Differences in outcomes in patients with stable coronary artery disease managed by cardiologists versus noncardiologists. Results from the international prospective CLARIFY registry

INTRODUCTION    Clinical outcomes of patients with stable coronary artery disease (CAD) may differ between those primarily managed by cardiologists versus noncardiologists. OBJECTIVES    Our main objective was to analyze the clinical outcomes of outpatients with stable CAD in relation to the specialty of the managing physicians. PATIENTS AND METHODS    We studied 32 468 outpatients with stable CAD included in the CLARIFY registry, with up to 4 years of follow‑up data. Cardiologists provided medical care in 84.1% and noncardiologists in 15.9% of the patients. Primary outcome was the composite of cardiovascular death, nonfatal myocardial infarction (MI), or stroke. RESULTS    Important differences in management as well as demographic and clinical characteristics were observed between the groups at baseline. Patients treated by cardiologists were younger and more of them had dyslipidemia, hypertension, and diabetes. The use of β‑blockers and thienopyridines, as well as history of percutaneous coronary intervention were more frequent in this group. More patients treated by noncardiologists had a history of MI as well as concomitant peripheral artery disease and asthma or chronic obstructive pulmonary disease. They also had lower left ventricular ejection fraction and more often received lipid‑lowering drugs. After adjustment for baseline differences, patients treated by cardiologists had a lower risk of the primary outcome (adjusted hazard ratio, 0.80; 95% confidence interval, 0.68–0.94; P = 0.0067) and of most secondary outcomes, but greater risk of bleeding. CONCLUSIONS Outpatients with stable CAD managed by cardiologists had a lower rate of cardiovascular outcomes than those managed by noncardiologists. We did not find clear evidence that cardiologists provided superior guideline‑based treatment, so the differences in outcome were most likely due to unquantifiable differences in patient characteristics.

Rationale and design of Apo-I Event Reduction in Ischemic Syndromes I (AEGIS-I): A phase 2b, randomized, placebo-controlled, dose-ranging trial to investigate the safety and tolerability of CSL112, a reconstituted, infusible, human apoA-I, after acute myocardial infarction

BACKGROUND

Despite aggressive pharmacotherapy and stenting, there is a residual risk of major adverse cardiovascular events among patients with acute coronary syndrome. High-density lipoprotein (HDL) has been a major target for secondary acute coronary syndrome prevention; however, a better understanding of the physiologic function of HDL has demonstrated that a high cholesterol efflux capacity, rather than high HDL concentrations alone, may be critical to improving outcomes. CSL112, a reconstituted, infusible human apolipoprotein A-I, has been demonstrated to increase cholesterol efflux capacity and to have a protective effect in experimental models of atherosclerotic cardiovascular disease.

DESIGN

The AEGIS-I trial (ClinicalTrials.govNCT02108262) is a phase 2b, multicenter, randomized, placebo-controlled, dose-ranging clinical trial to evaluate the hepatic and renal safety of multiple administrations of 2 doses of CSL112 among subjects with acute myocardial infarction (AMI). Approximately 1,200 subjects (400 per treatment group) with either normal renal function or mild renal impairment will be enrolled up to 7 days after an AMI and will be stratified by renal function and randomized in a 1:1:1 ratio to either 1 of 2 doses of CSL112 (either 2 g or 6 g) or placebo as a weekly 2-hour infusion over the course of 4 consecutive weeks. The coprimary safety endpoints will be the incidence of hepatic and renal toxicity, defined as either confirmed ALT >3 × ULN, total bilirubin >2 × ULN, serum creatinine ≥1.5×baseline value, or a new requirement for renal replacement therapy through the end of the active treatment period.

SUMMARY

The AEGIS-I trial will characterize the safety profile of CSL112, a reconstituted formulation of apolipoprotein A-I, and will assess if administration to patients with a recent AMI is associated with a clinically significant alteration in either liver or kidney function when compared with placebo.

