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Cappato R, Mark DB, Silverstein AP, Noseworthy PA, Bonitta G, Poole JE, Piccini JP, Bahnson TD, Daniels MR, Al-Khalidi HR, Lee KL, Packer DL. Regional differences in outcomes with ablation versus drug therapy for atrial fibrillation: Results from the CABANA trial. Am Heart J 2024; 270:103-116. [PMID: 38307365 PMCID: PMC11070931 DOI: 10.1016/j.ahj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The finding of unexpected variations in treatment benefits by geographic region in international clinical trials raises complex questions about the interpretation and generalizability of trial findings. We observed such geographical variations in outcome and in the effectiveness of atrial fibrillation (AF) ablation versus drug therapy in the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial. This paper describes these differences and investigates potential causes. METHODS The examination of treatment effects by geographic region was a prespecified analysis. CABANA enrolled patients from 10 countries, with 1,285 patients at 85 North American (NA) sites and 919 at 41 non-NA sites. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Death and first atrial fibrillation recurrence were secondary endpoints. RESULTS At least 1 primary endpoint event occurred in 157 patients (12.2%) from NA and 33 (3.6%) from non-NA sites over a median 54.9 and 40.5 months of follow-up, respectively (NA/non-NA adjusted hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.48-3.21, P < .001). In NA patients, 78 events occurred in the ablation and 79 in the drug arm, (HR 0.91, 95% CI 0.66, 1.24) while 11 and 22 events occurred in non-NA patients (HR 0.51, 95% CI 0.25,1.05, interaction P = .154). Death occurred in 53 ablation and 51 drug therapy patients in the NA group (HR 0.96, 95% CI 0.65,1.42) and in 5 ablation and 16 drug therapy patients in the non-NA group (HR 0.32, 95% CI 0.12,0.86, interaction P = .044). Adjusting for baseline regional differences or prognostic risk variables did not account for the regional differences in treatment effects. Atrial fibrillation recurrence was reduced by ablation in both regions (NA: HR 0.54, 95% CI 0.46, 0.63; non-NA: HR 0.44, 95% CI 0.30, 0.64, interaction P = .322). CONCLUSIONS In CABANA, primary outcome events occurred significantly more often in the NA group but assignment to ablation significantly reduced all-cause mortality in the non-NA group only. These differences were not explained by regional variations in procedure effectiveness, safety, or patient characteristics. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0091150; https://clinicaltrials.gov/study/NCT00911508.
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Affiliation(s)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC.
| | | | | | - Gianluca Bonitta
- L'altra Statistica Consultancy and Training, Biostatistics Office, Roma, Italy
| | | | | | | | | | | | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, NC
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2
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Li G, Quan H, Wang Y. Regional consistency assessment in multiregional clinical trials. J Biopharm Stat 2024:1-13. [PMID: 38557292 DOI: 10.1080/10543406.2024.2330214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Multiregional clinical trials (MRCTs) have become a favored strategy for new drug development. The accurate evaluation of treatment effects across different regions is crucial for interpreting the results of MRCTs. Consistency between regional and overall results ensures the extrapolability of the overall conclusions to individual regions. While numerous statistical methods have been proposed for consistency assessment, a notable proportion necessitate a substantial escalation in sample size, particularly in scenarios involving more than four regions within MRCTs. This, paradoxically, undermines the fundamental intent of MRCTs. In addition, standardized statistical criteria for concluding consistency are yet to be established. In this paper, we develop further consistency assessment approaches in the framework of two multivariate likelihood ratio test-based methods, namely mLRTa and mLRTb, wherein consistency is cast as the alternative and null hypotheses. Notably, our exploration unveils that qualitative methods such as the funnel approach and PMDA methods are special instances of mLRTa. Furthermore, our work underscores that these three qualitative methodologies roughly share the same level of assurance probability (AP). Intriguingly, when the number of regions in an MRCT surpasses five, even when the overall sample size guarantees a power of 90% or more and the true treatment effects remain uniform across regions, the AP remains below the 70% mark. Drawing from our meticulous examination of operational attributes, we recommend mLRTa with positive treatment effects in all regions in the alternative hypothesis with significance level 0.5 or mLRTb with all regional treatment effects being equal in the null and significance level of 0.2.
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Affiliation(s)
- Gang Li
- Global Medical Affairs, Eisai, Inc, Nutley, New Jersey, USA
| | - Hui Quan
- Biostatistics & Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Yining Wang
- Statistical Programming, Janssen Research & Development, Raritan, New Jersey, USA
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3
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Butler J, Khan MS, Fonarow GC. The Need for Global Optimization of Heart Failure Therapy: Some Differences Do Not Matter. J Am Coll Cardiol 2023; 82:1027-1029. [PMID: 37610399 DOI: 10.1016/j.jacc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA.
| | | | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA
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Wilson BE, Pearson SA, Barton MB, Amir E. Regional Variations in Clinical Trial Outcomes in Oncology. J Natl Compr Canc Netw 2022; 20:879-886.e2. [PMID: 35948036 DOI: 10.6004/jnccn.2022.7029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is unknown how often regional differences in oncology trials are observed. Based on our study findings, we quantified regional variation in registration studies in oncology and developed a question guide to help clinicians evaluate regional differences. METHODS Using FDA archives, we identified registration studies in solid tumor malignancies from 2010 to 2020. We extracted the baseline study characteristics and participating countries and determined whether the primary publication reported a regional subgroup analysis. For studies presenting outcomes stratified by region, we extracted the stratified hazard ratios (HRs) and extracted or calculated the test for heterogeneity. We performed a random effects meta-analysis and a pairwise comparison to determine whether outcomes differed between high-income versus mixed-income regions. RESULTS We included 147 studies in our final analysis. Studies supporting FDA drug approval have become increasingly multinational over time (β = 0.5; P=.04). The median proportion of countries from high-income groups was 81.2% (range, 44%-100%), with no participation from low-income countries in our cohort. Regional subgroup analysis was presented for 78 studies (53%). Regional heterogeneity was found in 17.8% (8/45) and 18% (8/44) of studies presenting an overall survival (OS) and progression-free survival endpoint, respectively. After grouping regions by income level, we found no difference in OS outcomes in high-income regions compared with mixed-income regions (n=20; HR, 0.95; 95% CI, 0.84-1.07). To determine whether regional variation is genuine, clinicians should evaluate the data according to the following 5 questions: (1) Are the regional groupings logical? (2) Is the regional difference on an absolute or relative scale? (3) Is the regional difference consistent and plausible? (4) Is the regional difference statistically significant? (5) Is there a clinical explanation? CONCLUSIONS As registration studies in oncology become increasingly international, regional variations in trial outcomes may be detected. The question guide herein will help clinicians determine whether regional variations are likely to be clinically meaningful or statistical anomalies.
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Affiliation(s)
- Brooke E Wilson
- Collaboration for Cancer Outcomes, Research and Evaluation, South West Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.,Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW, Sydney, Australia; and.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Michael B Barton
- Collaboration for Cancer Outcomes, Research and Evaluation, South West Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Eitan Amir
- Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
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5
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Snapinn S. A shrinkage estimator for subgroup analysis without the exchangeability assumption. J Biopharm Stat 2022; 31:723-735. [PMID: 35129420 DOI: 10.1080/10543406.2021.1998101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Shrinkage estimators for exploratory subgroup analyses are intuitively appealing and can greatly improve estimation over standard analysis approaches; however, adoption of these estimators has been limited by reliance on the exchangeability assumption. This paper describes a new shrinkage estimator that does not rely on this assumption. Rather than assuming that treatment effect sizes within subgroups are randomly distributed around an overall mean, this new estimator assumes that the difference between the effect sizes in any given pair of subgroups is randomly distributed around zero. The estimator is illustrated using data from a clinical trial in which the treatment effect size in one region was substantially different from the sizes in other regions. Simulation results show that the estimator has properties that are comparable to or superior to a standard shrinkage estimator when exchangeability is assumed, while allowing the flexibility to handle situations where exchangeability cannot be assumed.
