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Coats AJS, Butler J, Tsutsui H, Doehner W, Filippatos G, Ferreira JP, Böhm M, Chopra VK, Verma S, Nordaby M, Iwata T, Nitta D, Ponikowski P, Zannad F, Packer M, Anker SD. Efficacy of empagliflozin in heart failure with preserved ejection fraction according to frailty status in EMPEROR-Preserved. J Cachexia Sarcopenia Muscle 2024; 15:412-424. [PMID: 38158636 PMCID: PMC10834334 DOI: 10.1002/jcsm.13393] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/22/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Frailty is a severe, common co-morbidity associated with heart failure (HF) with preserved ejection fraction (HFpEF). The impact of frailty on HFpEF outcomes may affect treatment choices in HFpEF. The impact of frailty on HFpEF patients and any impact on the clinical benefits of sodium glucose co-transporter 2 (SGLT2) inhibition in HFpEF have been described in only a limited number of trials. Whether the SGLT2 inhibitor empagliflozin would improve or worsen frailty status when given to HFpEF patients is also not known. The aims of this study were, therefore, to evaluate, in HFpEF patients enrolled in the EMPEROR-Preserved trial (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction), the impact of frailty on clinical outcomes, and on the effects of empagliflozin, as well as the effect of empagliflozin on frailty status during treatment period. METHODS We calculated a cumulative deficit-derived frailty index (FI) using 44 variables including clinical, laboratory and quality of life parameters recorded in EMPEROR-Preserved. Patients were classified into four groups: non-frail (FI < 0.21), mild frailty (0.21 to <0.30), moderate frailty (0.30 to <0.40) and severe frailty (≥0.40). Clinical outcomes and health-related quality of life were evaluated according to baseline FI along with the effect of empagliflozin on chronological changes in FI (at 12, 32 and 52 weeks). RESULTS The patient distribution was 1514 (25.3%), 2100 (35.1%), 1501 (25.1%) and 873 (14.6%) in non-frail, mild frailty, moderate frailty and severe frailty, respectively. Severe frailty patients tended to be female and have low Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, more co-morbidities and more polypharmacy. Incidence rates of the primary outcome of cardiovascular death or HF hospitalization increased as frailty worsened (hazard ratio [HR] of each FI category compared with the non-frail group: 1.10 [95% confidence interval, CI, 0.89-1.35], 2.00 [1.63-2.47] and 2.61 [2.08-3.27] in the mild frailty, moderate frailty and severe frailty groups, respectively; P trend < 0.001). Compared with placebo, empagliflozin reduced the risk for the primary outcome across the four FI categories, HR: 0.59 [95% CI 0.42-0.83], 0.79 [0.61-1.01], 0.77 [0.61-0.96] and 0.90 [0.69-1.16] in non-frail to severe frailty categories, respectively (P value for trend = 0.097). Empagliflozin also improved other clinical outcomes and KCCQ score across frailty categories. Compared with placebo, empagliflozin-treated patients had a higher likelihood of being in a lower FI category at Weeks 12, 32 and 52 (P < 0.05), odds ratio: 1.12 [95% CI 1.01-1.24] at Week 12, 1.21 [1.09-1.34] at Week 32 and 1.20 [1.09-1.33] at Week 52. CONCLUSIONS Empagliflozin improved key efficacy outcomes with a possible diminution of effect in very frail patients. Empagliflozin also improved frailty status during follow-up.
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Affiliation(s)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Hiroyuki Tsutsui
- School of Medicine and Graduate School, International University of Health and Welfare, Okawa, Japan
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow), Charité Universitätsmedizin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - João Pedro Ferreira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, Heart Failure Clinic, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital Saarland, Saarland University, Homburg, Germany
| | | | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Daisuke Nitta
- Medicine Division, Nippon Boehringer Ingelheim Co. Ltd, Tokyo, Japan
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wrocław, Poland
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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2
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Dhingra NK, Verma S, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Zaremba-Pechmann L, Böhm M, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Efficacy and Safety of Empagliflozin According to Background Diuretic Use in HFrEF: Post-Hoc Analysis of EMPEROR-Reduced. JACC Heart Fail 2024; 12:35-46. [PMID: 37715769 DOI: 10.1016/j.jchf.2023.06.036] [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] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND The EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) trial established the efficacy of empagliflozin in reducing heart failure (HF) outcomes among patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVES The authors examined the outcomes of EMPEROR-Reduced as a function of background diuretic therapy. METHODS The EMPEROR-Reduced trial was a double-blind, randomized controlled trial of placebo vs empagliflozin 10 mg among 3,730 HFrEF patients. Herein, the population was stratified into 4 groups: no diuretic and diuretic dose equivalent to furosemide <40, 40, and >40 mg daily at baseline. RESULTS A total of 3,656 patients from the EMPEROR-Reduced trial were available for analysis. Of those patients, 482 (13.2%) were receiving no diuretic therapy, and 731 (20.0%), 1,411 (38.6%), and 1,032 (28.2%) were receiving <40 mg, 40 mg, and >40 mg, respectively. The efficacy of empagliflozin on the primary outcome (time to first event of hospitalization for HF or cardiovascular [CV] death) was consistent regardless of background diuretic therapy (>40 mg: HR: 0.88 [95% CI: 0.71-1.10]; 40 mg: HR: 0.65 [95% CI: 0.51-0.82]; <40 mg: HR: 0.65 [95% CI: 0.46-0.92]); no diuretic agents: HR: 0.78 [95% CI: 0.47-1.29]; Ptrend test = 0.192). Baseline diuretic doses did not influence the effect of empagliflozin on body weight, systolic blood pressure, NT-proBNP, or hematocrit at 52 weeks. The safety profile of empagliflozin vs placebo was unaffected by baseline diuretic dose; however, independently of treatment allocation, total rates of adverse events were higher among patients with higher baseline doses of diuretic agents. CONCLUSIONS Empagliflozin exhibits a consistent effect on time to CV death or HF hospitalization and an unaltered safety profile regardless of baseline diuretic therapy. (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977).
