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Brockmeyer M, Parco C, Vargas KG, Westenfeld R, Jung C, Kelm M, Roden M, Akbulut C, Schlesinger S, Wolff G, Kuss O. Absolute treatment effects of novel antidiabetic drugs on a composite renal outcome: meta-analysis of digitalized individual patient data. J Nephrol 2024; 37:309-321. [PMID: 38236473 PMCID: PMC11043149 DOI: 10.1007/s40620-023-01858-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Absolute treatment benefits-expressed as numbers needed to treat-of the glucose lowering and cardiovascular drugs, glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose transporter 2 (SGLT2) inhibitors on renal outcomes remain uncertain. With the present meta-analysis of digitalized individual patient data, we aimed to display and compare numbers needed to treat of both drugs on a composite renal outcome. METHODS From Kaplan-Meier plots of major cardiovascular outcome trials of GLP-1 receptor agonists and SGLT2 inhibitors vs. placebo, we digitalized individual patient time-to-event information on composite renal outcomes with WebPlotDigitizer 4.2; numbers needed to treat from individual cardiovascular outcome trials were estimated using parametric Weibull regression models and compared to original data. Random-effects meta-analysis generated meta-numbers needed to treat with 95% confidence intervals (CI). RESULTS Twelve cardiovascular outcome trials (three for GLP-1 receptor agonists, nine for SGLT2 inhibitors) comprising 90,865 participants were included. Eight trials were conducted in primary type 2 diabetes populations, two in a primary heart failure and two in a primary chronic kidney disease population. Mean estimated glomerular filtration rate at baseline ranged between 37.3 and 85.3 ml/min/1.73 m2. Meta-analyses estimated meta-numbers needed to treat of 85 (95% CI 60; 145) for GLP-1 receptor agonists and 104 (95% CI 81; 147) for SGLT2 inhibitors for the composite renal outcome at the overall median follow-up time of 36 months. CONCLUSION The present meta-analysis of digitalized individual patient data revealed moderate and similar absolute treatment benefits of GLP-1 receptor agonists and SGLT2 inhibitors compared to placebo for a composite renal outcome.
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Affiliation(s)
- Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Kris Gregory Vargas
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Michael Roden
- Cardiovascular Research Institute Düsseldorf (CARID), Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Division of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, Munich-Neuherberg, Germany
| | - Cihan Akbulut
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sabrina Schlesinger
- German Center for Diabetes Research, Partner Düsseldorf, Munich-Neuherberg, Germany
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Conservative Medicine, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Oliver Kuss
- German Center for Diabetes Research, Partner Düsseldorf, Munich-Neuherberg, Germany
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Vargas KG, Rütten T, Siemes B, Brockmeyer M, Parco C, Hoss A, Schlesinger S, Jung C, Roden M, Kelm M, Wolff G, Kuss O. Assessing the potential for precision medicine in body weight reduction with regard to type 2 diabetes mellitus therapies: A meta-regression analysis of 120 randomized controlled trials. Diabetes Obes Metab 2024. [PMID: 38425176 DOI: 10.1111/dom.15519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/25/2024] [Accepted: 02/05/2024] [Indexed: 03/02/2024]
Abstract
AIMS To assess the potential for precision medicine in type 2 diabetes by quantifying the variability of body weight as response to pharmacological treatment and to identify predictors which could explain this variability. METHODS We used randomized clinical trials (RCTs) comparing glucose-lowering drugs (including but not limited to sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists and thiazolidinediones) to placebo from four recent systematic reviews. RCTs reporting on body weight after treatment to allow for calculation of its logarithmic standard deviation (log[SD], i.e., treatment response heterogeneity) in verum (i.e., treatment) and placebo groups were included. Meta-regression analyses were performed with respect to variability of body weight after treatment and potential predictors. RESULTS A total of 120 RCTs with a total of 43 663 participants were analysed. A slightly larger treatment response heterogeneity was shown in the verum groups, with a median log(SD) of 2.83 compared to 2.79 from placebo. After full adjustment in the meta-regression model, the difference in body weight log(SD) was -0.026 (95% confidence interval -0.044; 0.008), with greater variability in the placebo groups. Scatterplots did not show any slope divergence (i.e., interaction) between clinical predictors and the respective treatment (verum or placebo). CONCLUSIONS We found no major treatment response heterogeneity in RCTs of glucose-lowering drugs for body weight reduction in type 2 diabetes. The precision medicine approach may thus be of limited value in this setting.
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Affiliation(s)
- Kris G Vargas
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tobias Rütten
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Benedikt Siemes
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Hoss
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sabrina Schlesinger
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Michael Roden
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Oliver Kuss
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
- Centre for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Parco C, Kreuels V, Kelm M, Jung C, Wolff G. Robotic-assisted early mobilization and virtual reality: a perspective on innovative support strategies for critically ill patients. Intensive Care Med Exp 2023; 11:86. [PMID: 38052739 DOI: 10.1186/s40635-023-00571-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/26/2023] [Indexed: 12/07/2023] Open
Affiliation(s)
- Claudio Parco
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Vanessa Kreuels
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, CARID, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Parco C, Tröstler J, Brockmeyer M, Hoss A, Lin Y, Quade J, Heinen Y, Schulze V, Jung C, Icks A, Kelm M, Wolff G. Risk-adjusted management in catheterization procedures for non-ST-segment elevation myocardial infarction: A standard operating procedure pilot study. Int J Cardiol 2023; 388:131111. [PMID: 37302420 DOI: 10.1016/j.ijcard.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND The effects of standardized risk-adjusted periprocedural management of cardiac catheterization procedures in Non-ST segment elevation myocardial infarction (NSTEMI) remain unknown. We implemented a standard operating procedure (SOP) specifying risk assessment (RA, using National Cardiovascular Data Registry (NCDR) risk models) and risk-adjusted management (RM, e.g. intensified monitoring) in 2018 and aimed to investigate staff SOP adherence and associations with patient outcomes. METHODS AND RESULTS All 430 invasively managed NSTEMI patients (mean age 72y; 70.9% male) in 2018 were analyzed for staff SOP adherence and in-hospital clinical outcomes. 207 patients (48.1%; RM+) received both RA and RM; 92 patients (21.4%; RM-) received RA but no RM; 131 patients (30.5%; RA-) received neither RA nor RM. Lower staff adherence to RA was associated with emergency settings (51.9% (RA-) vs. 22.1% (RA+); p<0.01), presentation in cardiogenic shock (17.6% (RA-) vs. 6.4% (RA+); p<0.01) and invasive mechanical ventilation (12.2% (RA-) vs. 3.3% (RA+); p<0.01). Early sheath removal (87.9% (RM+) vs. 56.5% (RM-); p<0.01) and intensified monitoring (p<0.01) were more frequent in the RM+ group. All-cause mortality was not different (1.4% (RM+) vs. 4.3% (RM-); p=0.13), but there were fewer major bleeding events with associated with RM (2.4% (RM+) vs. 12% (RM-); p<0.01), which remained independently associated with RM in a multivariate logistic regression model correcting for confounders (p<0.01). CONCLUSION In an all-comer patient cohort with NSTEMI, staff adherence to risk-adjusted periprocedural management was independently associated with fewer major bleeding events. Staff adherence to SOP-specified risk assessment was frequently neglected in more critical clinical situations.