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Affiliation(s)
- Steven Snapinn
- Seattle-Quilcene Biostatistics LLC, Seattle, Washington, USA
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Kaneko S, Hirakawa A. Assessment of Overall Treatment Effect in the Presence of Inconsistent Regional Effects in Multiregional Clinical Trials. Stat Biopharm Res 2020. [DOI: 10.1080/19466315.2020.1845233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Shuhei Kaneko
- Biostatistics Pharma, Integrated Biostatistics Japan, Clinical Development & Analytics Japan, Global Drug Development Division, Novartis Pharma K.K., Minato-ku, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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Progress in heart failure management in the Netherlands and beyond: long-term commitment to deliver high-quality research and patient care. Neth Heart J 2020; 28:31-38. [PMID: 32780329 PMCID: PMC7419384 DOI: 10.1007/s12471-020-01453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Heart failure (HF) remains a major global problem. In the Netherlands, 1.5–2.0% of the total population is diagnosed with HF. Over 30,000 HF patients are admitted annually in the Netherlands, and this number is expected to further increase given the ageing population and the chronic nature of HF. Despite ongoing efforts to reduce the burden of HF, morbidity and mortality rates of this disease remain high. However, several new treatment modalities have become available or are expected to become available in the coming years. This review will provide an overview of HF research conducted in the Netherlands (often in an international setting) that may have clinical consequences for diagnosis, treatment and prevention of HF, and will also evaluate outcomes of larger clinical trials that have been conducted in the Netherlands.
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Fors A, Wallbing U, Alfvén G, Kemani MK, Lundberg M, Wigert H, Nilsson S. Effects of a person‐centred approach in a school setting for adolescents with chronic pain—The HOPE randomized controlled trial. Eur J Pain 2020; 24:1598-1608. [DOI: 10.1002/ejp.1614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/31/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Andreas Fors
- Institute of Health and Care Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Centre for Person‐Centred Care (GPCC) University of GothenburgSahlgrenska AcademyUniversity of Gothenburg Sweden
- Närhälsan Research and Development Primary Health Care Region Västra Götaland Sweden
| | - Ulrika Wallbing
- Institute of Health and Care Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Neurobiology, Care Sciences and Society Division of Physiotherapy Karolinska Institute Huddinge Sweden
| | | | - Mike K. Kemani
- Department of Clinical Neuroscience (CNS) Stockholm Sweden
- Medical Unit Medical Psychology Section Behavioral Medicine Karolinska University Hospital Stockholm Sweden
- Stress Research InstituteStockholm University Stockholm Sweden
| | - Mari Lundberg
- Centre for Person‐Centred Care (GPCC) University of GothenburgSahlgrenska AcademyUniversity of Gothenburg Sweden
- Department of Neurobiology, Care Sciences and Society Division of Physiotherapy Karolinska Institute Huddinge Sweden
- Institute of Neuroscience and Physiology Department of Health and Rehabilitation Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Helena Wigert
- Institute of Health and Care Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Centre for Person‐Centred Care (GPCC) University of GothenburgSahlgrenska AcademyUniversity of Gothenburg Sweden
- Division of Neonatology Sahlgrenska University Hospital Gothenburg Sweden
| | - Stefan Nilsson
- Institute of Health and Care Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Centre for Person‐Centred Care (GPCC) University of GothenburgSahlgrenska AcademyUniversity of Gothenburg Sweden
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Ravn-Fischer A, Perers E, Karlsson T, Caidahl K, Hartford M. Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome. Cardiology 2019; 143:22-31. [PMID: 31352455 DOI: 10.1159/000501166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/24/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated. OBJECTIVES To assess long-term mortality and explore its association with the baseline variables in women and men. METHODS We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months. RESULTS At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05-1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78-1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76-0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender. CONCLUSION For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.
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Affiliation(s)
- Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Perers
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Karlsson
- Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kenneth Caidahl
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden.,Karolinska Institutet, Stockholm, Sweden
| | - Marianne Hartford
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden,
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, Piña IL. Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update. Circulation 2019; 140:e294-e324. [PMID: 31167558 DOI: 10.1161/cir.0000000000000691] [Citation(s) in RCA: 298] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, PiÑa IL. Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America. J Card Fail 2019; 25:584-619. [PMID: 31174952 DOI: 10.1016/j.cardfail.2019.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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12
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Li G, Quan H, Lan G, Ouyang SP, Chen F, Robieson W, Wang W, Binkowitz B, Yuan SS, Tanaka Y, Chen J, Matsuoka N, Zhang L, Yang S, Gallo P. Lessons Learned From Multi-regional Trials With Signals of Treatment Effect Heterogeneity. Ther Innov Regul Sci 2018. [DOI: 10.1177/2168479018805428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gang Li
- Janssen R&D US, Raritan, NJ, USA
| | | | | | | | - Fei Chen
- Janssen R&D US, Raritan, NJ, USA
| | | | - William Wang
- Merck Research Laboratories, Kendall Park, NJ, USA
| | | | | | | | | | | | | | - Song Yang
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Paul Gallo
- Novartis Pharmaceuticals, East Hanover, NJ, USA
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13
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Some Recent Advances on Statistical Approaches for Planning Multi-regional Clinical Trials. STATISTICS IN BIOSCIENCES 2018. [DOI: 10.1007/s12561-017-9196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Ofstad AP, Atar D, Gullestad L, Langslet G, Johansen OE. The heart failure burden of type 2 diabetes mellitus-a review of pathophysiology and interventions. Heart Fail Rev 2018; 23:303-323. [PMID: 29516230 PMCID: PMC5937871 DOI: 10.1007/s10741-018-9685-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes and heart failure (HF) are both global epidemics with tremendous costs on society with increased rates of HF hospitalizations and worsened prognosis when co-existing, making it a significant "deadly duo." The evidence for pharmacological treatment of HF in patients with type 2 diabetes mellitus (T2DM) stems typically from either subgroup analyses of patients that were recruited to randomized controlled trials of HF interventions, usually in patients with reduced ejection fraction (EF), or from subgroup analyses of HF patients recruited to cardiovascular (CV) outcome trials (CVOT) of glucose lowering agents involving patients with T2DM. Studies in patients with HF with preserved EF are sparse. This review summarizes the literature on pathophysiology and interventions aiming to reduce the HF burden in T2DM and includes HF trials of ACEi, digoxin, β-blocker, ARB, If-blocker, MRA, and ARNI involving 38,600 patients, with or without prevalent diabetes, and CV outcome trials in T2DM involving 74,351 patients, with or without prevalent HF. In all HF trials, HF outcomes by prevalent diabetes were reported with an incremental risk of HF and death confessed by prevalent diabetes and a treatment effect similar to those without diabetes. All T2DM CVOTs reported on HF outcomes with heterogeneity between trials with two reporting benefits (empagliflozin and canagliflozin) and two reporting increased risk (saxagliptin, pioglitazone). In vulnerable T2DM patients with concomitant HF, guideline-recommended HF drugs are effective. When choosing glucose-lowering therapy, outcomes from available CVOTs should be considered.
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Affiliation(s)
- Anne Pernille Ofstad
- Bærum Hospital, Vestre Viken HF, Rud, Norway.
- Medical Department, Boehringer Ingelheim, Asker, Norway.