Prognostic impact of non-compliance with guidelines-recommended times to reperfusion therapy in ST-elevation myocardial infarction. The FAST-MI 2010 registry

AIMS

Current guidelines recommend short time delays from qualifying ECG to reperfusion therapy in ST-elevation myocardial infarction (STEMI) patients. Recently, however, it has been suggested that shortening door-to-balloon times might not result in lower mortality, thereby questioning the relevance of current guidelines. The aim of this study was to assess in-hospital and one-year mortality in patients with fibrinolysis or primary percutaneous coronary intervention (PPCI) according to guidelines-recommended times to reperfusion therapy.

METHODS AND RESULTS

FAST-MI 2010 is a nationwide French registry including 4169 patients, of whom 1580 had ST-elevation myocardial infarction and had PPCI ( n=1289) or fibrinolysis ( n=291) as part of a pharmaco-invasive strategy. Four groups were constituted: Gr1 (within recommended times from ECG to PPCI; n=708), Gr2 (beyond recommended times from ECG to PPCI; n=581), Gr3 (time from ECG to lysis ⩽30 min, n=196), and Gr4 (time from ECG to lysis >30 min, n=95). In-hospital mortality was 3.6% in Gr2 vs. 1.0% in Gr1 and 3.2% in Gr4 vs. 1.0% in Gr3. After adjustment, hospital mortality was higher for reperfusion therapy beyond recommended times: odds ratio (OR) 3.29, 95% confidence interval (CI) 1.32-8.18; for PPCI, OR: 4.13; 95% CI: 1.50-11.35 and for fibrinolysis, OR: 2.72; 95% CI: 0.34-21.96. Likewise, one-year mortality was higher in patients with reperfusion beyond recommended times (hazard ratio 2.13, 95% CI:1.29-3.50). The results were confirmed by propensity score analyses.

CONCLUSIONS

Early and one-year mortality were lower for ST-elevation myocardial infarction patients when the recommended timelines for reperfusion therapy were met, suggesting that, in spite of recent interrogations, compliance with current guidelines remains a clinically relevant objective.

Editor's Choice-Medically managed patients with non-ST-elevation acute myocardial infarction have heterogeneous outcomes, based on performance of angiography and extent of coronary artery disease

BACKGROUND

Medically managed individuals represent a high-risk group among patients with non-ST-elevation acute myocardial infarction (NSTE-AMI). We hypothesized that prognosis in this group is heterogeneous, depending on whether medical management was decided with or without coronary angiography (CAG).

METHODS

Using data from the French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction (FAST-MI), we analysed data from 798 patients with NSTE-AMI who were medically managed (i.e. without revascularization during the index hospitalization). Patients were categorized according to the performance of CAG and, if performed, to the extent of coronary artery disease (CAD).

RESULTS

There were marked differences in baseline demographics, according to whether CAG was performed and to the extent of CAD. While the overall mortality rate at five years was high (56.2%), it differed greatly between groups, with patients who did not undergo CAG having a higher mortality rate (77.4%) than patients who underwent CAG (36.7%, p<0.001), and a higher mortality rate even than patients with multivessel CAD (54.2%, p<0.001). By multivariable analysis, non-performance of CAG was an independent predictor of all-cause mortality among medically managed NSTE-AMI patients (adjusted hazard ratios (95% confidence intervals) 3.19 (1.79-5.67) at 30 days, 2.28 (1.60-3.26) at one year, and 1.63 (1.28-2.07) at five years; all p<0.001).

CONCLUSION

Medically managed patients with NSTE-AMI are a heterogeneous group in terms of baseline characteristics and outcomes. The highest risk patients are those who do not undergo CAG. Non-performance of CAG is a strong predictor of death. (FAST-MI, NCT00673036).

Multicenter randomized controlled trial on Duration of Therapy for Thrombosis in Children and Young Adults (the Kids-DOTT trial): pilot/feasibility phase findings

BACKGROUND

Randomized controlled trials (RCTs) on pediatric venous thromboembolism (VTE) treatment have been challenged by unsubstantiated design assumptions and/or poor accrual. Pilot/feasibility (P/F) studies are critical to future RCT success.

