA, rivaroxaban, and dabigatran, respectively. The respective figures for gastro-intestinal bleeding were: 0.67 [0.61–0.74], 1.73 [1.64–1.81], 1.01 [0.94–1.08], 1.02 [0.89–1.17]; and those for non-intracranial and non-gastro-intestinal but other bleeding were: 0.84 [0.78–0.92], 2.22 [2.13–2.32], 1.24 [1.17–1.31] and 0.71 [0.60–0.84].
After adjustment on propensity-scores, patients initiating apixaban were at a lower risk of all major bleeding vs. VKA, rivaroxaban and dabigatran (HR=0.49 [0.46–0.52], 0.63 [0.58–0.67]) and 0.85 [0.76–0.95]). Apixaban was associated with a decreased risk of intracranial bleeding compared with VKAs (HR=0.46 [0.40–0.53]) and rivaroxaban (HR=0.80 [0.69–0.93]), and an increased risk compared with dabigatran (HR=1.53 [1.12–2.07]). The risk of gastro-intestinal bleeding was lower with apixaban than with VKAs (HR=0.57; [0.55–0.59]), rivaroxaban (HR=0.59; [0.52–0.66]), and dabigatran (HR=0.57; 0.48–0.68]). For other bleedings, apixaban was associated with a lower risk compared with VKAs (HR=0.47; [0.43–0.52]), and rivaroxaban (HR=0.59; [0.53–0.66]), and with a similar risk compared with dabigatran (HR=1.01; [0.84–1.23]).
Conclusion
In this large, real-world, population-based cohort, apixaban was associated with a lower risk of all types of bleedings requiring hospitalisation, compared with vitamin K antagonists. Differences between direct oral anticoagulants were also observed.
Results of the comparative analyses
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb, Pfizer
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Affiliation(s)
- N Danchin
- Hopital Europeen Georges Pompidou- University Paris Descartes, Paris, France
| | - P.G Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - O Hanon
- Hospital Broca of Paris, Paris, France
| | - I Mahe
- Hospital Louis Mourier, Colombes, France
| | | | | | | | - S Gollety
- Bristol-Myers Squibb, Rueil Malmaison, France
| | - F.E Cotte
- Bristol-Myers Squibb, Rueil Malmaison, France
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13
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Biscaglia S, Campo G, Fox K, Tardif J, Tendera M, Greenlaw N, Ford I, Stanley B, Ferrari R, Steg P. Prognosis in patients with prior myocardial infarction and PEGASUS-TIMI 54 criteria in the CLARIFY registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
The PEGASUS-TIMI 54 trial showed that prolonged treatment with ticagrelor reduces the cumulative occurrence of ischemic adverse events. CLARIFY is the biggest real life registry on chronic coronary syndrome.
Purpose
- To evaluate the percentage of patients eligible for long-term ticagrelor therapy in the CLARIFY registry.
– To compare the outcome of this subgroup of patients with those with PEGASUS exclusion criteria or without PEGASUS inclusion criteria.
Methods
Within the CLARIFY population, we selected post MI patients and we excluded those with missing info (post MI evaluable population). Then, we divided patients into 3 groups: excluded (meeting PEGASUS exclusion criteria, namely use of P2Y12 receptor antagonists or chronic oral anticoagulant, any stroke, coronary-artery bypass grafting in the past 5 years); eligible (meeting PEGASUS high-risk inclusion criteria, namely age≥65 years; diabetes; multivessel disease; creatinine clearance <60 ml/min) and ineligible (not meeting PEGASUS high-risk inclusion criteria).
We therefore compared the ischemic (CV death, MI and stroke) and bleeding (major bleeding) outcome of the 3 groups adjusting for age, sex, smoking and geographical region.