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Gisle Langslet
- Rikshospitalet, Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Bærum Hospital, Vestre Viken HF, Rud, Norway
- Medical Department, Boehringer Ingelheim, Asker, Norway
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15
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Jhund PS. Analysing registries in heart failure: The case of angiotensin receptor blockers in Asians with heart failure with reduced ejection fraction. Int J Cardiol 2018; 257:224-225. [PMID: 29506698 DOI: 10.1016/j.ijcard.2018.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/15/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
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Sullivan LT, Randolph T, Merrill P, Jackson LR, Egwim C, Starks MA, Thomas KL. Representation of black patients in randomized clinical trials of heart failure with reduced ejection fraction. Am Heart J 2018; 197:43-52. [PMID: 29447783 DOI: 10.1016/j.ahj.2017.10.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Black individuals have a disproportionately higher burden of heart failure with reduced ejection fraction (HFrEF) relative to other racial and ethnic populations. We conducted a systematic review to determine the representation, enrollment trends, and outcomes of black patients in historic and contemporary randomized clinical trials (RCTs) for HFrEF. METHODS We searched PubMed and Embase for RCTs of patients with chronic HFrEF that evaluated therapies that significantly improved clinical outcomes. We extracted trial characteristics and compared them by trial type. Linear regression was used to assess trends in enrollment among HFrEF RCTs over time. RESULTS A total of 25 RCTs, 19 for pharmacotherapies and 6 (n=9,501) for implantable cardioverter defibrillators, were included in this analysis. Among these studies, there were 78,816 patients, 4,640 black (5.9%), and the median black participation per trial was 162 patients. Black race was reported in the manuscript of 14 (56.0%) trials, and outcomes by race were available for 12 (48.0%) trials. Implantable cardiac defibrillator trials enrolled a greater percentage of black patients than pharmacotherapy trials (7.1% vs 5.7%). Overall, patient enrollment among the 25 RCTs increased over time (P = .075); however, the percentage of black patients has decreased (P = .001). Outcomes varied significantly between black and white patients in 6 studies. CONCLUSIONS Black patients are modestly represented among pivotal RCTs of individuals with HFrEF for both pharmacotherapies and implantable cardioverter defibrillators. The current trend for decreasing black representation in trials of HF therapeutics is concerning and must improve to ensure the generalizability for this vulnerable population.
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Abstract
We are now entering the very exciting era of treatment and management of diabetes mellitus (DM) with the emergence of new therapeutic agents, including sodium-glucose cotransporter 2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitor (DPP-4i). From a cardiology and echocardiography perspective, the existence of diabetic cardiomyopathy has been proven through over four decades of discussion. DM is highly prevalent in patients with heart failure (HF). Independent associations are found after adjusting for hypertension (HTN) and coronary artery disease (CAD). In patients with both DM and HF, the prognosis is extremely dismal. In this review, the main focus is on both diabetic cardiomyopathy per se and its typical features (including myocardial additive insult related to DM), diagnosis, and management.
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Affiliation(s)
- Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.,Royal Hobart Hospital, Hobart, Australia
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Aronson D. Subgroup analyses with special reference to the effect of antiplatelet agents in acute coronary syndromes. Thromb Haemost 2017; 112:16-25. [DOI: 10.1160/th13-09-0801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/29/2014] [Indexed: 11/05/2022]
Abstract
SummaryControlled trials estimate treatment effects averaged over the reference population of subjects. However, physicians are interested in whether the treatment effect varies across subgroups (effect heterogeneity) in order to target specific subgroups to maximise the benefit of treatment and minimise harm. Therefore, large clinical trials of antiplatelet agents include subgroup analyses that examine whether treatment effects differ between subgroups of subjects identified by baseline characteristics. Reporting subgroup is pervasive and often accompanied by claims of difference of treatment effects between subgroups with potential important implications for clinical practice. However, subgroup-specific analyses of clinical trial data have inherent limitations that reduce their reliability. These include reduced statistical power, failure to specify the subgroups of interest a priori, failure to account for examining large numbers of subgroups, lack of strong rationale for biological response modification, and performing analyses based on variables measured post randomisation or in trials showing no overall difference between treatments. Rules for interpretation of subgroup findings in subgroups have been suggested but are frequently not applied. In this article we draw attention to the pitfalls of subgroup analyses in the context of recent trials of antiplatelet agents.
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Quan H, Mao X, Tanaka Y, Binkowitz B, Li G, Chen J, Zhang J, Zhao PL, Ouyang SP, Chang M. Example-based illustrations of design, conduct, analysis and result interpretation of multi-regional clinical trials. Contemp Clin Trials 2017; 58:13-22. [PMID: 28455233 DOI: 10.1016/j.cct.2017.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/04/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
Extensive research has been conducted in the Multi-Regional Clinical Trial (MRCT) area. To effectively apply an appropriate approach to a MRCT, we need to synthesize and understand the features of different approaches. In this paper, examples are used to illustrate considerations regarding design, conduct, analysis and interpretation of result of MRCTs. We start with a brief discussion of region definitions and the scenarios where different regions have differing requirements for a MRCT. We then compare different designs and models as well as the corresponding interpretation of the results. We highlight the importance of paying special attention to trial monitoring and conduct to prevent potential issues associated with the final trial results. Besides evaluating the overall treatment effect for the entire MRCT, we also consider other key analyses including quantification of regional treatment effects within a MRCT, and assessment of consistency of these regional treatment effects.
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Affiliation(s)
- Hui Quan
- Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, United States.
| | - Xuezhou Mao
- Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, United States
| | - Yoko Tanaka
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285, United States
| | - Bruce Binkowitz
- Merck and Co. Inc., 200 Galloping Hill Road, Kenilworth, NJ 07033, United States
| | - Gang Li
- Janssen R&D US, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, United States
| | - Josh Chen
- Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, United States
| | - Ji Zhang
- Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, United States
| | - Peng-Liang Zhao
- Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, United States
| | - Soo Peter Ouyang
- SPO Consulting LLC4, Inverness Drive, Kendall Park, NJ 08824, United States
| | - Mark Chang
- Veristat, 118 Turnpike Road, Southborough, MA 01772, United States
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20
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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] [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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21
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Tanaka Y, Buchanan A, Lipsius S, Ibia EO, Rabbia M, Binkowitz B. Defining Regions in Multiregional Clinical Trials: An Analytical Approach to Considering Impact of Intrinsic and Extrinsic Factors. Ther Innov Regul Sci 2016; 50:91-100. [DOI: 10.1177/2168479015604183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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22
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Affiliation(s)
- Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (S.Y.); and Statistics Collaborative, Washington, DC (J.W.)
| | - Janet Wittes
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (S.Y.); and Statistics Collaborative, Washington, DC (J.W.)
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23
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Affiliation(s)
- David L DeMets
- From the Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison (D.L.D.); and the Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.S.E.)
| | - Susan S Ellenberg
- From the Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison (D.L.D.); and the Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.S.E.)