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Affiliation(s)
- Claudio Parco
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Hoss
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Julia Quade
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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Brockmeyer M, Wies E, Joerges J, Sommer J, Borgmann SO, Chernyak N, Lin Y, Parco C, Schulze V, Heinen Y, Kelm M, Icks A, Perings S, Wolff G. Knowledge of HbA1c and LDL-C treatment goals, subjective level of disease-related information and information needs in patients with atherosclerotic cardiovascular disease. Clin Cardiol 2022; 46:223-231. [PMID: 36448416 PMCID: PMC9933116 DOI: 10.1002/clc.23948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND/HYPOTHESIS Risk factor control of diabetes mellitus (DM) and especially dyslipidemia remains unsatisfactory in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to analyze the knowledge of low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c) treatment goals, subjective level of information, and information needs in very high-risk patients with ASCVD. METHODS ASCVD patients (n = 210; 75 ± 9 years; 71.4% male; 89.5% coronary disease) with DM (96.7% type 2) completed a questionnaire assessing knowledge of HbA1c and LDL-C treatment goals and subjective level of information and information needs on disease-related topics of DM and ASCVD. Serum LDL-C and HbA1c were measured. RESULTS HbA1c goal (<7.0% in 60.6%) was attained more frequently than LDL-C goal (<70 mg/dl in 39.9%; p < .01). Significantly more participants named the correct goal for HbA1c compared to LDL-C (52.9% vs. 2.4%; p < .01). Subjective levels of information were higher and information needs were lower for DM than for ASCVD (p < .01 for all topics). No associations of knowledge of treatment goals and level of information with the attainment of treatment goals for HbA1c and LDL-C were found. However, in multivariate regression, higher levels of education were associated with knowledge of treatment goals (HbA1c: odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.72, p = .04; LDL-C: OR 2.32, 95% CI 1.07-5.03; p = .03). CONCLUSION In very high-risk patients with ASCVD, a deficit of knowledge of treatment goals to control dyslipidemia exists when compared to DM, patients felt significantly better informed for topics of DM than for ASCVD and display higher information needs for topics of ASCVD.
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Affiliation(s)
- Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Emilia Wies
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Jamuna Joerges
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Jana Sommer
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University DüsseldorfDüsseldorfGermany,German Center for Diabetes Research, Partner Düsseldorf, München‐NeuherbergGermany,Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital DüsseldorfHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Sandra Olivia Borgmann
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University DüsseldorfDüsseldorfGermany,German Center for Diabetes Research, Partner Düsseldorf, München‐NeuherbergGermany,Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital DüsseldorfHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Nadja Chernyak
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University DüsseldorfDüsseldorfGermany,German Center for Diabetes Research, Partner Düsseldorf, München‐NeuherbergGermany,Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital DüsseldorfHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Yvonne Heinen
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany,CARID – Cardiovascular Research InstituteDüsseldorfGermany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University DüsseldorfDüsseldorfGermany,German Center for Diabetes Research, Partner Düsseldorf, München‐NeuherbergGermany,Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital DüsseldorfHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Stefan Perings
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal MedicineMedical Faculty and University Hospital Düsseldorf, Heinrich Heine University DüsseldorfDüsseldorfGermany
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Wolff G, Lin Y, Akbulut C, Brockmeyer M, Parco C, Hoss A, Sokolowski A, Westenfeld R, Kelm M, Roden M, Schlesinger S, Kuss O. Meta-analysed numbers needed to treat of novel antidiabetic drugs for cardiovascular outcomes. ESC Heart Fail 2022; 10:552-567. [PMID: 36337026 PMCID: PMC9871670 DOI: 10.1002/ehf2.14213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Absolute treatment effects-i.e. numbers needed to treat (NNTs)-of novel antidiabetic drugs for cardiovascular outcomes have not been comprehensively evaluated. We aimed to perform a meta-analysis of digitalized individual patient outcomes to display and compare absolute treatment effects. METHODS AND RESULTS Individual patient time-to-event information from Kaplan-Meier plots of cardiovascular mortality (CM) and/or hospitalization for heart failure (HHF) endpoints from cardiovascular outcome trials (CVOTs) evaluating dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium glucose transporter 2 (SGLT2) inhibitors vs. placebo were digitalized using WebPlotDigitizer 4.2 and the R code of Guyot et al.; Weibull regression models were generated, validated, and used to estimate NNT for individual trials; random-effects meta-analysis generated Meta-NNT with 95% confidence intervals. Sixteen CVOTs reported time-to-event information (14 in primary diabetes and 2 in primary heart failure populations). Thirteen studies including 96 860 patients were meta-analysed for CM: At the median follow-up of 30 months, Meta-NNTs were 178 (64 to ∞ to -223) for DPP-4 inhibitors, 261 (158 to 745) for GLP-1 receptor agonists, and 118 (68 to 435) for SGLT2 inhibitors. Ten studies including 96 128 patients were meta-analysed for HHF: At the median follow-up of 29 months, estimated Meta-NNTs were -644 (229 to ∞ to -134) for DPP-4 inhibitors, 441 (184 to ∞ to -1100) for GLP-1 receptor agonists, and 126 (91 to 208) for SGLT2 inhibitors. SGLT2 inhibitors were especially effective for HHF in primary heart failure populations [Meta-NNT 25 (19 to 39)] vs. primary diabetes populations [Meta-NNT 233 (167 to 385)] at 16 months of follow-up. CONCLUSIONS We found only modest treatment benefits of GLP-1 receptor agonists and SGLT2 inhibitors for CM and HHF in primary type 2 diabetes mellitus populations. In primary heart failure populations, SGLT2 inhibitor benefits were substantial and comparable in efficacy to established heart failure medication.
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Affiliation(s)
- Georg Wolff
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Yingfeng Lin
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Cihan Akbulut
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany,Centre for Health and Society, Faculty of MedicineHeinrich Heine University DüsseldorfDüsseldorfGermany
| | - Maximilian Brockmeyer
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Claudio Parco
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Alexander Hoss
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Alexander Sokolowski
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Ralf Westenfeld
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany
| | - Malte Kelm
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical FacultyHeinrich Heine University DüsseldorfMoorenstr. 540225DüsseldorfGermany,Cardiovascular Research Institute Düsseldorf (CARID)Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Michael Roden
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Cardiovascular Research Institute Düsseldorf (CARID)Heinrich Heine University DüsseldorfDüsseldorfGermany,Department of Endocrinology and Diabetology, Internal Medicine, Medical FacultyHeinrich Heine University DüsseldorfDüsseldorfGermany,Institute for Clinical Diabetology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Sabrina Schlesinger
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Oliver Kuss
- German Center for Diabetes Research, Partner DüsseldorfMünchen‐NeuherbergGermany,Institute for Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany,Centre for Health and Society, Faculty of MedicineHeinrich Heine University DüsseldorfDüsseldorfGermany
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Wolff G, Lin Y, Akbulut C, Brockmeyer M, Parco C, Hoss A, Sokolowski A, Westenfeld R, Kelm M, Roden M, Schlesinger S, Kuss O. Absolute treatment effects of novel oral antidiabetic drugs on cardiovascular mortality and hospitalization for heart failure: a meta-analysis of digitalized individual patient outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and purpose
Absolute treatment effects of novel oral antidiabetic drugs for cardiovascular outcomes have thus far not been comprehensively evaluated. We thus aimed to perform a meta-analysis of digitalized individual patient data.