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Affiliation(s)
- Nitish K Dhingra
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; University of Mississippi, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Nancy, France; Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France; UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-NUS Medical School, Singapore
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Scotland, United Kingdom
| | | | - Michael Böhm
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Nancy, France; Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA; Imperial College, London, United Kingdom
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Ferreira JP, Blatchford JP, Teerlink JR, Kosiborod MN, Angermann CE, Biegus J, Collins SP, Tromp J, Nassif ME, Psotka MA, Comin-Colet J, Mentz RJ, Brueckmann M, Nordaby M, Ponikowski P, Voors AA. Mineralocorticoid receptor antagonist use and the effects of empagliflozin on clinical outcomes in patients admitted for acute heart failure: Findings from EMPULSE. Eur J Heart Fail 2023; 25:1797-1805. [PMID: 37540060 DOI: 10.1002/ejhf.2982] [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: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients hospitalized for acute heart failure (AHF) empagliflozin produced greater clinical benefit than placebo. Many patients with AHF are treated with mineralocorticoid receptor antagonists (MRAs). The interplay between empagliflozin and MRAs in AHF is yet to be explored. This study aimed to evaluate the efficacy and safety of empagliflozin versus placebo according to MRA use at baseline in the EMPULSE trial (NCT04157751). METHODS AND RESULTS In this analysis all comparisons were performed between empagliflozin and placebo, stratified by baseline MRA use. The primary outcome included all-cause death, heart failure events, and a ≥5 point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score at 90 days, assessed using the win ratio (WR). First heart failure hospitalization or cardiovascular death was a secondary outcome. From the 530 patients randomized, 276 (52%) were receiving MRAs at baseline. MRA users were younger, had lower ejection fraction, better renal function, and higher KCCQ scores. The primary outcome showed benefit of empagliflozin irrespective of baseline MRA use (WR 1.46, 95% confidence interval [CI] 1.08-1.97 and WR 1.27, 95% CI 0.93-1.73 in MRA users and non-users, respectively; interaction p = 0.52). The effect of empagliflozin on first heart failure hospitalization or cardiovascular death was not modified by MRA use (hazard ratio [HR] 0.58, 95% CI 0.30-1.11 and HR 0.85, 95% CI 0.47-1.52 in MRA users and non-users, respectively; interaction p = 0.39). Investigator-reported and severe hyperkalaemia events were infrequent (<6%) irrespective of MRA use. CONCLUSIONS In patients admitted for AHF, initiation of empagliflozin produced clinical benefit and was well tolerated irrespective of background MRA use. These findings support the early use of empagliflozin on top of MRA therapy in patients admitted for AHF.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Bietigheim-Bissingen, Germany on behalf of Boehringer Ingelheim, Pharma GmbH & Co. KG, Biberach, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore, Singapore, Singapore
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas, MO, USA
| | | | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL and CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Matias Nordaby
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Verma S, Dhingra NK, Bonaca MP, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Iwata T, Nordaby M, Brueckmann M, Pocock SJ, Packer M. Presence of Peripheral Artery Disease Is Associated With Increased Risk of Heart Failure Events: Insights From EMPEROR-Pooled. Arterioscler Thromb Vasc Biol 2023. [PMID: 37199158 DOI: 10.1161/atvbaha.123.319156] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Canada (S.V., N.K.D.)
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Canada (S.V., N.K.D.)
| | - Marc P Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Aurora (M.P.B.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- University of Mississippi, Jackson (J.B.)
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin, Germany (S.D.A.)
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques, Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France (J.P.F.)
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, UnIC@RISE, Cardiovascular Research and Development Center, Portugal (J.P.F.)
- Internal Medicine Department, Heart Failure Clinic, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal (J.P.F.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Greece (G.F.)
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston (J.L.J.)
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-NUS Medical School (C.S.P.L.)
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Scotland, United Kingdom (N.S.)
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH and Co. KG, Biberach, Germany (T.I.)