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24
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Zannad F, Ferreira JP. Globalization of heart failure trials: no turning back on this paradigm. Eur Heart J 2016; 37:3175-3177. [DOI: 10.1093/eurheartj/ehw326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Fors A, Gyllensten H, Swedberg K, Ekman I. Effectiveness of person-centred care after acute coronary syndrome in relation to educational level: Subgroup analysis of a two-armed randomised controlled trial. Int J Cardiol 2016; 221:957-62. [PMID: 27441475 DOI: 10.1016/j.ijcard.2016.07.060] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/04/2016] [Indexed: 11/24/2022]
Abstract
AIM The aim of this study was to evaluate the effects of person-centred care (PCC) after acute coronary syndrome (ACS) in relation to educational level of participants. METHOD 199 Patients <75years with ACS were randomised to PCC plus usual care or usual care alone and followed for 6months from hospital to outpatient care and primary care. For the PCC group, patients and health care professionals co-created a PCC health plan reflecting both perspectives, which induced a continued collaboration in person-centred teams at each health care level. A composite score of changes that included general self-efficacy assessment, return to work or previous activity level, re-hospitalisation or death was used as outcome measure. RESULTS In the group of patients without postsecondary education (n=90) the composite score showed a significant improvement in favour of the PCC intervention (n=40) vs. usual care (n=50) at six months (35.0%, n=14 vs. 16.0%, n=8; odds ratio (OR)=2.8, 95% confidence interval (CI): 1.0-7.7, P=0.041). In patients with postsecondary education (n=109), a non-significant difference in favour of the PCC intervention (n=54) vs. usual care (n=55) was observed in the composite score (13.0%, n=7 vs 3.6%, n=2; OR=3.9, 95% CI: 0.8-19.9, P=0.097). CONCLUSION A PCC approach, which stresses the necessity of a patient-health care professional partnership, is beneficial in patients with low education after an ACS event. Because these patients have been identified as a vulnerable group in cardiac rehabilitation, we suggest that PCC can be integrated into conventional cardiac rehabilitation programmes to improve both equity in uptake and health outcomes. TRIAL REGISTRATION Swedish registry, Researchweb.org, ID NR 65 791.
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Affiliation(s)
- Andreas Fors
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden; Närhälsan Research and Development, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. http://www.gpcc.gu.se
| | - Karl Swedberg
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; National Heart and Lung Institute, Imperial College, London, United Kingdom. http://www.gpcc.gu.se
| | - Inger Ekman
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden. http://www.gpcc.gu.se
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26
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Kristensen SL, Martinez F, Jhund PS, Arango JL, Bĕlohlávek J, Boytsov S, Cabrera W, Gomez E, Hagège AA, Huang J, Kiatchoosakun S, Kim KS, Mendoza I, Senni M, Squire IB, Vinereanu D, Wong RCC, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR, Packer M, McMurray JJV. Geographic variations in the PARADIGM-HF heart failure trial. Eur Heart J 2016; 37:3167-3174. [PMID: 27354044 PMCID: PMC5106574 DOI: 10.1093/eurheartj/ehw226] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/07/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022] Open
Abstract
Aims The globalization of clinical trials has highlighted geographic variations in patient characteristics, event rates, and treatment effects. We investigated these further in PARADIGM-HF, the largest and most globally representative trial in heart failure (HF) to date. Methods and results We looked at five regions: North America (NA) 602 (8%), Western Europe (WE) 1680 (20%), Central/Eastern Europe/Russia (CEER) 2762 (33%), Latin America (LA) 1433 (17%), and Asia-Pacific (AP) 1487 (18%). Notable differences included: WE patients (mean age 68 years) and NA (65 years) were older than AP (58 years) and LA (63 years) and had more coronary disease; NA and CEER patients had the worst signs, symptoms, and functional status. North American patients were the most likely to have a defibrillating-device (54 vs. 2% AP) and least likely prescribed a mineralocorticoid receptor antagonist (36 vs. 65% LA). Other evidence-based therapies were used most frequently in NA and WE. Rates of the primary composite outcome of cardiovascular (CV) death or HF hospitalization (per 100 patient-years) varied among regions: NA 13.6 (95% CI 11.7–15.7) WE 9.6 (8.6–10.6), CEER 12.3 (11.4–13.2), LA 11.2 (10.0–12.5), and AP 12.5 (11.3–13.8). After adjustment for prognostic variables, relative to NA, the risk of CV death was higher in LA and AP and the risk of HF hospitalization lower in WE. The benefit of sacubitril/valsartan was consistent across regions. Conclusion There were many regional differences in PARADIGM-HF, including in age, symptoms, comorbidity, background therapy, and event-rates, although these did not modify the benefit of sacubitril/valsartan. Clinical trial registration URL http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
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Affiliation(s)
- Søren Lund Kristensen
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK .,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Felipe Martinez
- Emeritus Professor of Medicine, Universidad Nacional of Cordoba, Cordoba, Argentina
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Jan Bĕlohlávek
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital and 1st Medical School, Charles University in Prague, Prague, Czech Republic
| | - Sergey Boytsov
- National Research Center for Preventive Medicine, Moscow, Russia
| | | | | | - Albert A Hagège
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Cardiologie ; Paris Descartes University, Sorbonne Paris Cité ; INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Jun Huang
- First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | | | - Kee-Sik Kim
- Daegu Catholic University Hospital, Daegu, Korea
| | - Iván Mendoza
- Venezuela Instituto Tropical Medicine Universidad Central Venezuela, Caracas, Venezuela
| | - Michele Senni
- Azienda Ospedaliera Papa Giovanni XXIII, Cardiologia 1 - Scompenso e Trapianti di Cuore, Bergamo, Italy
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila - University and Emergency Hospital, Bucharest, Romania
| | | | - Jianjian Gong
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor C Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | - Karl Swedberg
- University of Gothenburg, Gothenburg, Sweden .,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
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27
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Bristow MR, Enciso JS, Gersh BJ, Grady C, Rice MM, Singh S, Sopko G, Boineau R, Rosenberg Y, Greenberg BH. Detection and Management of Geographic Disparities in the TOPCAT Trial: Lessons Learned and Derivative Recommendations. ACTA ACUST UNITED AC 2016; 1:180-189. [PMID: 27747305 PMCID: PMC5065247 DOI: 10.1016/j.jacbts.2016.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial) was a multinational clinical trial of 3,445 heart failure with preserved ejection fraction patients that enrolled in 233 sites in 6 countries in North America, Eastern Europe, and South America. Patients with a heart failure hospitalization in the last 12 months or an elevated B-type natriuretic peptide were randomized to the mineralocorticoid receptor antagonist spironolactone versus placebo. Sites in Russia and the Republic of Georgia provided the majority of early enrollment, primarily based on the hospitalization criterion because B-type natriuretic peptide levels were initially unavailable there. With the emergence of country-specific aggregate event rate data indicating lower rates in Eastern Europe and differences in patient characteristics there, the Data Safety and Monitoring Board recommended relatively increasing enrollment in North America plus other corrective measures. Although final enrollment reflected the increased contribution from North America, a plurality of the final cohort came from Russia and Georgia (49% vs. 43% in North America). B-type natriuretic peptide measurements from Russia and Georgia, available later in the trial, suggested no or a mild level of heart failure consistent with low event rates. The primary results showed no significant spironolactone treatment effect overall (primary endpoint hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.77 to 1.04), with a significant hazard ratio in North and South America (HR: 0.82; 95% CI: 0.69 to 0.98; p = 0.026) but not in Russia and Georgia (HR: 1.10; 95% CI: 0.79 to 1.51; interaction p = 0.12). This report describes the Data Safety and Monitoring Board’s detection and management recommendations for regional differences in patient characteristics in TOPCAT and suggests methods of surveillance and corrective actions that may be useful for future trials. (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial [TOPCAT]; NCT00094302)
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Affiliation(s)
- Michael R Bristow
- Cardiovascular Institute, University of Colorado, Boulder and Aurora, CO
| | | | | | - Christine Grady
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD
| | | | | | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Robin Boineau