Methods and results
Individual patient outcomes from Cardiovascular Outcome Trials (CVOTs) evaluating dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists and sodium glucose transporter 2 (SGLT2) inhibitors against placebo with time-to-event information for cardiovascular mortality (CM) and/or hospitalization for heart failure (HHF) endpoints were digitalized from Kaplan-Meier plots; Weibull regression models with random-effects meta-analysis were used to estimate numbers-needed-to-treat (NNT) and Meta-NNT with 95% confidence intervals (CI). Sixteen CVOTs reported time-to-event information (14 in primary diabetes, two in primary heart failure populations). Thirteen studies including 96,860 patients were meta-analyzed for CM: at the median follow-up of 30 months, Meta-NNTs were 178 (64 to ∞ to −223) for DPP-4 inhibitors, 261 (158 to 745) for GLP-1 receptor agonists and 118 (68 to 435) for SGLT2 inhibitors. Ten studies including 96,128 patients were meta-analyzed for HHF: at the median follow-up of 29 months, estimated Meta-NNTs were −644 (229 to ∞ to −134) for DPP-4 inhibitors, 441 (184 to ∞ to −1100) for GLP-1 receptor agonists and 126 (91 to 208) for SGLT2 inhibitors. SGLT2 inhibitors were especially effective for HHF in primary heart failure populations (Meta-NNT 25 (19 to 39)) vs. primary diabetes populations (Meta-NNT 233 (167 to 385)) at 16 months of follow-up.
Conclusion
We found modest treatment benefits of GLP-1 receptor agonists and SGLT2 inhibitors for CM and HHF in primary T2DM populations. In primary heart failure populations, however, SGLT2 inhibitor benefits were substantial and comparable to established heart failure medication.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - C Akbulut
- Heinrich Heine University, Institute for Biometrics and Epidemiology , Duesseldorf , Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - C Parco
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - A Hoss
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - A Sokolowski
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - R Westenfeld
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology , Dusseldorf , Germany
| | - M Roden
- Heinrich Heine University, Institute for Clinical Diabetology , Duesseldorf , Germany
| | - S Schlesinger
- Heinrich Heine University, Institute for Biometrics and Epidemiology , Duesseldorf , Germany
| | - O Kuss
- Heinrich Heine University, Institute for Biometrics and Epidemiology , Duesseldorf , Germany
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Heinen Y, Wolff G, Klein K, Brockmeyer M, Parco C, Perings S, Zeus T, Kelm M, Icks A, Jung C. Process Standardization in High-Risk Coronary Interventions is Associated With Quality of Care Measures. J Invasive Cardiol 2022; 34:E743-E749. [PMID: 36200997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patient safety is one of the most important issues in healthcare. High-risk percutaneous coronary interventions (HR-PCIs) offer well-established treatment options for patients with complex coronary artery disease and multiple comorbidities. Whether process standardization using standard operating procedure (SOP) management and checklists improves HR-PCI is still unknown. METHODS AND RESULTS This retrospective study analyzed procedural characteristics, in-hospital outcomes, and length of hospital stay in patients who received HR-PCI in a German heart center 12 months before the introduction of process standardization using SOP management-the SOP (-) group-and after the introduction of process standardization using SOP management-the SOP (+) group. A total of 192 patients were included, with 77 patients in the SOP (-) group and 115 patients in the SOP (+) group. The mean age in the SOP (-) group was 72.0 ± 10.2 years and 81.8% were male; mean age in the SOP (+) group was 75.2 ± 10.4 years and 68.7% were male. Acute kidney events were significantly lower in the SOP (+) group than in the SOP (-) group (7.0% vs 10.4%; P=.04). Bleeding was the most common adverse event and significantly lower in the SOP (+) group than in the SOP (-) group (13.1% vs 31.2%, respectively; P<.01). There were trends toward shorter length of hospital stay in the SOP (+) group compared with the SOP (-) group (9.3 ± 6.4 days vs 10.9 ± 7.3 days, respectively; P=.10) and days of hospital stay in the intensive care unit (3.7 ± 4.0 days vs 4.7 ± 4.3 days; P=.07). SOP management was independently associated with shorter length of hospital stay in multivariate regression analysis. CONCLUSION This retrospective study shows significantly better quality of care measures after the introduction of process standardization techniques using SOP management in HRPCIs, with a lower risk of adverse outcomes and shorter length of hospital stay.
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Affiliation(s)
- Yvonne Heinen
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany.
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Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Chernyak N, Icks A, Kelm M, Brockmeyer M, Wolff G. Clinical efficacy and safety outcomes of bempedoic acid for LDL-C lowering therapy in patients at high cardiovascular risk: a systematic review and meta-analysis. BMJ Open 2022; 12:e048893. [PMID: 35210334 PMCID: PMC8883220 DOI: 10.1136/bmjopen-2021-048893] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Bempedoic acid (BA) is a novel oral low-density lipoprotein cholesterol lowering drug. This systematic review and meta-analysis aims to assess efficacy and safety for clinical outcomes in high cardiovascular (CV) risk patients. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, Google Scholar, Embase, ClinicalTrials.gov, Clinical Trial Results and the American College of Cardiology web site were searched. STUDY SELECTION Randomised controlled trials (RCTs) of BA versus placebo in high CV risk patients reporting clinical outcomes were included. MAIN OUTCOMES AND MEASURES Primary efficacy outcomes were major adverse cardiovascular events (MACE), all-cause mortality, CV mortality and non-fatal myocardial infarction (MI). Safety outcomes included new onset or worsening of diabetes mellitus (DM), muscular disorders, gout and worsening of renal function. RESULTS Six RCTs with a total of 3956 patients and follow-ups of four to 52 weeks were identified. Heterogeneity mainly derived from differing follow-up duration and baseline CV risk. No difference in MACE (OR 0.84; 95% CI 0.61 to 1.15), all-cause mortality (OR 2.37; CI 0.80 to 6.99) and CV mortality (OR 1.66; CI 0.45 to 6.04) for BA versus placebo was observed. BA showed beneficial trends for non-fatal MI (OR 0.57; CI 0.32 to 1.00) and was associated with a lower risk of new-onset or worsening of DM (OR 0.68; CI 0.49 to 0.94), but higher risk of gout (OR 3.29; CI 1.28 to 8.46) and a trend for muscular disorders (OR 2.60; CI 1.15 to 5.91) and worsening of renal function (OR 4.24; CI 0.98 to 18.39). CONCLUSION BA in high CV risk patients showed no significant effects on major CV outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and gout sound a note of caution. Hence, further studies with longer term follow-up in carefully selected populations are needed to clarify the risk/benefit ratio of this novel therapy.