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Germany (M.N., M.B.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.N., M.B.)
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Germany (M.B.)
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (S.J.P.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
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Bianzano S, Nordaby M, Plum-Mörschel L, Peil B, Heise T. Safety, tolerability, pharmacodynamics and pharmacokinetics following once-daily doses of BI 187004, an inhibitor of 11 beta-hydroxysteroid dehydrogenase-1, over 28 days in patients with type 2 diabetes mellitus and overweight or obesity. Diabetes Obes Metab 2023; 25:832-843. [PMID: 36478142 PMCID: PMC10107759 DOI: 10.1111/dom.14932] [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: 08/16/2022] [Revised: 11/17/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
AIMS To study the oral 11 beta-hydroxysteroid dehydrogenase-1 (11β-HSD1) inhibitor BI 187004 (NCT02150824), as monotherapy and in combination with metformin, versus placebo in patients with type 2 diabetes mellitus (T2DM) affected by overweight or obesity. MATERIALS AND METHODS This Phase II, randomized controlled trial investigated multiple rising doses of BI 187004 as monotherapy (Arm 1: 20, 80 or 240 mg) and in combination with metformin (Arm 2: 240 mg), in adults with T2DM and a body mass index of 28-40 kg/m2 . RESULTS In total, 103 patients (Arm 1: n = 62, Arm 2: n = 41) were included in this study. BI 187004 was rapidly absorbed and exposure increased approximately dose-dependently. Target engagement of 11β-HSD1 was observed with near-full inhibition of 11β-HSD1 in the liver [decreased (5α-tetrahydrocortisol + 5β-tetrahydrocortisol)/tetrahydrocortisone ratio]; hypothalamic-pituitary-adrenal axis activation was also seen (increased total urinary corticosteroids). No clinically relevant changes from baseline with BI 187004 treatment were observed for bodyweight or meal tolerance test parameters, or in most efficacy endpoints testing glucose and lipid metabolism; a significant increase was observed in weighted mean plasma glucose (p < .05 for 80 and 240 mg BI 187004) but not fasting plasma glucose. Drug-related adverse events were reported for 14 patients (22.6%) in Arm 1 and 10 patients (24.4%) in Arm 2, most frequently headache, diarrhoea, flushing and dizziness. A dose-dependent increase in heart rate was seen with BI 187004 treatment. CONCLUSIONS BI 187004 was generally well tolerated in patients with T2DM. Despite complete 11β-HSD1 inhibition, no clinically relevant effects were observed with BI 187004.
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Affiliation(s)
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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6
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Verma S, Dhingra NK, Butler J, Anker SD, Pedro Ferreira J, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Pfarr E, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Empagliflozin in Black Versus White Patients With Heart Failure: Analysis of EMPEROR-Pooled. Circulation 2023; 147:101-104. [PMID: 36342827 DOI: 10.1161/circulationaha.122.062644] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Canada (S.V., N.K.D.)
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Canada (S.V., N.K.D.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi School of Medicine, Jackson (J.B.)
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Germany (S.D.A.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France (J.P.F., F.Z.)
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Greece (G.F.)
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston (J.L.J.)
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-NUS Medical School (C.S.P.L.)
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, UK (N.S.)
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (E.P.)
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.N., M.B.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.N., M.B.)
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Germany (M.B.)
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (S.J.P.)
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France (J.P.F., F.Z.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
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7
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Verma S, Dhingra NK, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Peil B, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Empagliflozin in the treatment of heart failure with reduced ejection fraction in addition to background therapies and therapeutic combinations (EMPEROR-Reduced): a post-hoc analysis of a randomised, double-blind trial. Lancet Diabetes Endocrinol 2022; 10:35-45. [PMID: 34861154 DOI: 10.1016/s2213-8587(21)00292-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; pinteraction=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; pinteraction=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; pinteraction=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING Boehringer Ingelheim and Eli Lilly and Company.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Joao Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke- National University of Singapore Medical School, Singapore
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany; Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA; Imperial College London, London, UK