- Office of Clinical and Regulatory Affairs, National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
| | - Yves Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, MD
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28
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Packer M. Unbelievable Folly of Clinical Trials in Heart Failure. Circ Heart Fail 2016; 9:e002837. [DOI: 10.1161/circheartfailure.116.002837] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/05/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
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Wolf A, Fors A, Ulin K, Thorn J, Swedberg K, Ekman I. An eHealth Diary and Symptom-Tracking Tool Combined With Person-Centered Care for Improving Self-Efficacy After a Diagnosis of Acute Coronary Syndrome: A Substudy of a Randomized Controlled Trial. J Med Internet Res 2016; 18:e40. [PMID: 26907584 PMCID: PMC4783584 DOI: 10.2196/jmir.4890] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/29/2015] [Accepted: 01/04/2016] [Indexed: 12/05/2022] Open
Abstract
Background Patients with cardiovascular diseases managed by a person-centered care (PCC) approach have been observed to have better treatment outcomes and satisfaction than with traditional care. eHealth may facilitate the often slow transition to more person-centered health care by increasing patients’ beliefs in their own capacities (self-efficacy) to manage their care trajectory. eHealth is being increasingly used, but most studies continue to focus on health care professionals’ logic of care. Knowledge is lacking regarding the effects of an eHealth tool on self-efficacy when combined with PCC for patients with chronic heart diseases. Objective The objective of our study was to investigate the effect of an eHealth diary and symptom-tracking tool in combination with PCC for patients with acute coronary syndrome (ACS). Methods This was a substudy of a randomized controlled trial investigating the effects of PCC in patients hospitalized with ACS. In total, 199 patients with ACS aged <75 years were randomly assigned to a PCC intervention (n=94) or standard treatment (control group, n=105) and were followed up for 6 months. Patients in the intervention arm could choose to use a Web-based or mobile-based eHealth tool, or both, for at least 2 months after hospital discharge. The primary end point was a composite score of changes in general self-efficacy, return to work or prior activity level, and rehospitalization or death 6 months after discharge. Results Of the 94 patients in the intervention arm, 37 (39%) used the eHealth tool at least once after the index hospitalization. Most of these (24/37, 65%) used the mobile app and not the Web-based app as the primary source of daily self-rating input. Patients used the eHealth tool a mean of 38 times during the first 8 weeks (range 1–118, SD 33) and 64 times over a 6-month period (range 1–597, SD 104). Patients who used the eHealth tool in combination with the PCC intervention had a 4-fold improvement in the primary end point compared with the control group (odds ratio 4.0, 95% CI 1.5–10.5; P=.005). This improvement was driven by a significant increase in general self-efficacy compared with the control group (P=.011). Patients in the PCC group who did not use the eHealth tool (n=57) showed a nonsignificant composite score improvement compared with those in the control group (n=105) (odds ratio 2.0, 95% CI 0.8–5.2; P=.14). Conclusions We found a significant effect on improved general self-efficacy and the composite score for patients using an eHealth diary and symptom-tracking tool in combination with PCC compared with traditional care. Trial Registration Swedish registry, Researchweb.org, ID NR 65 791.
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Affiliation(s)
- Axel Wolf
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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30
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Guo H, Chen J, Quan H. Evaluation of local treatment effect by borrowing information from similar countries in multi-regional clinical trials. Stat Med 2015; 35:671-84. [DOI: 10.1002/sim.6815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 09/16/2015] [Accepted: 10/28/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Hua Guo
- Department of Statistics Sciences; Allergan Inc.; Jersey City NJ 07311 U.S.A
| | - Joshua Chen
- Biostatistics; Sanofi Pasteur; Swiftwater PA 18370 U.S.A
| | - Hui Quan
- Biostatistics and Programming; Sanofi; Bridgewater NJ 08807 U.S.A
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31
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Daka B, Olausson J, Larsson CA, Hellgren MI, Råstam L, Jansson PA, Lindblad U. Circulating concentrations of endothelin-1 predict coronary heart disease in women but not in men: a longitudinal observational study in the Vara-Skövde Cohort. BMC Cardiovasc Disord 2015; 15:146. [PMID: 26573599 PMCID: PMC4647275 DOI: 10.1186/s12872-015-0141-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/02/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The vasoconstricting peptide endothelin-1 has been proposed to be a marker of cardiovascular disease. Our aim was to investigate whether circulating endothelin-1 levels predict coronary heart disease (CHD) in Sweden. METHODS In 2002-2005, 2816 adult participants (30-74 years) were randomly selected from two municipalities in south-western Sweden. Cardiovascular risk factors and endothelin-1 levels were assessed at baseline, and incident CHD was followed-up in all participants through 2011. After exclusion of 50 participants due to known CHD at baseline and 21 participants because of unsuccessful analysis of endothelin-1, 2745 participants were included in the study. In total, 72 CHD events (52 in men and 20 in women) were registered during the follow-up time. RESULTS We showed that baseline circulating endothelin-1 levels were higher in women with incident CHD than in women without CHD (3.2 pg/ml, SE: 0.36 vs 2.4 pg/ml, SE: 0.03, p = 0.003) whereas this difference was not observed in men (2.3 pg/ml, SE: 0.16 vs 2.3 pg/ml, SE: 0.04, p = 0.828). An age-adjusted Cox proportional regression analysis showed an enhanced risk of CHD with increasing baseline endothelin-1 levels in women (hazard ratio (HR) = 1.51, 95 % CI = 1.1-2.1, p = 0.015) but not in men (HR = 0.98, 95 % CI = 0.8-1.2, p = 0.854). Furthermore, the predictive value of endothelin-1 for incident CHD in women was still significant after adjustments for age, HOMA-IR, apolipoprotein (apo)B/apoA1 and smoking (HR = 1.53, CI = 1.1-1.2, p = 0.024). CONCLUSION Circulating endothelin-1 levels may predict CHD in women.
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Affiliation(s)
- Bledar Daka
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, S-405 30, Gothenburg, Sweden.
| | - Josefin Olausson
- Department of Molecular and Clinical Medicine, The Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Charlotte A Larsson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, S-405 30, Gothenburg, Sweden. .,Department of Clinical Sciences, Social Medicine and Global Health, Lund University, Malmö, Sweden.
| | - Margareta I Hellgren
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, S-405 30, Gothenburg, Sweden.
| | - Lennart Råstam
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.
| | - Per-Anders Jansson
- Department of Molecular and Clinical Medicine, The Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Ulf Lindblad
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, S-405 30, Gothenburg, Sweden.
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Daka B, Langer RD, Larsson CA, Rosén T, Jansson PA, Råstam L, Lindblad U. Low concentrations of serum testosterone predict acute myocardial infarction in men with type 2 diabetes mellitus. BMC Endocr Disord 2015; 15:35. [PMID: 26209521 PMCID: PMC4514972 DOI: 10.1186/s12902-015-0034-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of the present study was to investigate the associations between endogenous testosterone concentrations and the incidence of acute myocardial infarction (AMI) in men and women with and without type 2 diabetes. METHODS The study comprised 1109 subjects ≥40 years of age (mean age 62 ± 12 years) participating in a baseline survey in Sweden in 1993-94. Information about smoking habits and physical activity was obtained using validated questionnaires. Serum concentrations of testosterone and sex hormone-binding globulin (SHBG) were obtained using radioimmunoassay. Diagnosis of type 2 diabetes was based on WHO's 1985 criteria. Individual patient information on incident AMI was ascertained by record linkage with national inpatient and mortality registers from baseline through 2011. RESULTS The prevalence of type 2 diabetes at baseline was 10.0% in men and 7.5% in women. During a mean follow-up of 14.1 years (±5.3), there were 74 events of AMI in men and 58 in women. In age-adjusted Cox models, a significant inverse association between concentrations of testosterone and AMI-morbidity was found in men with type 2 diabetes (HR = 0.86 CI (0.75-0.98)). In a final model also including waist-to-hip ratio, systolic blood pressure, total cholesterol and active smoking, the association still remained statistically significant (HR = 0.754 CI (0.61-0.92)). CONCLUSION Low concentrations of testosterone predicted AMI in men with type 2 diabetes independent of other risk factors. Trials with testosterone investigating the effect regarding cardiovascular outcome are still lacking. Future trials in this field should take into account a modification effect of diabetes.