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Affiliation(s)
- Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Athanasios Karathanos
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Torben Krieger
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Nadja Chernyak
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Chernyak N, Icks A, Kelm M, Brockmeyer M, Wolff G. Clinical efficacy and safety outcomes of bempedoic acid for LDL-C lowering therapy in patients at high cardiovascular risk: a systematic review and meta-analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Bempedoic acid (BA) is a novel oral low-density lipoprotein cholestrol (LDL-C) lowering drug. Its efficacy and safety for clinical outcomes in high cardiovascular risk patients remains unknown.
Objectives and methods
A systematic review was performed and randomized controlled trials (RCTs) of BA vs. placebo in high cardiovascular risk patients reporting clinical efficacy and safety outcomes were included in a meta-analysis. Cumulative odds ratios (OR) and mean differences with 95% confidence intervals (CI) were reported as summary statistics.
Results
Six RCTs with a total of 3,956 patients and follow-ups of four to 52 weeks were identified. There was no difference in MACE (OR 0.84; CI 0.61, 1.15), all-cause mortality (OR 2.37; CI 0.80, 6.99) and cardiovascular mortality (OR 1.66; CI 0.45, 6.04) for BA vs. placebo. BA showed beneficial trends for nonfatal myocardial infarction (OR 0.57; CI 0.32, 1.00) and was associated with a lower risk of new-onset or worsening of diabetes mellitus (OR 0.68; CI 0.49, 0.94) and non-coronary revascularization (OR 0.41; CI 0.18, 0.95), but higher risk of gout (OR 3.29; CI 1.28, 8.46) and a trend for worsening of renal function (OR 4.24; CI 0.98, 18.39) and muscular disorders (OR 2.60; CI 1.15, 5.91).
Conclusion
Bempedoic acid in high cardiovascular risk patients showed no significant effects on major cardiovascular outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and the incidence of gout sound a note of caution. Hence, further studies with longer-term follow-up are needed to clarify the risk/benefit ratio of this novel therapy.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - N Chernyak
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Icks
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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11
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Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, Lin Y, Sokolowski A, Hoss A, Heinen Y, Schulze V, Icks A, Jung C, Kelm M, Wolff G. National Cardiovascular Data Registry-Acute Kidney Injury (NCDR) vs. Mehran risk models for prediction of contrast-induced nephropathy and need for dialysis after coronary angiography in a German patient cohort. J Nephrol 2021; 34:1491-1500. [PMID: 34363595 PMCID: PMC8494719 DOI: 10.1007/s40620-021-01124-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) is a major adverse event in patients undergoing coronary angiography. The Mehran risk model is the gold-standard for CIN risk prediction. However, its performance in comparison to more contemporary National Cardiovascular Data Registry-Acute Kidney Injury (NCDR-AKI) risk models remains unknown. We aimed to compare both in this study. METHODS AND RESULTS Predictions of Mehran and NCDR-AKI risk models and clinical events of CIN and need for dialysis were assessed in a total of 2067 patients undergoing coronary angiography with or without percutaneous coronary intervention. Risk models were compared regarding discrimination (receiver operating characteristic analysis), net reclassification improvement (NRI) and calibration (graphical and statistical analysis). The NCDR risk model showed superior risk discrimination for predicting CIN (NCDR c-index 0.75, 95% CI 0.72-0.78; vs. Mehran c-index 0.69, 95% CI 0.66-0.72, p < 0.01), and continuous NRI (0.22; 95% CI 0.12-0.32; p < 0.01) compared to the Mehran model. The NCDR risk model tended to underestimate the risk of CIN, while the Mehran model was more evenly calibrated. For the prediction of need for dialysis, NCDR-AKI-D also discriminated risk better (c-index 0.85, 95% CI 0.79-0.91; vs. Mehran c-index 0.75, 95% CI 0.66-0.84; pNCDRvsMehran < 0.01), but continuous NRI showed no benefit and calibration analysis revealed an underestimation of dialysis risk. CONCLUSION In German patients undergoing coronary angiography, the modern NCDR risk model for predicting contrast-induced nephropathy showed superior discrimination compared to the GRACE model while showing less accurate calibration. Results for the outcome 'need for dialysis' were equivocal.
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Affiliation(s)
- Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lucin Kosejian
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Julia Quade
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jennifer Tröstler
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Selina Bader
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Sokolowski
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Hoss
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Yvonne Heinen
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty and University Hospital, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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12
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Brockmeyer M, Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Heinen Y, Bejinariu A, Müller P, Makimoto H, Kelm M, Wolff G. Uninterrupted anticoagulation during catheter ablation for atrial fibrillation: no difference in major bleeding and stroke between direct oral anticoagulants and vitamin K antagonists in an updated meta-analysis of randomised controlled trials. Acta Cardiol 2021; 76:288-295. [PMID: 32056498 DOI: 10.1080/00015385.2020.1724689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Periprocedural uninterrupted anticoagulation for catheter ablation of atrial fibrillation (AF) became standard after positive results of vitamin K antagonist (VKA) trials. Previous studies of uninterrupted direct oral anticoagulants (DOACs) vs. VKA have given controversial results. We thus aimed to elucidate the risk/benefit ratio of uninterrupted DOAC vs. VKA during catheter ablation of AF in an updated meta-analysis of randomised controlled trials (RCTs). METHODS Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing catheter ablation of AF. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischaemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (MRI), and mortality. RESULTS Six eligible RCTs comprising 2,369 patients were included. There were no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30-1.56; p = .37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20-4.72; p = .97). Pooled meta-analysis of secondary outcomes revealed no significant differences (OR 0.73, p = .49 for composite of major bleeding and stroke or TIA; OR 1.08, p = .52 for minor bleeding; OR 1.12, p = .59 for acute cerebral lesions on MRI; and OR 0.60, p = .64 for all-cause mortality). CONCLUSION Our meta-analysis suggests that uninterrupted DOAC is not superior to VKA in patients undergoing catheter ablation of AF with comparable rates of major bleeding and stroke.
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Affiliation(s)
- Maximilian Brockmeyer
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Claudio Parco
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alexandru Bejinariu
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Patrick Müller
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hisaki Makimoto
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
- CARID – Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, Lin Y, Karathanos A, Krieger T, Heinen Y, Schulze V, Icks A, Jung C, Kelm M, Wolff G. Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort. Int J Cardiol 2021; 329:28-35. [PMID: 33412182 DOI: 10.1016/j.ijcard.2020.12.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/18/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients. METHODS AND RESULTS A total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, pGRACE1.0vsGRACE2.0 = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; pACTIONvsNCDR < 0.0001; pGRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (pGRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, pGRACEvsACTION = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); pGRACEvsACTION = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models. CONCLUSIONS In a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.