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Zeymer U, Leiva O, Hohnloser S, Steg PG, Oldgren J, Nickenig G, Gabor Kiss R, Ongen Z, Navarro Estrada J, Oude Ophuis T, Lip GY, Nordaby M, Miede C, ten Berg JM, Bhatt DL, Cannon CP. Dual antithrombotic therapy with dabigatran in patients with atrial fibrillation after percutaneous coronary intervention for ST-segment elevation myocardial infarction: a post hoc analysis of the randomised RE-DUAL PCI trial. EUROINTERVENTION 2021; 17:474-480. [PMID: 33164896 PMCID: PMC9724936 DOI: 10.4244/eij-d-20-00799] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little is known about the optimal antithrombotic therapy in patients with atrial fibrillation undergoing PCI for ST-elevation myocardial infarction (STEMI). AIMS The aim of this study was to investigate the safety and efficacy of dabigatran dual therapy (110 or 150 mg twice daily, plus clopidogrel or ticagrelor) versus warfarin triple therapy in patients with atrial fibrillation and STEMI. METHODS In the RE-DUAL PCI trial, 305 patients with STEMI were randomised to dabigatran 110 mg (n=113 versus 106 warfarin) or 150 mg (n=86 versus 84 warfarin). The primary endpoint was the time to first major/clinically relevant non-major bleeding event (MBE/CRNMBE). The thrombotic endpoint was a composite of death, thromboembolic events, or unplanned revascularisation. RESULTS In STEMI patients, dabigatran 110 mg (HR 0.39, 95% CI: 0.20-0.74) and 150 mg (0.43, 0.21-0.89) dual therapy reduced the risk of MBE/CRNMBE versus warfarin triple therapy (p for interaction vs all other patients=0.31 and 0.16). The risk of thrombotic events for dabigatran 110 mg (HR 1.61, 95% CI: 0.85-3.08) and 150 mg (0.56, 0.20-1.51) had p interactions of 0.20 and 0.33, respectively. For net clinical benefit, the HRs were 0.74 (95% CI: 0.46-1.17) and 0.49 (0.27-0.91) for dabigatran 110 and 150 mg (p for interaction=0.80 and 0.12), respectively. CONCLUSIONS After PCI for STEMI, patients on dabigatran dual therapy had lower risks of bleeding events versus warfarin triple therapy with similar risks of thromboembolic events, supporting dabigatran dual therapy even in patients with high thrombotic risk.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Bremserstrasse 79, 67063 Ludwigshafen, Germany
| | - Orly Leiva
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
| | | | - Philippe Gabriel Steg
- Université Paris Diderot, Paris, France,INSERM U_1148, Paris, France,Hôpital Bichat Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences Uppsala University, Uppsala, Sweden
| | | | | | - Zeki Ongen
- Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom,Aalborg Thrombosis Research Unit Department of Clinical Medicine, Aalborg University Aalborg, Denmark
| | | | | | | | - Deepak L. Bhatt
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
| | - Christopher P. Cannon
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
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9
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Eccleston DS, Kim JM, Ten Berg JM, Steg PG, Bhatt DL, Hohnloser SH, de Veer A, Nordaby M, Miede C, Kimura T, Lip GYH, Oldgren J, Cannon CP. The effect of sex on the efficacy and safety of dual antithrombotic therapy with dabigatran versus triple therapy with warfarin after PCI in patients with atrial fibrillation (a RE-DUAL PCI subgroup analysis and comparison to other dual antithrombotic therapy trials). Clin Cardiol 2021; 44:1002-1010. [PMID: 34042199 PMCID: PMC8259156 DOI: 10.1002/clc.23649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/27/2022] Open
Abstract
Background The RE‐DUAL PCI trial demonstrated that in patients with nonvalvular atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), dual therapy with dabigatran and a P2Y12 inhibitor, either clopidogrel or ticagrelor, reduced the risk of bleeding without an increased risk of thromboembolic events as compared to triple therapy with warfarin in addition to a P2Y12 inhibitor and aspirin. What remains unclear is whether this effect is consistent between males and females undergoing PCI. Hypothesis The reduction in risk of bleeding without increased risk of thromboembolic events with dual therapy with dabigatran and a P2Y12 inhibitor in comparison to triple therapy with warfarin, a P2Y12 inhibitor and aspirin is consistent in females and males. Methods The primary safety endpoint was the first International Society on Thrombosis and Hemostasis (ISTH) major bleeding event (MBE) or clinically relevant non‐major bleeding event (CRNMBE). The efficacy endpoint was the composite of death, thromboembolic event (stroke, myocardial infarction, and systemic embolism) or unplanned revascularization. Cox proportional hazard regression analyses were applied to calculate corresponding hazard ratios and interaction p values for each endpoint. Results A total of 655 women and 2070 men were enrolled. The risk of major or CRNM bleeding was lower with both dabigatran 110 mg dual therapy and dabigatran 150 mg dual therapy compared with warfarin triple therapy in female and male patients (for 110 mg: females: HR 0.69, 95% CI 0.47–1.01, males: HR 0.46, 95% CI 0.37–0.59, interaction p value: 0.084 and for 150 mg: females HR 0.74, 95% CI 0.48–1.16, males HR 0.71, 95% CI 0.56–0.90, interaction p value: 0.83). There was also no detectable difference in the composite efficacy endpoint of death, thromboembolic events or unplanned revascularization between dabigatran dual therapy and warfarin triple therapy, with no statistically significant interaction between sex and treatment (interaction p values: 0.73 and 0.72, respectively). Conclusions Consistent with the overall study results, the risk of bleeding was lower with dabigatran 110 mg and 150 mg dual therapy compared with warfarin triple therapy, and risk of thromboembolic events was comparable with warfarin triple therapy independent of the patient's sex.