METHODS

The Kids-DOTT trial is a multicenter RCT investigating non-inferiority of a 6-week (shortened) versus 3-month (conventional) duration of anticoagulation in patients aged < 21 years with provoked venous thrombosis. Primary efficacy and safety endpoints are symptomatic recurrent VTE at 1 year and anticoagulant-related, clinically relevant bleeding. In the P/F phase, 100 participants were enrolled in an open, blinded-endpoint, parallel-cohort RCT design.

RESULTS

No eligibility violations or randomization errors occurred. Of the enrolled patients, 69% were randomized, 3% missed the randomization window, and 28% were followed in prespecified observational cohorts for completely occlusive thrombosis or persistent antiphospholipid antibodies. Retention at 1 year was 82%. Interobserver agreement between local and blinded central determination of venous occlusion by imaging at 6 weeks after diagnosis was strong (k-statistic = 0.75; 95% confidence interval [CI] 0.48-1.0). The primary efficacy and safety event rates were 3.3% (95% CI 0.3-11.5%) and 1.4% (95% CI 0.03-7.4%).

CONCLUSIONS

The P/F phase of the Kids-DOTT trial has demonstrated the validity of vascular imaging findings of occlusion as a randomization criterion, and defined randomization, retention and endpoint rates to inform the fully powered RCT.

ST-segment resolution with bivalirudin versus heparin and routine glycoprotein IIb/IIIa inhibitors started in the ambulance in ST-segment elevation myocardial infarction patients transported for primary percutaneous coronary intervention: The EUROMAX ST-segment resolution substudy

BACKGROUND

Myocardial reperfusion after primary percutaneous coronary intervention (PCI) can be assessed by the extent of post-procedural ST-segment resolution. The European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) trial compared pre-hospital bivalirudin and pre-hospital heparin or enoxaparin with or without GPIIb/IIIa inhibitors (GPIs) in primary PCI. This nested substudy was performed in centres routinely using pre-hospital GPI in order to compare the impact of randomized treatments on ST-resolution after primary PCI.

METHODS

Residual cumulative ST-segment deviation on the single one hour post-procedure electrocardiogram (ECG) was assessed by an independent core laboratory and was the primary endpoint. It was calculated that 762 evaluable patients were needed to show non-inferiority (85% power, alpha 2.5%) between randomized treatments.

RESULTS

A total of 871 participated with electrocardiographic data available in 824 patients (95%). Residual ST-segment deviation one hour after PCI was 3.8±4.9 mm versus 3.9±5.2 mm for bivalirudin and heparin+GPI, respectively ( p=0.0019 for non-inferiority). Overall, there were no differences between randomized treatments in any measures of ST-segment resolution either before or after the index procedure.

CONCLUSIONS

Pre-hospital treatment with bivalirudin is non-inferior to pre-hospital heparin + GPI with regard to residual ST-segment deviation or ST-segment resolution, reflecting comparable myocardial reperfusion with the two strategies.

The cost implications of an early versus delayed invasive strategy in Acute Coronary Syndromes: the TIMACS study

BACKGROUND

The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial demonstrated that early invasive intervention (within 24 hours) was similar to a delayed approach (after 36 hours) overall but improved outcomes were seen in patients at high risk. However, the cost implications of an early versus delayed invasive strategy are unknown.

METHODS AND RESULTS

A third-party perspective of direct cost was chosen and United States Medicare costs were calculated using average diagnosis related grouping (DRG) units. Direct medical costs included those of the index hospitalization (including clinical, procedural and hospital stay costs) as well as major adverse cardiac events during 6 months of follow-up. Sensitivity and sub-group analyses were performed. The average total cost per patient in the early intervention group was lower compared with the delayed intervention group (-$1170; 95% CI -$2542 to $202). From the bootstrap analysis (5000 replications), the early invasive approach was associated with both lower costs and better clinical outcomes regarding death/myocardial infarction (MI)/stroke in 95.1% of the cases (dominant strategy). In high-risk patients (GRACE score ≥141), the net reduction in cost was greatest (-$3720; 95% CI -$6270 to -$1170). Bootstrap analysis revealed 99.8% of cases were associated with both lower costs and better clinical outcomes (death/MI/stroke).

LIMITATIONS

We were unable to evaluate the effect of community care and investigations without hospitalization (office visits, non-invasive testing, etc). Medication costs were not captured. Indirect costs such as loss of productivity and family care were not included.