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Affiliation(s)
- Claudio Parco
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Maximilian Brockmeyer
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Lucin Kosejian
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Julia Quade
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Selina Bader
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christian Jung
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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14
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Troestler J, Parco C, Brockmeyer M, Lin Y, Krieger T, Quade J, Bader S, Kosejian L, Karathanos A, Heinen Y, Schulze V, Icks A, Kelm M, Wolff G. Standardized risk management in catheterization procedures for non-ST-segment elevation myocardial infarction: associations with in-hospital clinical outcomes. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction and purpose
Patient risk in non-ST-segment elevation myocardial infarction (NSTEMI) depends on clinical setting, individual patient variables and procedural characteristics. Standardized risk-adjusted periprocedural management for catheterization procedures using a Standard Operating Procedure (SOP) was investigated to evaluate associations with in-hospital clinical outcomes.
Methods
In 01/2018, our heart center established an SOP for coronary catheterization procedures in NSTEMI, targeting 1) standardized pre-procedural risk assessment using National Cardiovascular Data Registry (NCDR) risk models, and 2) standardized post-procedural risk-adjusted safety measures, including advanced patient monitoring (intermediate/intensive care) and use of vascular closure devices. All patients presenting with invasively-managed NSTEMI in 2018 were retrospectively evaluated for SOP-based pre-procedural risk scoring, SOP-based post-procedural management and in-hospital clinical outcomes of mortality, major bleeding (MB, according to BARC ≥3) and acute kidney injury (AKI, according to KDIGO).
Results
A total of 430 patients (age 72±12 years, 71% male, BMI 27±5) presenting with NSTEMI from 01 to 12/2018 were included, 9.8% presented in cardiogenic shock and 4.7% had suffered a preclinical cardiac arrest. Overall in-hospital mortality was 3.7%, MB occurred in 6.5%. 207 patients (48.1%, SOP+ group) had received both 1) pre-procedural risk assessment and 2) post-procedural risk-adjusted safety measures; the other 223 patients (51.9%, SOP- group) had not received either 1) or 2). There were no significant differences in baseline characteristics and prior-existing medical conditions between groups, however, significantly more patients in SOP- group were treated in emergency settings (39.9% vs. 21.7%, p=0.004). However, significantly more patients in SOP- were treated in emergency settings at higher risk (39.9% (SOP-) vs. 21.7% (SOP+); p<0.001). In univariate analysis, all in-hospital clinical outcomes of mortality (1.4% (SOP+) vs. 5.8% (SOP-); p=0.016), MB (2.9% (SOP+) vs. 9.9% (SOP-); p=0.003) and AKI were significantly lower in the SOP+ group (15.9% (SOP+) vs. 24.2% (SOP-); p=0.033). After correction for the difference in risk between groups due to emergency settings by multivariate logistic regression analysis, MB remained significantly lower in SOP+ (p=0.02), while mortality (p=0.14) and AKI (p=0.19) were not significantly associated with SOP-status anymore.
Conclusion
Standardized risk management in invasively managed NSTEMI was associated with significantly lower rates of in-hospital major bleedings.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Junior Clinician Scientist Track, Medical faculty, Heinrich-Heine-University Düsseldorf, Germany
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Affiliation(s)
- J Troestler
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Krieger
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - J Quade
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - S Bader
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - L Kosejian
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Heinen
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Icks
- Heinrich Heine University, Institute for Health Services Research and Health Economics, Centre for Health and Society, Duesseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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15
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Karathanos A, Simon I, Brockmeyer M, Lin Y, Parco C, Krieger T, Schulze V, Hellhammer K, Kelm M, Zeus T, Wolff G. Iron status, anemia and functional capacity in adults with congenital heart disease: a single center analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Iron is essential to the mitochondrial energy production in cardiomyocytes and its depletion is negatively associated with symptoms, functional capacity, quality of life and outcomes in patients with heart failure – independent of anemia. The relevance of iron deficiency in adults with congenital heart disease however has not been evaluated to date, and we thus aimed to evaluate it in an all-comer cohort of patients with congenital heart disease in correlation with symptoms and functional capacity.
Methods and results
527 patient cases from one referral center over 2 years were evaluated concerning their iron status, anemia, functional capacity and ejection fraction of their systemic ventricle. 264 were female, 94 had a shunt lesion, 96 had left-sided obstructive lesions, 181 right-sided lesions, while 108 were considered to have complex lesions and 28 were cyanotic. The median age was 34 years, the mean BMI was 25.2±5 kg/m2, 429 patients had a normal ejection fraction and 34 moderately and severely depressed. 35 patients were classified as NYHA III, and 56 as NYHA II, while their functional capacity was evaluated via cardiopulmonary testing with a mean VO2max/kg of 22.6±6.5 and mean 69±17% of the expected. The mean serum iron concentration was 99.4±42.3 mcg/dL, their mean transferrin saturation was 27.36±13%, the mean ferritin concentration was 130.8±185 ng/mL, the mean soluble transfer factor was 1.3±0.66 mg/l and their mean Hemoglobin 14.8±2 mg/dL, while the mean MCV was 88±5.3 and the mean MCHC 33.7±1.4.
40 patients were anemic according to the WHO definition for anemia, in 28 of those patients that was already known. Iron deficiency according to stratified according to ferritin was present in 53 patients. However, when stratified according to the heart failure guidelines definition for iron deficiency 299 patients were found affected. Using the soluble transferrin receptor (sTfR) and sTfR-ferritin index iron deficiency was suspected in 10 additional individuals. Iron deficiency was associated with the ejection fraction (p=0.0001) - patients with moderately or severely depressed systemic ventricular function more often were diagnosed with iron deficiency (p=0.007)-, while it did not correlate with functional NYHA classification (p=0.622) or functional capacity (p=0.1 and 0.057). Iron deficiency was also not found significantly different amongst congenital defects but did correlate with all laboratory iron studies.
Conclusions
In this ambulatory population of adults with congenital heart disease we found an association of ejection fraction with iron deficiency, however no association of iron deficiency with functional capacity. The question arising is if a new definition of iron deficiency anemia in congenital heart disease similar to heart failure would be of clinical value.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- A Karathanos
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - I Simon
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - T Krieger
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - K Hellhammer
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - G Wolff
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
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16
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Brockmeyer M, Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Heinen Y, Bejinariu A, Mueller P, Makimoto H, Kelm M, Wolff G. Uninterrupted direct oral anticoagulants and vitamin K antagonists during ablation for atrial fibrillation: an updated meta-analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Uninterrupted anticoagulation during catheter ablation of atrial fibrillation (CAAF) became standard of care after positive results of trials investigating vitamin K antagonists (VKA). Previous studies and meta-analyses of uninterrupted direct oral anticoagulants (DOAC) vs. VKA have given controversial results. We thus aimed to elucidate the risks and benefits of uninterrupted DOAC vs. VKA during CAAF in an updated meta-analysis of randomized controlled trials (RCTs).
Methods
Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing CAAF until September 2019. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (ACL) and mortality.
Results
Six eligible RCTs comprising 2,369 patients were included. Pooled meta-analysis showed no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30–1.56; p=0.37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20–4.72; p=0.97). There were no significant differences found in secondary outcomes (OR 0.73, p=0.49 for composite of major bleeding and stroke or TIA; OR 1.08, p=0.52 for minor bleeding; OR 1.12, p=0.59 for ACL; and OR=0.60, p=0.64 for all-cause mortality).