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Affiliation(s)
- David S Eccleston
- Department of Medicine, University of Melbourne and GenesisCare, Melbourne, Australia
| | - Joseph M Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jurien M Ten Berg
- Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - P Gabriel Steg
- FACT, an F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM U_1148 and Hôpital Bichat Assistance Publique, Paris, France
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stefan H Hohnloser
- Johann Wolfgang Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
| | | | | | | | - Takeshi Kimura
- Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christopher P Cannon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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10
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Abraham WT, Lindenfeld J, Ponikowski P, Agostoni P, Butler J, Desai AS, Filippatos G, Gniot J, Fu M, Gullestad L, Howlett JG, Nicholls SJ, Redon J, Schenkenberger I, Silva-Cardoso J, Störk S, Krzysztof Wranicz J, Savarese G, Brueckmann M, Jamal W, Nordaby M, Peil B, Ritter I, Ustyugova A, Zeller C, Salsali A, Anker SD. Effect of empagliflozin on exercise ability and symptoms in heart failure patients with reduced and preserved ejection fraction, with and without type 2 diabetes. Eur Heart J 2021; 42:700-710. [PMID: 33351892 DOI: 10.1093/eurheartj/ehaa943] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [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: 06/09/2020] [Revised: 07/31/2020] [Accepted: 11/05/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS The EMPERIAL (Effect of EMPagliflozin on ExeRcise ability and HF symptoms In patients with chronic heArt faiLure) trials evaluated the effects of empagliflozin on exercise ability and patient-reported outcomes in heart failure (HF) with reduced and preserved ejection fraction (EF), with and without type 2 diabetes (T2D), reporting, for the first time, the effects of sodium-glucose co-transporter-2 inhibition in HF with preserved EF (HFpEF). METHODS AND RESULTS HF patients with reduced EF (HFrEF) (≤40%, N = 312, EMPERIAL-Reduced) or preserved EF (>40%, N = 315, EMPERIAL-Preserved), with and without T2D, were randomized to empagliflozin 10 mg or placebo for 12 weeks. The primary endpoint was 6-minute walk test distance (6MWTD) change to Week 12. Key secondary endpoints included Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and Chronic Heart Failure Questionnaire Self-Administered Standardized format (CHQ-SAS) dyspnoea score. 6MWTD median (95% confidence interval) differences, empagliflozin vs. placebo, at Week 12 were -4.0 m (-16.0, 6.0; P = 0.42) and 4.0 m (-5.0, 13.0; P = 0.37) in EMPERIAL-Reduced and EMPERIAL-Preserved, respectively. As the primary endpoint was non-significant, all secondary endpoints were considered exploratory. Changes in KCCQ-TSS and CHQ-SAS dyspnoea score were non-significant. Improvements with empagliflozin in exploratory pre-specified analyses of KCCQ-TSS responder rates, congestion score, and diuretic use in EMPERIAL-Reduced are hypothesis generating. Empagliflozin adverse events were consistent with those previously reported. CONCLUSION The primary outcome for both trials was neutral. Empagliflozin was well tolerated in HF patients, with and without T2D, with a safety profile consistent with that previously reported in T2D. Hypothesis-generating improvements in exploratory analyses of secondary endpoints with empagliflozin in HFrEF were observed.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, 473 West 12th Ave., Columbus, OH 43210, USA
| | - JoAnn Lindenfeld
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Piotr Ponikowski
- Wroclaw Medical University, Wybrzeże L. Pasteura 1, 50-367, Wroclaw, Poland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino-IRCCS, Via Carlo Parea, 4 - 20138, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19 20122, Milan, Italy
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS-39216, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens 157 72, Greece.,University of Cyprus, School of Medicine, Shacolas Educational Centre for Clinical Medicine, Palaios dromos Lefkosias Lemesou No.215/6, 2029 Aglantzia, Nicosia, Cyprus
| | - Jacek Gniot
- Department of Cardiology, Independent Public Healthcare, General Hospital in Puławy; ul. Bema 1; 24 - 100 Pulawy, Poland
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Søsterhjemmet, Kirkeveien 166, 2.etasje, 0450 Oslo, Norway.,KG Jebsen Center for Cardiac Research, University of Oslo, Sogn Arena, Klaus Torgårds vei 3, 2. Etg, 0372 Oslo, Norway.,Center for Heart Failure Research, Department of Cardiology Medicine (Building 3), 1st floor, Oslo University Hospital, Kirkeveien 166, 0407 Oslo, Norway
| | - Jonathan G Howlett
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Monash University, 27 Rainforest Walk, Clayton VIC 3800, Melbourne, Australia
| | - Josep Redon
- INCLIVA Research Institute, University of Valencia, vinguda de Menéndez y Pelayo, 4, 46010 Valencia, and CIBERObn, Madrid, Spain
| | | | - José Silva-Cardoso
- CardioCare, CINTESIS-Center for Health Technology and Services Research, and Director of the Cardiology Service, Porto University Medical School, São João University Medical Centre, Rua Dr. Plácido da Costa, s/n 4200-450, Porto, Portugal
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, Würzburg University and University Hospital Würzburg, Straubmühlweg 2, 97078 Würzburg, Germany
| | - Jerzy Krzysztof Wranicz
- Department of Electrocardiology, Medical University of Lodz, al. Tadeusza Kościuszki 4, 90-41, Lodz, Poland
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, Solna Karolinska University Hospital D1:04, SE-171 76 Stockholm, Sweden