Results
Among the 11811 post-MI evaluable patients, 4706 (39.8%) were included in the eligible group, 5715 (48.4%) in the excluded group, and 1390 in the ineligible group (11.8%). Both the ischemic and bleeding endpoints were significantly different among the 3 groups with the excluded patients with the worst and ineligible patients with the best outcome (see table). The same trend was shown for CV death, while the occurrence of MI was not significantly different among the 3 groups. In the eligible group, the ratio between ischemic and bleeding events was 6:1, whereas between CV death and major bleeding was 3.5:1.
Conclusions
Around 40% of CLARIFY post-MI patients could benefit from prolonged ticagrelor therapy. In this group of patients, ischemic risk seems to be higher than the bleeding one.
Ischemic & bleeding risk in the 3 groups
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): CLARIFY registry was funded by Servier
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Affiliation(s)
- S Biscaglia
- Azienda Ospedaliero Universitaria Sant'Anna, Ferrara, Ferrara, Italy
| | - G Campo
- Azienda Ospedaliero Universitaria Sant'Anna, Ferrara, Ferrara, Italy
| | - K Fox
- Imperial College London, NHLI, London, United Kingdom
| | - J.C Tardif
- Montreal Heart Institute, Montreal, Canada
| | - M Tendera
- School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - N Greenlaw
- University of Glasgow, Glasgow, United Kingdom
| | - I Ford
- University of Glasgow, Glasgow, United Kingdom
| | - B Stanley
- University of Glasgow, Glasgow, United Kingdom
| | - R Ferrari
- University Hospital of Ferrara, Medical Sciences, Ferrara, Italy
| | - P.G Steg
- Bichat Hospital, University Paris-Diderot, INSERM-UMR1148, FACT French Alliance for Cardiovascular T, Paris, France
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14
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Gragnano F, Zwahlen M, Vranckx P, Juni P, Heg D, Hamm C, Steg P, Hagenbuch N, Gargiulo G, Van Geuns R, Huber K, Van Amsterdam R, Serruys P, Valgimigli M, Windecker S. Ticagrelor monotherapy beyond 1 month versus standard dual antiplatelet therapy after drug-eluting coronary stenting: a pre-specified per-protocol analysis of the GLOBAL LEADERS trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In the GLOBAL LEADERS trial, the intention-to-treat (ITT) effect of ticagrelor monotherapy after 1 month of dual antiplatelet therapy (DAPT) was not superior to that of 12-month DAPT followed by aspirin alone in the prevention of 2-year all-cause mortality or new Q-wave myocardial infarction (MI) after coronary stenting. Intention-to-treat analyses can be affected by incomplete protocol adherence. We present a pre-specified per-protocol analysis.
Purpose
To determine whether 1 month of ticagrelor plus aspirin followed by 23 months of ticagrelor monotherapy is superior to 12 months of DAPT followed by aspirin alone in the per-protocol population of the GLOBAL LEADERS (NCT01813435).
Methods
The GLOBAL LEADERS compared two antiplatelet strategies after drug-eluting stenting for stable coronary artery disease or acute coronary syndromes. Per-protocol population consisted of randomized patients fulfilling enrollment criteria and receiving protocol-mandated treatment. Adherence to the allocated antiplatelet therapy was evaluated at discharge, 30 days, and 3, 6, 12, 18, and 24 months, with non-adherence reasons categorized following a hierarchical approach. A protocol-deviation was defined in the case of high perceived bleeding/thrombotic risk, a medical decision without evident clinical reason, patients unwilling to take study drugs, prescription error, logistical issues, unclear reasons. Baseline characteristics, including (but not limited to) age, sex, diabetes, prior PCI, were used to construct time-varying inverse probabilities for not deviation from the protocol to reconstruct a study population with no protocol-deviations. Protocol deviators were artificially censored at the time at which they deviated. The primary endpoint was the composite of 2-year all-cause mortality or non-fatal new Q-wave MI. We used a weighted pooled logistic regression to estimate the per-protocol rate ratio (RR) of experimental vs. control treatment for the primary endpoint.