Conclusion
Our meta-analysis suggests that uninterrupted periprocedural anticoagulation with DOAC or VKA is characterized by a similar risk/benefit ratio in patients undergoing CAAF with comparable rates of major bleeding and stroke.
Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Medical faculty of the Heinrich-Heine-University Düsseldorf, Germany
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Affiliation(s)
- M Brockmeyer
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - Y Lin
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - C Parco
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - A Karathanos
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - T Krieger
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - V Schulze
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - Y Heinen
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - A Bejinariu
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - P Mueller
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - H Makimoto
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - M Kelm
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - G Wolff
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
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17
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Wolff G, Shamekhi J, Al-Kassou B, Tabata N, Parco C, Klein K, Maier O, Sedaghat A, Polzin A, Sugiura A, Jung C, Grube E, Westenfeld R, Icks A, Zeus T, Sinning JM, Baldus S, Nickenig G, Kelm M, Veulemans V. Risk modeling in transcatheter aortic valve replacement remains unsolved: an external validation study in 2946 German patients. Clin Res Cardiol 2020; 110:368-376. [PMID: 32851491 PMCID: PMC7907023 DOI: 10.1007/s00392-020-01731-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/12/2020] [Indexed: 12/31/2022]
Abstract
Background Surgical risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR). New and updated TAVR-specific models have been developed to improve risk stratification; however, the best option remains unknown. Objective To perform a comparative validation study of six risk models for the prediction of 30-day mortality in TAVR Methods and results A total of 2946 patients undergoing transfemoral (TF, n = 2625) or transapical (TA, n = 321) TAVR from 2008 to 2018 from the German Rhine Transregio Aortic Diseases cohort were included. Six surgical and TAVR-specific risk scoring models (LogES I, ES II, STS PROM, FRANCE-2, OBSERVANT, GAVS-II) were evaluated for the prediction of 30-day mortality. Observed 30-day mortality was 3.7% (TF 3.2%; TA 7.5%), mean 30-day mortality risk prediction varied from 5.8 ± 5.0% (OBSERVANT) to 23.4 ± 15.9% (LogES I). Discrimination performance (ROC analysis, c-indices) ranged from 0.60 (OBSERVANT) to 0.67 (STS PROM), without significant differences between models, between TF or TA approach or over time. STS PROM discriminated numerically best in TF TAVR (c-index 0.66; range of c-indices 0.60 to 0.66); performance was very similar in TA TAVR (LogES I, ES II, FRANCE-2 and GAVS-II all with c-index 0.67). Regarding calibration, all risk scoring models—especially LogES I—overestimated mortality risk, especially in high-risk patients. Conclusions Surgical as well as TAVR-specific risk scoring models showed mediocre performance in prediction of 30-day mortality risk for TAVR in the German Rhine Transregio Aortic Diseases cohort. Development of new or updated risk models is necessary to improve risk stratification. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01731-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Jasmin Shamekhi
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Baravan Al-Kassou
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Noriaki Tabata
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Kathrin Klein
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Oliver Maier
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alexander Sedaghat
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Atsushi Sugiura
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Eberhard Grube
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jan-Malte Sinning
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany.,Transregio 259: Aortic Diseases-Scientific Network of University Heart Centers in Düsseldorf/Bonn/Cologne, Düsseldorf/Bonn/Cologne, Germany
| | - Stephan Baldus
- Division of Cardiology, Pneumology, Angiology and Intensive Care, Department of Internal Medicine III, University of Cologne, Cologne, Germany.,Transregio 259: Aortic Diseases-Scientific Network of University Heart Centers in Düsseldorf/Bonn/Cologne, Düsseldorf/Bonn/Cologne, Germany
| | - Georg Nickenig
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany.,Transregio 259: Aortic Diseases-Scientific Network of University Heart Centers in Düsseldorf/Bonn/Cologne, Düsseldorf/Bonn/Cologne, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany.,Transregio 259: Aortic Diseases-Scientific Network of University Heart Centers in Düsseldorf/Bonn/Cologne, Düsseldorf/Bonn/Cologne, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich Heine University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
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18
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Lin Y, Schulze V, Brockmeyer M, Parco C, Karathanos A, Heinen Y, Gliem M, Hartung HP, Antoch G, Jander S, Turowski B, Perings S, Kelm M, Wolff G. Endovascular Thrombectomy as a Means to Improve Survival in Acute Ischemic Stroke: A Meta-analysis. JAMA Neurol 2020; 76:850-854. [PMID: 30958530 DOI: 10.1001/jamaneurol.2019.0525] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality. Objective To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis. Data Sources All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines. Study Selection Ten American Stroke Association/American Heart Association guideline-relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT. Data Extraction and Synthesis Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs. Main Outcomes and Measures Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward). Results In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials. Conclusions and Relevance This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.
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Affiliation(s)
- Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Athanasios Karathanos
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yvonne Heinen
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Michael Gliem
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sebastian Jander
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Perings
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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19
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Lin Y, Schulze V, Brockmeyer M, Parco C, Karathanos A, Krieger T, Heinen Y, Gliem M, Hartung HP, Antoch G, Jander S, Turowski B, Perings S, Kelm M, Wolff G. 283Endovascular thrombectomy as a means to improve survival in acute ischemic stroke - A meta-analysis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and purpose
Although endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) is guideline-recommended to improve functional recovery, thus far there are only inconclusive data from underpowered singular trials of EVT vs. medical therapy (MT) on mortality. We here aimed to perform a meta-analysis on short-term mortality in guideline-relevant EVT vs. MT randomized controlled trials (RCTs).
Methods
All randomized controlled trials (RCT) reporting EVT vs. MT in the latest 2018 American Stroke Association/American Heart Association (ASA/AHA) Guidelines were eligible for inclusion. Data were abstracted by two independent investigators and double-checked by four others. Study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% confidence intervals (CI). Ninety-day mortality and intracranial hemorrhage (ICH) were analyzed.
Results
Ten of the twelve guideline-relevant EVT vs. MT RCTs (DAWN, DEFUSE 3, ESCAPE, EXTEND-IA, MR CLEAN, MR RESCUE, REVASCAT, SWIFT PRIME, THERAPY, THRACE) with 2,313 patients were selected for inclusion. Studies IMS III and SYNTHESIS were excluded due to their very infrequent use of EVT. Stent retrievers (Trevo, Solitaire, Merci) were most frequently applied, followed by thrombus aspiration (Penumbra). Intravenous thrombolysis was administered in addition to EVT in the majority of patients. In the pooled meta-analysis of all eligible RCTs, EVT significantly reduced the risk for 90-day mortality by 3.7% compared to MT (15.0% vs. 18.7%; RR 0.81 with CI 0.68 to 0.98; p=0.03), accounting for a number-needed-to-treat of 27 to prevent one all-cause death. Trends were similar in early-window (RR 0.83) and late-window trials only (RR 0.76). There was no difference in the risk for ICH in EVT vs. MT (4.2% vs. 4.0%; RR 1.11 with CI 0.71 to 1.72; p=0.65). All included trials were published in high-quality journals and risk of bias was judged low.