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Affiliation(s)
- Bledar Daka
- Department of Public Health and Community Medicine/Primary Health Care, University of Gothenburg, Gothenburg, Sweden.
| | - Robert D Langer
- University of Nevada School of Medicine, Las Vegas, NV, USA.
| | | | - Thord Rosén
- Department of Endocrinology, Medicine, Göteborg, Sweden.
| | | | - Lennart Råstam
- Department of Clinical Sciences, Community Medicine, Lund, Sweden.
| | - Ulf Lindblad
- Department of Public Health and Community Medicine/Primary Health Care, University of Gothenburg, Gothenburg, Sweden.
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Abstract
Randomized controlled trials (RCTs) are essential to develop advances in heart failure (HF). The need for increasing numbers of patients (without substantial cost increase) and generalization of results led to the disappearance of international boundaries in large RCTs. The significant geographic differences in patients' characteristics, outcomes, and, most importantly, treatment effect observed in HF trials have recently been highlighted. Whether the observed regional discrepancies in HF trials are due to trial-specific issues, patient heterogeneity, structural differences in countries, or a complex interaction between factors are the questions we propose to debate in this review. To do so, we will analyse and review data from HF trials conducted in different world regions, from heart failure with preserved ejection fraction (HF-PEF), heart failure with reduced ejection fraction (HF-REF), and acute heart failure (AHF). Finally, we will suggest objective and actionable measures in order to mitigate regional discrepancies in future trials, particularly in HF-PEF where prognostic modifying treatments are urgently needed and in which trials are more prone to selection bias, due to a larger patient heterogeneity.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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Person-centred care after acute coronary syndrome, from hospital to primary care - A randomised controlled trial. Int J Cardiol 2015; 187:693-9. [PMID: 25919754 DOI: 10.1016/j.ijcard.2015.03.336] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/19/2015] [Accepted: 03/21/2015] [Indexed: 12/17/2022]
Abstract
AIM To evaluate if person-centred care can improve self-efficacy and facilitate return to work or prior activity level in patients after an event of acute coronary syndrome. METHOD 199 patients with acute coronary syndrome < 75 years were randomly assigned to person-centred care intervention or treatment as usual and followed for 6 months. In the intervention group a person-centred care process was added to treatment as usual, emphasising the patient as a partner in care. Care was co-created in collaboration between patients, physicians, registered nurses and other health care professionals and documented in a health plan. A team-based partnership across three health care levels included transparent knowledge about the disease and medical state to achieve agreed goals during recovery. Main outcome measure was a composite score of changes in general self-efficacy ≥ 5 units, return to work or prior activity level and re-hospitalisation or death. RESULTS The composite score showed that more patients (22.3%, n=21) improved in the intervention group at 6 months compared to the control group (9.5%, n=10) (odds ratio, 2.7; 95% confidence interval: 1.2-6.2; P=0.015). The effect was driven by improved self-efficacy ≥ 5 units in the intervention group. Overall general self-efficacy improved significantly more in the intervention group compared with the control group (P=0.026). There was no difference between groups on re-hospitalisation or death, return to work or prior activity level. CONCLUSION A person-centred care approach emphasising the partnership between patients and health care professionals throughout the care chain improves general self-efficacy without causing worsening clinical events.
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Pfeffer MA, Claggett B, Assmann SF, Boineau R, Anand IS, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Heitner JF, Lewis EF, O'Meara E, Rouleau JL, Probstfield JL, Shaburishvili T, Shah SJ, Solomon SD, Sweitzer NK, McKinlay SM, Pitt B. Regional variation in patients and outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. Circulation 2014; 131:34-42. [PMID: 25406305 DOI: 10.1161/circulationaha.114.013255] [Citation(s) in RCA: 639] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) patients with heart failure and preserved left ventricular ejection fraction assigned to spironolactone did not achieve a significant reduction in the primary composite outcome (time to cardiovascular death, aborted cardiac arrest, or hospitalization for management of heart failure) compared with patients receiving placebo. In a post hoc analysis, an ≈4-fold difference was identified in this composite event rate between the 1678 patients randomized from Russia and Georgia compared with the 1767 enrolled from the United States, Canada, Brazil, and Argentina (the Americas). METHODS AND RESULTS To better understand this regional difference in clinical outcomes, demographic characteristics of these populations and their responses to spironolactone were explored. Patients from Russia/Georgia were younger, had less atrial fibrillation and diabetes mellitus, but were more likely to have had prior myocardial infarction or a hospitalization for heart failure. Russia/Georgia patients also had lower left ventricular ejection fraction and creatinine but higher diastolic blood pressure (all P<0.001). Hyperkalemia and doubling of creatinine were more likely and hypokalemia was less likely in patients receiving spironolactone in the Americas with no significant treatment effects in Russia/Georgia. All clinical event rates were markedly lower in Russia/Georgia, and there was no detectable impact of spironolactone on any outcomes. In contrast, in the Americas, the rates of the primary outcome, cardiovascular death, and hospitalization for heart failure were significantly reduced by spironolactone. CONCLUSIONS This post hoc analysis demonstrated greater potassium and creatinine changes and possible clinical benefits with spironolactone in patients with heart failure and preserved ejection fraction from the Americas. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
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Affiliation(s)
- Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.).
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Susan F Assmann
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Robin Boineau
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Inder S Anand
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nadine Clausell
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Akshay S Desai
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Rafael Diaz
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jerome L Fleg
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Ivan Gordeev
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - John F Heitner
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Eldrin F Lewis
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Eileen O'Meara
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jean-Lucien Rouleau
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Jeffrey L Probstfield
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Tamaz Shaburishvili
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Sanjiv J Shah
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Scott D Solomon
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nancy K Sweitzer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Sonja M McKinlay
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Bertram Pitt
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Inc, Watertown, MA (S.F.A., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F.); VA Medical Center and University of Minnesota, Minneapolis, MN (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow, Russia (I.G.); New York Methodist Hospital, Brooklyn, NY (J.F.H.); Montreal Heart Institute, Montreal, QC, Canada (E.O., J.L.R.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago, IL (S.J.S.); University of Wisconsin, Madison (N.K.S.); and University of Michigan School of Medicine, Ann Arbor (B.P.)
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Kristensen SL, Køber L, Jhund PS, Solomon SD, Kjekshus J, McKelvie RS, Zile MR, Granger CB, Wikstrand J, Komajda M, Carson PE, Pfeffer MA, Swedberg K, Wedel H, Yusuf S, McMurray JJV. International geographic variation in event rates in trials of heart failure with preserved and reduced ejection fraction. Circulation 2014; 131:43-53. [PMID: 25406306 DOI: 10.1161/circulationaha.114.012284] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND International geographic differences in outcomes may exist for clinical trials of heart failure and reduced ejection fraction (HF-REF), but there are few data for those with preserved ejection fraction (HF-PEF). METHODS AND RESULTS We analyzed outcomes by international geographic region in the Irbesartan in Heart Failure with Preserved systolic function trial (I-Preserve), the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM)-Preserved trial, the CHARM-Alternative and CHARM-Added HF-REF trials, and the Controlled Rosuvastatin Multinational Trial in HF-REF (CORONA). Crude rates of heart failure hospitalization varied by geographic region, and more so for HF-PEF than for HF-REF. Rates in patients with HF-PEF were highest in the United States/Canada (HF hospitalization rate 7.6 per 100 patient-years in I-Preserve; 8.8 in CHARM-Preserved), intermediate in Western Europe (4.8/100 and 4.7/100), and lowest in Eastern Europe/Russia (3.3/100 and 2.8/100). The difference between the United States/Canada versus Eastern Europe/Russia persisted after adjustment for key prognostic variables: adjusted hazard ratios 1.34 (95% confidence interval, 1.01-1.74; P=0.04) in I-Preserve and 1.85 (95% confidence interval, 1.17-2.91; P=0.01) in CHARM-Preserved. In HF-REF, rates of HF hospitalization were slightly lower in Western Europe compared with other regions. For both HF-REF and HF-PEF, there were few regional differences in rates of all-cause or cardiovascular mortality. CONCLUSIONS The differences in event rates observed suggest there is international geographic variation in 1 or more of the definition and diagnosis of HF-PEF, the risk profile of patients enrolled, and the threshold for hospitalization, which has implications for the conduct of future global trials.