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Ludolf-Krehl-Str. 13-17, 68167 Mannheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Ivana Ritter
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Anastasia Ustyugova
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88397 Biberach an der Riß, Germany
| | - Afshin Salsali
- Heart Failure and DM Global Development, Boehringer Ingelheim Pharmaceuticals, Inc, 900 Ridgebury Rd, Ridgefield, CT 06877, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Föhrer Str. 15, 13353 Berlin, Germany
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11
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Nicolau JC, Bhatt DL, Hohnloser SH, Kimura T, Lip GYH, Miede C, Nordaby M, Oldgren J, Steg PG, Ten Berg JM, Godoy LC, Cannon CP. Dabigatran Dual Therapy vs Warfarin Triple Therapy Post-Percutaneous Coronary Intervention in Patients with Atrial Fibrillation With/Without a Proton Pump Inhibitor: A Pre-Specified Analysis of the RE-DUAL PCI Trial. Drugs 2021; 80:995-1005. [PMID: 32562206 PMCID: PMC7320045 DOI: 10.1007/s40265-020-01323-x] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Objective In patients with atrial fibrillation following percutaneous coronary intervention, if a proton pump inhibitor is used, could that allow the use of warfarin triple therapy, or is there additional reduction in bleeding while using it with dual therapy? Methods The RE-DUAL PCI trial randomized 2725 patients with atrial fibrillation post-percutaneous coronary intervention to dabigatran dual therapy (110 or 150 mg twice daily, with clopidogrel or ticagrelor) or warfarin triple therapy (with clopidogrel or ticagrelor, and aspirin for 1–3 months). This prespecified subgroup analysis evaluated risks of a first major bleeding event or clinically relevant non-major bleeding event, all gastrointestinal bleeding, and a composite efficacy endpoint of all-cause mortality/thromboembolic event or unplanned revascularization according to baseline use of a proton pump inhibitor. Results Of 2678 analyzed patients, 1641 (61.3%) were receiving a proton pump inhibitor at baseline. Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy regardless of proton pump inhibitor use, with comparable risk of the composite efficacy endpoint (all interaction p values > 0.05). For gastrointestinal bleeding, no interaction was observed between study treatment and proton pump inhibitor use (interaction p values 0.84 and 0.62 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin triple therapy). Conclusions Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy, regardless of proton pump inhibitor use at baseline, in patients with atrial fibrillation who underwent percutaneous coronary intervention. Risk of the composite efficacy endpoint appeared to be similar for dabigatran dual therapy vs warfarin triple therapy in patients receiving/not receiving a proton pump inhibitor. ClinicalTrials.gov unique identifier NCT02164864. Video abstract
Electronic supplementary material The online version of this article (10.1007/s40265-020-01323-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
| | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- Université de Paris, FACT, INSERM U_1148, Paris, France.,Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Lucas C Godoy
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.,Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Christopher P Cannon
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
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12
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Costa F, Valgimigli M, Steg PG, Bhatt DL, Hohnloser SH, Ten Berg JM, Miede C, Nordaby M, Lip GYH, Oldgren J, Cannon CP. Antithrombotic therapy according to baseline bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention: applying the PRECISE-DAPT score in RE-DUAL PCI. European Heart Journal - Cardiovascular Pharmacotherapy 2020; 8:216-226. [DOI: 10.1093/ehjcvp/pvaa135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/30/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022]
Abstract
Abstract
Aims
Patients with atrial fibrillation undergoing coronary intervention are at higher bleeding risk due to the concomitant need for oral anticoagulation and antiplatelet therapy. The RE-DUAL PCI trial demonstrated better safety with dual antithrombotic therapy (DAT: dabigatran 110 or 150 mg b.i.d., clopidogrel or ticagrelor) compared to triple antithrombotic therapy (TAT: warfarin, clopidogrel or ticagrelor, and aspirin). We explored the impact of baseline bleeding risk based on the PRECISE-DAPT score for decision-making regarding DAT vs. TAT.
Methods and results
A score ≥25 points qualified high bleeding risk (HBR). Comparisons were made for the primary safety endpoint International Society of Thrombosis and Haemostasis major or clinically relevant non-major bleeding, and the composite efficacy endpoint of death, thrombo-embolic events, or unplanned revascularization, analysed by time-to-event analysis. PRECISE-DAPT was available in 2336/2725 patients, and 37.9% were HBR. Compared to TAT, DAT with dabigatran 110 mg reduced bleeding risk both in non-HBR [hazard ratio (HR) 0.42, 95% confidence interval (CI) 0.31–0.57] and HBR (HR 0.70, 95% CI 0.52–0.94), with a greater magnitude of benefit among non-HBR (Pint = 0.02). Dual antithrombotic therapy with dabigatran 150 mg vs. TAT reduced bleeding in non-HBR (HR 0.60, 95% CI 0.45–0.80), with a trend toward less benefit in HBR patients (HR 0.92, 95% CI 0.63–1.34; Pint = 0.08). The risk of ischaemic events was similar on DAT with dabigatran (both 110 and 150 mg) vs. TAT in non-HBR and HBR patients (Pint = 0.45 and Pint = 0.56, respectively).