Conclusions
This meta-analysis lends evidence to EVT benefits for survival already during the first 90 days after acute ischemic stroke. These results further highlight the evolution of interventional techniques in this setting.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - Y Heinen
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Gliem
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - H P Hartung
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Antoch
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Jander
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - B Turowski
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Perings
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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20
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Lin Y, Parco C, Brockmeyer M, Karathanos A, Schulze V, Krieger T, Heinen Y, Perings S, Kelm M, Wolff G. P6268Cardiovascular outcomes of new anti-diabetic agents - A meta-analysis of randomized controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and purpose
The risk of major cardiovascular events (MACE) is increased in patients with diabetes mellitus. Recently published clinical trials of three different pharmacological classes (DPP4 inhibitors (DPP4i), SGLT2-inhibitors (SGLT2i), GLP-1-receptor-antagonists (GLP1RA)) of new anti-diabetic agents (ADA) showed potential benefits for cardiovascular (CV) outcomes. We thus aimed to perform a meta-analysis of randomized controlled trials (RCTs) of these ADA to elucidate benefits on CV outcomes in diabetic patients.
Methods
Following a systematic online database search, all RCTs reporting CV outcomes of DPP4i, SGLT2i or GLP1RA vs. Placebo in diabetic patients up until December 2018 were eligible for inclusion in the meta-analysis. Studies including patients with acute coronary syndrome (ACS) were excluded. Data were abstracted and analyzed with the inverse-variance method and a random-effects model, hazard ratios (HR) with 95% confidence intervals (CI) were used as summary statistics. CV outcomes of MACE, myocardial infarction (MI), stroke, heart failure (HF), CV death and all-cause mortality were analyzed.
Results
Eleven RCTs (DPP4i: SAVOR, TECOS, CARMELINA; GLP1RA: LEADER, SUSTAIN-6, EXSCEL, Harmony; SGLT2i: EMPA-REG OUTCOME, CANVAS Program, DECLARE) with 109,316 patients were selected for inclusion. ELIXA and EXAMINE were excluded due to their inclusion of patients with ACS, CAROLINA was excluded for lack of placebo-control. In the pooled meta-analysis of all trials, ADA significantly reduced the risk for MACE (Hazard ratio (HR) 0.91, CI 0.86–0.96, p=0.0004), MI (HR 0.91, CI 0.85–0.96, p=0.02), CV death (HR 0.9, CI 0.82–0.99, P=0.02) and all-cause mortality (HR 0.92, CI 0.85–0.99, p=0.03). There was no difference in the risk for stroke (HR 0.94, CI 0.87–1.02, p=0.16) and HF (HR 0.88, CI 0.76–1.02, p=0.08). In agent-specific subgroup analyses, GLP1RA and SGLT2i showed significant reductions in MACE (GLP1RA: HR 0.85, CI 0.78–0.92, p<0.0001; SGLT2i: HR 0.89, CI 0.83–0.96, p=0.001), MI (GLP1RA: HR 0.86, CI 0.76–0.98, p=0.02; SGLT2i: HR 0.88, CI 0.79–0.97, p=0.01) and all-cause mortality (GLP1RA: HR 0.88, CI 0.81–0.95; p=0.001; SGLT2i: HR 0.83, CI 0.70–0.99; p=0.03). GLP1RA significantly reduced risk for stroke (HR 0.85, CI 0.75–0.96, p=0.008) and CV death (HR 0.86, CI 0.78–0.95, p=0.002). SGLT2I were especially effective in the reduction of risk for HF (HR 0.69, CI 0.61–0.79; p<0.0001). DPP4i inhibitors however failed to show superiority in all analyzed outcomes.
Conclusions
This meta-analysis lends evidence to GLP1RA and SGLT2i benefits for MACE, MI and all-cause mortality, while DPP4i failed to show superiority in cardiovascular outcomes. Individualized medication for diabetic patients depending on CV disease status should be considered.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - Y Heinen
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Perings
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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21
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Brockmeyer M, Lin Y, Karathanos A, Parco C, Krieger T, Heinen Y, Albert A, Kelm M, Schulze V, Wolff G. P2792Preoperative levosimendan improves survival in patients with low cardiac output syndrome undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and purpose
Previous studies and meta-analyses of perioperative levosimendan to improve the outcomes of patients with low cardiac output syndrome (LCOS) undergoing cardiac surgery have given controversial results and the optimal time of infusion of levosimendan remains uncertain. We thus aimed to elucidate the risk/benefit ratio of preoperative levosimendan in a meta-analysis of randomized controlled trials (RCTs).
Methods
Online databases were searched for RCTs comparing preoperative levosimendan to placebo in patients with LCOS undergoing cardiac surgery until February 2019. Data from retrieved studies were abstracted and analyzed in a comprehensive meta-analysis. Primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction, renal failure/replacement therapy, need for inotropic therapy, need for left ventricular assist devices, ventricular arrhythmia and arterial hypotension.
Results
As a result of the online database search, six eligible RCTs with 1,326 patients were included in the meta-analysis. Preoperative levosimendan showed a significant reduction in all-cause mortality (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.29–0.83; p<0.01), renal failure/replacement therapy (OR 0.48, CI 0.29–0.80; p<0.01) and need for inotropic therapy (OR 0.24, CI 0.06–0.95; p=0.04) compared to placebo. There were no significant differences in levosimendan vs. placebo concerning the rates of myocardial infarction (OR 0.61, p=0.38), need for left ventricular assist devices (OR 0.38, p=0.1), ventricular arrhythmia (OR 0.7, p=0.33), and arterial hypotension (OR 1.28, p=0.07).
Conclusions
Preoperative administration of levosimendan may improve survival in patients with low cardiac output syndrome undergoing cardiac surgery. It reduces need for inotropic medical support and renal failure/replace-ment therapy compared to placebo.
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Affiliation(s)
- M Brockmeyer
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - Y Lin
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - A Karathanos
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - C Parco
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - T Krieger
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - Y Heinen
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - A Albert
- Heinrich Heine University, Division of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany, Dusseldorf, Germany
| | - M Kelm
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - V Schulze
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - G Wolff
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
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22
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Karathanos A, Lin YF, Dannenberg L, Parco C, Schulze V, Brockmeyer M, Krieger T, Jung C, Heinen Y, Perings S, Zeymer U, Kelm M, Polzin A, Wolff G. P957Survival benefits of routine glycoprotein IIb/IIIa inhibitors during primary PCI in ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiovascular guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPI) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI).
Purpose
This study aimed to evaluate routine GPI use in STEMI treated with primary PCI.
Methods
Online databases were systematically searched for randomised controlled trials (RCTs) of routine GPI vs. control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis using Mantel-Haenszel estimates of risk ratios (RR) as summary statistics.