Results
Of the 15,968 randomized patients, 805 out of 7,980 (10.1%) in experimental group and 537 out of 7,988 (6.7%) in control group were classified as protocol deviators and artificially censored by month 12, not contributing events in the second year. The events for the adherence-adjusted analysis were 279 in experimental group and 325 in control group (25 and 24 less than in ITT analysis, respectively). The estimated adherence-adjusted RR was 0.87 (95% CI: 0.74–1.02; p=0.09), comparable to the ITT RR (0.87; 95% CI: 0.75–1.01; p=0.07).
Conclusion
At per-protocol analysis, ticagrelor monotherapy after 1 month of DAPT was not superior to conventional treatment, in line with the previously reported ITT effect. Similar per-protocol and ITT effects can be accounted for similar per-protocol and ITT populations, as a substantial proportion of patients were non-adherent due to clinically grounded reasons (anticipated in the protocol) and, accordingly, not considered as protocol deviators.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): GLOBAL LEADERS was sponsored by the European Clinical Research Institute, which received funding from Biosensors International, AstraZeneca, and the Medicines Company.
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Affiliation(s)
- F Gragnano
- Bern University Hospital, Inselspital, Department of Cardiology, Bern, Switzerland
| | - M Zwahlen
- University of Bern, Institute of Social and Preventive Medicine (ISPM), Bern, Switzerland
| | - P Vranckx
- Heart Centre Hasselt, Department of Cardiology and Critical Care Medicine, Hasselt, Belgium
| | - P Juni
- St. Michael's Hospital, Department of Medicine, Applied Health Research Centre (AHRC), Toronto, Canada
| | - D Heg
- University of Bern, Institute of Social and Preventive Medicine (ISPM) and Clinical Trials Unit, Bern, Switzerland
| | - C Hamm
- Justus-Liebig University of Giessen, Department of Cardiology and Angiology, Giessen, Germany
| | - P.G Steg
- Bichat APHP Site of Paris Nord University Hospital, Department of Cardiology, Paris, France
| | - N Hagenbuch
- University of Bern, Institute of Social and Preventive Medicine (ISPM), Bern, Switzerland
| | - G Gargiulo
- Federico II University of Naples, Department of Advanced Biomedical Sciences, Naples, Italy
| | - R.J Van Geuns
- Radboud University Medical Center, Department of Cardiology, Nijmegen, Netherlands (The)
| | - K Huber
- Wilhelminen Hospital, 3rd Medical Department, Cardiology, Vienna, Austria
| | | | - P.W Serruys
- Imperial College London, Department of Cardiology, London, United Kingdom
| | - M Valgimigli
- Bern University Hospital, Inselspital, Department of Cardiology, Bern, Switzerland
| | - S Windecker
- Bern University Hospital, Inselspital, Department of Cardiology, Bern, Switzerland
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Bhatt D, Steg P, Miller M, Brinton E, Jacobson T, Ketchum S, Juliano R, Jiao L, Doyle R, Granowitz C, Tardif J, Verma S, Ballantyne C. SIGNIFICANT CARDIOVASCULAR BENEFITS OF ICOSAPENT ETHYL FROM REDUCE-IT. Can J Cardiol 2020. [DOI: 10.1016/j.cjca.2020.07.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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16
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White H, Steg P, Szarek M, Bhatt D, Bittner V, Diaz R, Edelberg J, Goodman S, Hantoin C, Harrington R, Jukema J, Lecorps G, Moryusef A, Pordy R, Roe M, Zeiher A, Schwartz G. Cardiovascular Outcomes With Alirocumab After Acute Coronary Syndrome: Results of the Odyssey Outcomes Trial. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Shavadia J, Welsh R, Gershlick A, Zheng Y, Huber K, Halvorsen S, Steg P, Van de Werf F, Armstrong P. RELATIONSHIP BETWEEN ARTERIAL ACCESS AND OUTCOMES IN A PHARMACOINVASIVE VERSUS PRIMARY PCI STRATEGY IN ST-ELEVATION MYOCARDIAL INFARCTION: INSIGHTS FROM THE STRATEGIC REPERFUSION EARLY AFTER MYOCARDIAL INFARCTION (STREAM) STUDY. Can J Cardiol 2015. [DOI: 10.1016/j.cjca.2015.07.