CONCLUSIONS

An early invasive management strategy is as effective as a delayed approach and is likely to be less costly in most patients with acute coronary syndromes.

Patient education after acute myocardial infarction: cardiologists should adapt their message--French registry of acute ST-elevation or non-ST-elevation myocardial infarction 2010 registry

AIMS

A shorter time delay between onset of symptoms and first call for medical attention would be expected in patients with a history of ischemic heart disease (IHD). We aimed to determine whether time to first call for an ST-elevation myocardial infarction (STEMI) differed between patients with or without history of coronary artery disease from the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) 2010 registry.

METHODS

FAST-MI 2010 is a nationwide French registry that included 4169 patients with acute myocardial infarction (AMI, 2193 STEMI) at the end of 2010 in 213 centers. Factors correlated with time to first call were assessed, with a specific emphasis on previous history of IHD (IHD+; n = 402), compared with patients without history of IHD (IHD-; n = 1791).

RESULTS

Time from onset to first call was 222 ± 420 min (median time 68 min) in IHD+ patients versus 240 ± 4423 min (median time 75 min) in IHD- patients (P = 0.28). In multivariate analysis, only a few factors were significantly related to a shorter time from onset to first call (≤75min); time of onset during the day (7:00 a.m. to 11:00 p.m.), upper socioeconomic class, anterior MI, cardiac arrest as the initial symptom, whereas history of IHD was not associated with a shorter time delay (odds ratio 0.86; 95% confidence interval 0.70-1.05). Similar results were found between patients with previous AMI and IHD- patients.

CONCLUSION

Patients with a history of IHD do not call earlier than IHD-naïve patients when they are confronted with symptoms of AMI. Cardiologists should spend more time educating their coronary patients to recognize symptoms of AMI.Clinicaltrials.gov identifier: NCT01237418.

Safety and efficacy of drug-eluting stents in women: a patient-level pooled analysis of randomised trials

BACKGROUND

The safety and efficacy of drug-eluting stents (DES) in the treatment of coronary artery disease have been assessed in several randomised trials. However, none of these trials were powered to assess the safety and efficacy of DES in women because only a small proportion of recruited participants were women. We therefore investigated the safety and efficacy of DES in female patients during long-term follow-up.

METHODS

We pooled patient-level data for female participants from 26 randomised trials of DES and analysed outcomes according to stent type (bare-metal stents, early-generation DES, and newer-generation DES). The primary safety endpoint was a composite of death or myocardial infarction. The secondary safety endpoint was definite or probable stent thrombosis. The primary efficacy endpoint was target-lesion revascularisation. Analysis was by intention to treat.

FINDINGS

Of 43,904 patients recruited in 26 trials of DES, 11,557 (26·3%) were women (mean age 67·1 years [SD 10·6]). 1108 (9·6%) women received bare-metal stents, 4171 (36·1%) early-generation DES, and 6278 (54·3%) newer-generation DES. At 3 years, estimated cumulative incidence of the composite of death or myocardial infarction occurred in 132 (12·8%) women in the bare-metal stent group, 421 (10·9%) in the early-generation DES group, and 496 (9·2%) in the newer-generation DES group (p=0·001). Definite or probable stent thrombosis occurred in 13 (1·3%), 79 (2·1%), and 66 (1·1%) women in the bare-metal stent, early-generation DES, and newer-generation DES groups, respectively (p=0·01). The use of DES was associated with a significant reduction in the 3 year rates of target-lesion revascularisation (197 [18·6%] women in the bare-metal stent group, 294 [7·8%] in the early-generation DES group, and 330 [6·3%] in the newer-generation DES group, p<0·0001). Results did not change after adjustment for baseline characteristics in the multivariable analysis.

INTERPRETATION

The use of DES in women is more effective and safe than is use of bare-metal stents during long-term follow-up. Newer-generation DES are associated with an improved safety profile compared with early-generation DES, and should therefore be thought of as the standard of care for percutaneous coronary revascularisation in women.

FUNDING

Women in Innovation Initiative of the Society of Cardiovascular Angiography and Interventions.