Conclusions
PRECISE-DAPT score appeared useful to identify AF patients undergoing PCI at further increased risk of bleeding complications and may help clinicians identifying the antithrombotic regimen intensity with the best benefit–risk ratio in an individual patient.
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Affiliation(s)
- Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic “G Martino,” University of Messina, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Philippe Gabriel Steg
- FACT, an F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM U_1148 and Hôpital Bichat Assistance Publique, Paris, France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stefan H Hohnloser
- Department of Cardiology, Division of Clinical Electrophysiology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | | | | | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Christopher P Cannon
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
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13
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Calkins H, Willems S, Verma A, Schilling R, Hohnloser SH, Okumura K, Nordaby M, Kleine E, Bis B, Gerstenfeld EP. Heparin dosing in uninterrupted anticoagulation with dabigatran vs. warfarin in atrial fibrillation ablation: RE-CIRCUIT study. Europace 2020; 21:879-885. [PMID: 30982849 PMCID: PMC6781146 DOI: 10.1093/europace/euz057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/18/2019] [Indexed: 01/10/2023] Open
Abstract
AIMS To describe heparin dosing requirements in patients who underwent catheter ablation of atrial fibrillation with uninterrupted anticoagulation using dabigatran etexilate (dabigatran) or warfarin to attain therapeutic activated clotting time (ACT) in the RE-CIRCUIT® study. The RE-CIRCUIT study showed significantly fewer major bleeding events in the dabigatran vs. warfarin treatment group. Unfractionated heparin was administered during the procedure to maintain ACT >300 s. METHODS AND RESULTS Patients were randomly assigned to dabigatran 150 mg bid or international normalized ratio-adjusted warfarin. Ablation was performed with uninterrupted anticoagulation and continued for 8 weeks after the procedure. Heparin was administered after placement of femoral sheaths before or immediately after transseptal puncture. Ablation was performed in 635 patients (dabigatran, 317; warfarin, 318); data were available from 396 patients administered heparin (dabigatran, 191; warfarin, 205). Most frequent time window from last dose of study drug to septal puncture was 0 to <4 h in the dabigatran (41.3%) and 16 to <24 h in the warfarin arms (44.7%). Overall mean (standard deviation) heparin dose was similar between the dabigatran and warfarin groups [12 402 (10 721) vs. 11 910 (8359) IU, respectively]. Heparin dosing requirement to reach therapeutic ACT was lowest when time from last dose of dabigatran to septal puncture was 0 to <4 h. CONCLUSION Patients treated with dabigatran required a similar amount of unfractionated heparin as those treated with warfarin to achieve an ACT of >300 s during ablation. More heparin units were required when the time from the last dose of dabigatran to septal puncture increased.
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Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Atul Verma
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Cardiovascular Center, Kumamoto, Japan
| | - Matias Nordaby
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
| | - Eva Kleine
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
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14
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Oldgren J, Steg PG, Hohnloser SH, Lip GYH, Kimura T, Nordaby M, Brueckmann M, Kleine E, Ten Berg JM, Bhatt DL, Cannon CP. Dabigatran dual therapy with ticagrelor or clopidogrel after percutaneous coronary intervention in atrial fibrillation patients with or without acute coronary syndrome: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J 2020; 40:1553-1562. [PMID: 30793734 PMCID: PMC6514838 DOI: 10.1093/eurheartj/ehz059] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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: 05/11/2018] [Revised: 08/08/2018] [Accepted: 01/23/2019] [Indexed: 12/16/2022] Open
Abstract
AIMS After percutaneous coronary intervention (PCI) in patients with atrial fibrillation, safety and efficacy with dabigatran dual therapy were evaluated in pre-specified subgroups of patients undergoing PCI due to acute coronary syndrome (ACS) or elective PCI, and those receiving ticagrelor or clopidogrel treatment. METHODS AND RESULTS In the RE-DUAL PCI trial, 2725 patients were randomized to dabigatran 110 mg or 150 mg with P2Y12 inhibitor, or warfarin with P2Y12 inhibitor and aspirin. Mean follow-up was 14 months, 50.5% had ACS, and 12% received ticagrelor. The risk of the primary endpoint, major or clinically relevant non-major bleeding event, was reduced with both dabigatran dual therapies vs. warfarin triple therapy in patients with ACS [hazard ratio (95% confidence interval), 0.47 (0.35-0.63) for 110 mg and 0.67 (0.50-0.90) for 150 mg]; elective PCI [0.57 (0.43-0.76) for 110 mg and 0.76 (0.56-1.03) for 150 mg]; receiving ticagrelor [0.46 (0.28-0.76) for 110 mg and 0.59 (0.34-1.04) for 150 mg]; or clopidogrel [0.51 (0.41-0.64) for 110 mg and 0.73 (0.58-0.91) for 150 mg], all interaction P-values >0.10. Overall, dabigatran dual therapy was comparable to warfarin triple therapy for the composite endpoint of death, myocardial infarction, stroke, systemic embolism, or unplanned revascularization, with minor variations across the subgroups, all interaction P-values >0.10. CONCLUSION The benefits of both dabigatran 110 mg and 150 mg dual therapy compared with warfarin triple therapy in reducing bleeding risks were consistent across subgroups of patients with or without ACS, and patients treated with ticagrelor or clopidogrel.