Results
After systematic review, twenty-one RCTs with 8,585 patients were included: ten trials randomized tirofiban (T), nine abciximab (A), one eptifibatide (E), one trial used A+T; only one trial used DAPT with prasugrel/ ticagrelor. Routine GPI were associated with a significant reduction in all-cause mortality at 30 days (2.4% (GPI) vs. 3.2%; risk ratio (RR) 0.72; p=0.01) and 6 months (3.7% vs. 4.8%; RR 0.76; p=0.02), and a reduction in recurrent MI (1.1% vs. 2.1%; RR 0.55; p=0.0006), repeat revascularization (2.5% vs. 4.1%; RR 0.63; p=0.0001), TIMI flow <3 after PCI (5.4% vs. 8.2%; RR 0.61; p<0.0001) and ischemic stroke (RR 0.42; p=0.04). Major (4.7% vs. 3.4%; RR 1.35; p=0.005) and minor bleedings (7.2% vs. 5.1%; RR 1.39; p=0.006) but not intracranial bleedings (0.1% vs. 0%; RR 2.7; p=0.37) were significantly increased under routine GPI.
Conclusions
Routine GPI administration during primary PCI in STEMI resulted in mortality reduction, driven by reductions in recurrent ischemic events – however predominantly in trials pre-prasugrel/ticagrelor. Trials in contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
| | - Y F Lin
- University of Dusseldorf, Duesseldorf, Germany
| | | | - C Parco
- University of Dusseldorf, Duesseldorf, Germany
| | - V Schulze
- University of Dusseldorf, Duesseldorf, Germany
| | | | - T Krieger
- University of Dusseldorf, Duesseldorf, Germany
| | - C Jung
- University of Dusseldorf, Duesseldorf, Germany
| | - Y Heinen
- University of Dusseldorf, Duesseldorf, Germany
| | - S Perings
- University of Dusseldorf, Duesseldorf, Germany
| | - U Zeymer
- University of Dusseldorf, Duesseldorf, Germany
| | - M Kelm
- University of Dusseldorf, Duesseldorf, Germany
| | - A Polzin
- University of Dusseldorf, Duesseldorf, Germany
| | - G Wolff
- University of Dusseldorf, Duesseldorf, Germany
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23
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Wolff G, Klein K, Parco C, Lin Y, Maier O, Karathanos A, Brockmeyer M, Zeus T, Polzin A, Westenfeld R, Jung C, Blehm A, Lichtenberg A, Kelm M, Veulemans V. P1853Comparative evaluation of risk model performance for prediction of 30-day mortality in transcatheter aortic valve replacement. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and purpose
EuroSCORE (ES) and Society of Thoracic Surgeons (STS) risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR), however their accuracy remains limited, especially in very old and high-risk patients. New and updated scoring models have thus been developed to improve risk stratification. We performed a comparative evaluation of classical and new risk scoring models for prediction of 30d mortality in transcatheter aortic valve interventions.
Methods and results
A total of 1,569 patients undergoing transfemoral (TF, n=1.235) or transapical (TA, n=334) TAVR from 2009 to 2018 were included in a single-center all-comer analysis. Six risk scoring models (logES_I, ES_II, STS-PROM, FRANCE-2, OBSERVANT, GAV-2) were calculated for all patients and evaluated for prediction of 30d mortality in their model discrimination (c-indices with 95% confidence intervals (CI)) and calibration (graphical evaluation). Mean classical risk scores confirmed an intermediate-to-high-risk patient collective (logES_I 27.0±16.9%; STS-PROM 7.0±6.4%), mean 30-day mortality was 3.4% (TF 2.3%; TA 7.8%). Overall discrimination performance was best in FRANCE-2 (c-index 0.73, 95% CI 0.67–0.80), followed by STS-PROM (c-index 0.68, 95% CI 0.62–0.75), OBSERVANT (c-index 0.68, 95% CI 0.61–0.76), ES_II (c-index 0.64) and logES_I and GAV-2 (both c-indices 0.63). FRANCE-2 discriminated best in TF TAVR (c-index 0.72; range of c-indices 0.63 to 0.72), while OBSERVANT performed best in TA TAVR (c-index 0.70; range of c-indices 0.61 to 0.70). All risk scoring models – with the exception of lowest-risk deciles of STS-PROM and ES_II – showed an overestimation of mortality probability in all risk strata.
Conclusion
FRANCE-2 and OBSERVANT risk models showed superior discrimination performance to classical risk scoring models in TF and TA TAVR, however all models tended to overestimate mortality probability.
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Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - K Klein
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - O Maier
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Polzin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - R Westenfeld
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Jung
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Blehm
- University Hospital Dusseldorf, Cardiovascular surgery, Dusseldorf, Germany
| | - A Lichtenberg
- University Hospital Dusseldorf, Cardiovascular surgery, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Veulemans
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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24
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Karathanos A, Lin Y, Dannenberg L, Parco C, Schulze V, Brockmeyer M, Jung C, Heinen Y, Perings S, Zeymer U, Kelm M, Polzin A, Wolff G. Routine Glycoprotein IIb/IIIa Inhibitor Therapy in ST-Segment Elevation Myocardial Infarction: A Meta-analysis. Can J Cardiol 2019; 35:1576-1588. [PMID: 31542257 DOI: 10.1016/j.cjca.2019.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPIs) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate routine GPI use in STEMI treated with primary percutaneous coronary intervention. METHODS Online databases were searched for randomized controlled trials of routine GPI vs control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis. Twenty-one randomized controlled trials with 8585 patients were included: 10 trials randomized tirofiban, 9 abciximab, 1 trial eptifibatide, and 1 trial used abciximab+tirofiban; only 1 trial used dual antiplatelet therapy with prasugrel/ticagrelor. RESULTS Routine GPI use was associated with a significant reduction in all-cause mortality at 30 days (2.4% [GPI] vs 3.2%; risk ratio [RR], 0.72; P = 0.01) and 6 months (3.7% vs 4.8%; RR, 0.76; P = 0.02), and a reduction in recurrent myocardial infarction (1.1% vs 2.1%; RR, 0.55; P = 0.0006), repeat revascularization (2.5% vs 4.1%; RR, 0.63; P = 0.0001), thrombolysis in myocardial infarction flow <3 after percutaneous coronary intervention (5.4% vs 8.2%; RR, 0.61; P < 0.0001), and ischemic stroke (RR, 0.42; P = 0.04). Major (4.7% vs 3.4%; RR, 1.35; P = 0.005) and minor bleedings (7.2% vs 5.1%; RR, 1.39; P = 0.006) but not intracranial bleedings (0.1% vs 0%; RR, 2.7; P = 0.37) were significantly increased under routine GPI. CONCLUSIONS Routine GPI administration in STEMI resulted in a reduction in mortality, driven by reductions in recurrent ischemic events-however predominantly in pre-prasugrel/ticagrelor trials. Trials with contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
| | - Yingfeng Lin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Lisa Dannenberg
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Claudio Parco
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Volker Schulze
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | | | - Christian Jung
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Yvonne Heinen
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Stefan Perings
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Uwe Zeymer
- Heart Center Ludwigshafen, Clinic for Cardiology, Pulmonology, Vascular and Intensive Care Medicine, Ludwigshafen, Germany
| | - Malte Kelm
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany; CARID-Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Georg Wolff
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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