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Affiliation(s)
- Søren L Kristensen
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Lars Køber
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Pardeep S Jhund
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Scott D Solomon
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John Kjekshus
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Robert S McKelvie
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Michael R Zile
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Christopher B Granger
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John Wikstrand
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Michel Komajda
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Peter E Carson
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Marc A Pfeffer
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Karl Swedberg
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Hans Wedel
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - Salim Yusuf
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.)
| | - John J V McMurray
- From the BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom (S.L.K., P.S.J., J.J.V.M.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (S.L.K.); Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (L.K.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.D.S., M.A.P.); the Department of Cardiology, Rikshospitalet, University of Oslo, Oslo, Norway (J.K.); Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (R.S.M., S.Y.); Ralph H. Johnsons Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, SC (M.R.Z.); Duke Clinical Research Institute, Duke University Medical Centre, Durham, NC (C.B.G.); Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (J.W.); Université Paris 6 and Hospital Pitié-Salpétrière, Paris, France (M.K.); Georgetown University and Washington DC Veterans Affairs Medical Center, Washington, DC (P.E.C.); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (K.S.); and Nordic School of Public Health, Gothenburg, Sweden (H.W.).
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Schou IM, C Marschner I. Methods for exploring treatment effect heterogeneity in subgroup analysis: an application to global clinical trials. Pharm Stat 2014; 14:44-55. [PMID: 25376518 DOI: 10.1002/pst.1656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 10/09/2014] [Accepted: 10/15/2014] [Indexed: 11/09/2022]
Abstract
Multi-country randomised clinical trials (MRCTs) are common in the medical literature, and their interpretation has been the subject of extensive recent discussion. In many MRCTs, an evaluation of treatment effect homogeneity across countries or regions is conducted. Subgroup analysis principles require a significant test of interaction in order to claim heterogeneity of treatment effect across subgroups, such as countries in an MRCT. As clinical trials are typically underpowered for tests of interaction, overly optimistic expectations of treatment effect homogeneity can lead researchers, regulators and other stakeholders to over-interpret apparent differences between subgroups even when heterogeneity tests are insignificant. In this paper, we consider some exploratory analysis tools to address this issue. We present three measures derived using the theory of order statistics, which can be used to understand the magnitude and the nature of the variation in treatment effects that can arise merely as an artefact of chance. These measures are not intended to replace a formal test of interaction but instead provide non-inferential visual aids, which allow comparison of the observed and expected differences between regions or other subgroups and are a useful supplement to a formal test of interaction. We discuss how our methodology differs from recently published methods addressing the same issue. A case study of our approach is presented using data from the Study of Platelet Inhibition and Patient Outcomes (PLATO), which was a large cardiovascular MRCT that has been the subject of controversy in the literature. An R package is available that implements the proposed methods.
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Affiliation(s)
- I Manjula Schou
- Department of Statistics, Macquarie University, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
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Kitsche A. Detecting qualitative interactions in clinical trials with binary responses. Pharm Stat 2014; 13:309-15. [PMID: 25049176 DOI: 10.1002/pst.1632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 03/21/2014] [Accepted: 06/23/2014] [Indexed: 11/07/2022]
Abstract
This study considers the detection of treatment-by-subset interactions in a stratified, randomised clinical trial with a binary-response variable. The focus lies on the detection of qualitative interactions. In addition, the presented method is useful more generally, as it can assess the inconsistency of the treatment effects among strata by using an a priori-defined inconsistency margin. The methodology presented is based on the construction of ratios of treatment effects. In addition to multiplicity-adjusted p-values, simultaneous confidence intervals are recommended to use in detecting the source and the amount of a potential qualitative interaction. The proposed method is demonstrated on a multi-regional trial using the open-source statistical software R.
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Affiliation(s)
- Andreas Kitsche
- Institut für Biostatistik, Leibniz Universität Hannover, Herrenhäuser Straße 2, Hannover, Germany
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Go YY, Allen JC, Chia SY, Sim LL, Jaufeerally FR, Yap J, Ching CK, Sim D, Kwok B, Liew R. Predictors of mortality in acute heart failure: interaction between diabetes and impaired left ventricular ejection fraction. Eur J Heart Fail 2014; 16:1183-9. [DOI: 10.1002/ejhf.119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 03/09/2014] [Accepted: 05/02/2014] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yun Yun Go
- Department of Cardiology; National Heart Centre Singapore; Singapore
| | | | | | | | | | - Jonathan Yap
- Department of Cardiology; National Heart Centre Singapore; Singapore
| | - Chi Keong Ching
- Department of Cardiology; National Heart Centre Singapore; Singapore
| | - David Sim
- Department of Cardiology; National Heart Centre Singapore; Singapore
| | - Bernard Kwok
- Department of Cardiology; National Heart Centre Singapore; Singapore
| | - Reginald Liew
- Duke-NUS Graduate Medical School Singapore; Singapore
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Quan H, Mao X, Chen J, Shih WJ, Ouyang SP, Zhang J, Zhao PL, Binkowitz B. Multi-regional clinical trial design and consistency assessment of treatment effects. Stat Med 2014; 33:2191-205. [DOI: 10.1002/sim.6108] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 01/14/2014] [Accepted: 01/16/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Hui Quan
- Biostatistics and Programming, Sanofi; Bridgewater NJ 08807, U.S.A
| | - Xuezhou Mao
- Biostatistics and Programming, Sanofi; Bridgewater NJ 08807, U.S.A
| | - Joshua Chen
- Biostatistics and Research Decision Science, Merck Research Laboratories; Rahway NJ 07065, U.S.A
| | - Weichung Joe Shih
- Department of Biostatistics, School of Public Health, Rutgers; Piscataway NJ 08854, U.S.A
| | | | - Ji Zhang
- Biostatistics and Programming, Sanofi; Bridgewater NJ 08807, U.S.A
| | - Peng-Liang Zhao
- Biostatistics and Programming, Sanofi; Bridgewater NJ 08807, U.S.A
| | - Bruce Binkowitz
- Biostatistics and Research Decision Science, Merck Research Laboratories; Rahway NJ 07065, U.S.A
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Wang SJ, Hung HMJ. A Regulatory Perspective on Essential Considerations in Design and Analysis of Subgroups When Correctly Classified. J Biopharm Stat 2014; 24:19-41. [DOI: 10.1080/10543406.2013.856022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sue-Jane Wang
- a Office of Biostatistics, OTS/CDER , Food and Drug Administration , Silver Spring , Maryland , USA
| | - H. M. James Hung
- b Division of Biometrics I, OB/OTS/CDER , Food and Drug Administration , Silver Spring , Maryland , USA
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Chen J, Zheng H, Quan H, Li G, Gallo P, Ouyang SP, Binkowitz B, Ting N, Tanaka Y, Luo X, Ibia E. Graphical assessment of consistency in treatment effect among countries in multi-regional clinical trials. Clin Trials 2013; 10:842-51. [DOI: 10.1177/1740774513500387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background One key objective of a multi-regional clinical trial (MRCT) is to use the trial results to ‘bridge’ from the global level to local region in support of local registrations. However, data from each individual country are typically limited and the large number of countries will increase the chance of false positive findings. Purpose Graphical tools to facilitate identification of potential outlying countries could be useful for country-level assessment. Existing methods such as funnel plot and expected range of treatment effect can substantially increase the false positive rate. The expected range approach can also have a very low power when there are a large number of small countries, which is typical in a MRCT. Methods In this article, we apply normal probability plots, commonly used as a diagnostic tool in linear regression analysis, to assess the differences among countries. Evidence of possible inconsistency, which incorporates both the estimated treatment effect and sample size, is plotted against its expected order statistic. Results A simulation study is conducted to assess the impact of the negative correlation among residuals due to unequal sample sizes among countries and the performance of the proposed methods compared to existing approaches. The proposed methods tend to have a balanced consideration with substantially smaller false positive rate and reasonable probability to identify outlying countries in realistic scenarios. Limitations While much lower than that of commonly used methods, the false positive rates of the proposed methods are not strictly controlled. This may be acceptable for these graphical tools with intention to flag potential outliers for investigation. Conclusions We recommend routine use of normal probability plots in MRCTs as a tool to identify potential outliers. If the normal probability plot is approximately linear but has heavy tails with a few outlying countries, these potential outliers should be examined carefully to understand the possible reasons.