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Reid C, Shiel L, Jelinek M, Freedman B, Hockings B, Alwyard P, Hamilton-Craig I, Steg P, Ford I, Fox K. Clinical outcomes for patients with stable coronary disease in Australia - findings from the CLARIFY registry. Heart Lung Circ 2015. [DOI: 10.1016/j.hlc.2015.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zhang H, Goodman S, Yan R, Steg P, Kornder J, Gyenes G, Grondin F, Brieger D, DeYoung J, Gallo R, Yan A. IN-HOSPITAL MANAGEMENT AND OUTCOMES OF ACUTE CORONARY SYNDROMES IN RELATION TO PRIOR HISTORY OF HEART FAILURE. Can J Cardiol 2014. [DOI: 10.1016/j.cjca.2014.07.612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Tan N, Goodman S, Yan R, Tan M, Fox K, Gore J, Brieger D, Steg P, Langer A, Yan A. PROGNOSTIC SIGNIFICANCE OF LOW QRS VOLTAGE ON THE ADMISSION ELECTROCARDIOGRAM IN ACUTE CORONARY SYNDROMES. Can J Cardiol 2014. [DOI: 10.1016/j.cjca.2014.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Lee D, Goodman S, Fox K, DeYoung J, Lai C, Bhatt D, Huynh T, Yan R, Gallo R, Steg P, Yan A. 119 Prognostic Significance of Presenting Blood Pressure in Non-ST Elevation Acute Coronary Syndromes in Relation to Prior History of Hypertension. Can J Cardiol 2012. [DOI: 10.1016/j.cjca.2012.07.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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22
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Ademi Z, Liew D, Hollingsworth B, Steg P, Bhatt D, Reid C. Cost Effectiveness of Aspirin Among Participants with Atherothrombotic Disease in Australian General Practice, Using “Real World” Data from the Australian REACH Registry. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Maillard L, Ziol M, Tahlil O, Le Feuvre C, Feldman LJ, Branellec D, Bruneval P, Steg P. Pre-treatment with elastase improves the efficiency of percutaneous adenovirus-mediated gene transfer to the arterial media. Gene Ther 1998; 5:1023-30. [PMID: 10326024 DOI: 10.1038/sj.gt.3300682] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The endothelium and internal elastic lamina (IEL) appear to be the main barriers to adenovirus-mediated gene transfer to medial smooth muscle cells (SMC). The present randomized study tested whether controlled incubation with elastase enhanced the efficiency of catheter-based gene transfer to medial SMC by adenoviral vectors. After an initial safety dose ranging study, rabbits underwent balloon abrasion of the iliac endothelium followed by local incubation of either elastase (2 x 10(-7) IU over 5 min) or saline using a double balloon catheter (DBC). Then, adenoviral vectors (5 x 10(9) p.f.u.) carrying Cmv-Luc or RSV-beta gal reporter genes were instilled for 30 min. Three days later, the number of medial SMC expressing lacZ was increased in the elastase-treated arteries compared with saline-treated arteries (7.2 +/- 2.5 versus 2.3 +/- 0.9 cells per section, P = 0.003). Likewise, the amount of luciferase protein product was increased (70 +/- 32 versus 36 +/- 15 pg luciferase/mg tissue, P = 0.03). No vessel enlargement, light or electron microscopic evidence of injury or inflammation was seen in elastase-treated arteries up to 7 weeks. Preincubation with elastase increased transduction efficiency of catheter-based gene delivery of replication-defective adenoviral vectors to rabbit iliac arteries without detectable arterial damage.
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Affiliation(s)
- L Maillard
- Unité Physiopathologie du Coeur et des Artères, Faculté Bichat, Paris
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Steg P. Should we Stent all the Patients? Preliminary Answer From the Multicenter Randomized FROST Study. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(97)85092-9] [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: 11/30/2022]
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