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Affiliation(s)
- Joshua Chen
- Merck Research Laboratories, Rahway, NJ, USA
| | - Hao Zheng
- Department of Statistics, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Gang Li
- Johnson & Johnson, Raritan, NJ, USA
| | | | | | | | | | | | | | - Ekopimo Ibia
- Merck Research Laboratories, Washington, DC, USA
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Bartos JA, Francis GS. The High-Risk Patient With Heart Failure With Reduced Ejection Fraction: Treatment Options and Challenges. Clin Pharmacol Ther 2013; 94:509-18. [DOI: 10.1038/clpt.2013.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/08/2013] [Indexed: 12/17/2022]
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Regulatory and Scientific Issues Regarding Use of Foreign Data in Support of New Drug Applications in the United States: An FDA Perspective. Clin Pharmacol Ther 2013; 94:230-42. [DOI: 10.1038/clpt.2013.70] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/28/2013] [Indexed: 11/09/2022]
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Pocock S, Calvo G, Marrugat J, Prasad K, Tavazzi L, Wallentin L, Zannad F, Alonso Garcia A. International differences in treatment effect: do they really exist and why?†. Eur Heart J 2013; 34:1846-52. [DOI: 10.1093/eurheartj/eht071] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hypertension management in the high cardiovascular risk population. Int J Hypertens 2013; 2013:382802. [PMID: 23476746 PMCID: PMC3580899 DOI: 10.1155/2013/382802] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/26/2012] [Indexed: 01/13/2023] Open
Abstract
The incidence of hypertension is increasing every year. Blood pressure (BP) control is an important therapeutic goal for the slowing of progression as well as for the prevention of Cardiovascular disease. The management of hypertension in the high cardiovascular risk population remains a real challenge as the population continues to age, the incidence of diabetes increases, and more and more people survive acute myocardial infarction. We will review hypertension management in the high cardiovascular risk population: patients with coronary heart disease (CHD) and heart failure (HF) as well as in diabetic patients.
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Ohishi M. Potential Factors Influencing Regional Differences and Similarities in Multiregional Clinical Trials. ACTA ACUST UNITED AC 2012. [DOI: 10.1177/0092861512443747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Mentz RJ, Kaski JC, Dan GA, Goldstein S, Stockbridge N, Alonso-Garcia A, Ruilope LM, Martinez FA, Zannad F, Pitt B, Fiuzat M, O'Connor CM. Implications of geographical variation on clinical outcomes of cardiovascular trials. Am Heart J 2012; 164:303-12. [PMID: 22980295 DOI: 10.1016/j.ahj.2012.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
Abstract
Cardiovascular clinical trials are increasingly conducted globally as a means to reduce costs, expedite timelines, provide broad applicability, and satisfy regulatory authorities. Potential problems with trial globalization include regional differences in patient characteristics, medical practice patterns, and health policies which may influence outcomes and limit generalizability. Moreover, concerns have been raised about ethical misconduct and unsatisfactory quality oversight in regions with less trial experience and infrastructure. This article reviews geographical differences in cardiovascular trials in heart failure, acute coronary syndromes, hypertension and atrial fibrillation. It also explores potential explanations for these differences and methods to standardize the presentation of trial results. This review is based on discussions between basic scientists and clinical trialists at the 8th Global Cardio Vascular Clinical Trialists Forum 2011 in Paris, France, from December 2 to 3.
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Abstract
Background This article addresses a problem arising when a trial shows such strong evidence of benefit of the tested intervention that it stops early with an observed effect size for the experimental treatment that is statistically significantly better than the control. Within the classical frequentist framework of group sequential trials, the observed estimated effect size, the associated naïve confidence interval, and the p-value are all biased estimates of the true values. The bias is in the direction of the overestimation of the treatment effect, creation of narrower confidence intervals than appropriate, and a p-value that is too small. Purpose To discuss methods for correcting the bias in observed effect sizes, confidence intervals, and p-values for trials stopped early and to show the extent to which such correction would have modified the conclusions of the Randomized Aldactone Evaluation Study (RALES). Results In RALES, the effect of not correcting for bias is negligible. Limitations This article does not show general results; it only explores a few examples that use conservative methods for early stopping. It does not consider sequential methods that allow a relatively high probability of stopping early. Conclusions This article points out that there is no unique solution to the correction of the p-value, but it recommends stagewise ordering, which states that earlier stopping of a trial is ipso facto stronger evidence of effect than later stopping so long as the stopping is governed by a monitoring boundary that preserves the Type I error rate. Associated with stagewise ordering is a method for calculating the estimated effect size and its confidence interval. In the RALES trial, which stopped at 50% information time, the corrections to the estimated values are small.
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Affiliation(s)
- Janet Wittes
- Statistics Collaborative, Inc., Washington, DC, USA
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50
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Quan H, Li M, Shih WJ, Ouyang SP, Chen J, Zhang J, Zhao PL. Empirical shrinkage estimator for consistency assessment of treatment effects in multi-regional clinical trials. Stat Med 2012; 32:1691-706. [PMID: 22855311 DOI: 10.1002/sim.5543] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 06/11/2012] [Indexed: 11/06/2022]
Abstract
Multi-regional clinical trials have been widely used for efficient global new drug developments. Both a fixed-effect model and a random-effect model can be used for trial design and data analysis of a multi-regional clinical trial. In this paper, we first compare these two models in terms of the required sample size, type I error rate control, and the interpretability of trial results. We then apply the empirical shrinkage estimation approach based on the random-effect model to two criteria of consistency assessment of treatment effects across regions. As demonstrated in our computations, compared with the sample estimator, the shrinkage estimator of the treatment effect of an individual region borrowing information from the other regions is much closer to the estimator of the overall treatment effect, has smaller variability, and therefore provides much higher probability for demonstrating consistency. We use a multinational trial example with time to event endpoint to illustrate the application of the method.
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Affiliation(s)
- Hui Quan
- Biostatistics and Programming, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, U.S.A.
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