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Affiliation(s)
- Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds väg 38, SE-751 85 Uppsala, Sweden
| | - Philippe Gabriel Steg
- FACT, an F-CRIN Network, Université Paris Diderot, INSERM U_1148 and Hôpital Bichat Assistance Publique, Paris, France.,Royal Brompton Hospital, Imperial College, Sydney Street, London, UK
| | - Stefan H Hohnloser
- Department of Medicine, Division of Cardiology, Johann Wolfgang Goethe University, Theodor Stern-Kai 7, DE-60590 Frankfurt/Main, Germany
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Søndre Skovvej 15, Aalborg, Denmark
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, TA CardioMetabolism, Binger Str. 173, Ingelheim, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, TA CardioMetabolism, Binger Str. 173, Ingelheim, Germany.,Faculty of Medicine, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Eva Kleine
- Boehringer Ingelheim International GmbH, TA CardioMetabolism, Binger Str. 173, Ingelheim, Germany
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Ziekenhuis, Koekoekslaan 1, Nieuwegein 3435 CM, The Netherlands
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Christopher P Cannon
- Brigham and Women's Hospital, Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA, USA.,Baim Institute for Clinical Research, 930-W Commonwealth Avenue, Boston, MA, USA
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15
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Maeng M, Bhatt DL, Nordaby M, Miede C, Cannon CP. Reply: Our Perspective on Anticoagulation Therapy Post-PCI in Atrial Fibrillation Patients With Diabetes. JACC Cardiovasc Interv 2020; 13:658-659. [PMID: 32139229 DOI: 10.1016/j.jcin.2020.01.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 11/19/2022]
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16
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ten Berg JM, Steg PG, Bhatt DL, Hohnloser SH, de Veer A, Nordaby M, Miede C, Kimura T, Lip GY, Oldgren J, Cannon CP. Comparison of the Effect of Age (< 75 Versus ≥ 75) on the Efficacy and Safety of Dual Therapy (Dabigatran + Clopidogrel or Ticagrelor) Versus Triple Therapy (Warfarin + Aspirin + Clopidogrel or Ticagrelor) in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention (from the RE-DUAL PCI Trial). Am J Cardiol 2020; 125:735-743. [PMID: 31924322 DOI: 10.1016/j.amjcard.2019.11.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
The RE-DUAL PCI trial reported that dabigatran dual therapy (110/150 mg twice daily, plus clopidogrel or ticagrelor) reduced bleeding events versus warfarin triple therapy (warfarin plus aspirin and clopidogrel or ticagrelor) in patients with atrial fibrillation who underwent percutaneous coronary intervention, with noninferiority in composite thromboembolic events. In this prespecified analysis, risks of first major or clinically relevant nonmajor bleeding event and composite end point of death, thromboembolic events, or unplanned revascularization were compared between dabigatran dual therapy and warfarin triple therapy in older (≥ 75 years) and younger (< 75 years) patients, using Cox proportional hazard regression. Of 2,725 patients randomized to treatment, 1,026 (37.7%) were categorized into older and 1,699 (62.3%) into younger age groups. Dabigatran 110 mg dual therapy lowered bleeding risk versus warfarin triple therapy in older (hazard ratio [HR] 0.67; 95% confidence interval [CI] 0.51 to 0.89) and younger patients (HR 0.40; 95% CI 0.30 to 0.54); interaction p value: 0.0125. Dabigatran 150 mg dual therapy lowered bleeding risk versus warfarin triple therapy in younger patients (HR 0.57; 95% CI 0.44 to 0.74), whereas no benefit could be observed in older patients (HR 1.21; 95% CI 0.83 to 1.77); interaction p value: 0.0013. For the thromboembolic end point, there was a trend for a higher risk with dabigatran 110 mg dual therapy in older patients, compared with warfarin triple therapy, whereas the risk was similar in younger patients. For dabigatran 150 mg dual therapy, the thromboembolic risk versus warfarin triple therapy was similar in older and younger patients. In conclusion, the benefits of dabigatran dual therapy differed in the 2 age groups, which may help dose selection when using dabigatran dual therapy.
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17
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Eccleston D, Ten Berg JM, Steg PG, Bhatt DL, Hohnloser SH, De Veer A, Nordaby M, Miede C, Kimura T, Lip GYH, Oldgren J, Cannon CP. P34 The effect of sex on the efficacy and safety of dabigatran dual therapy in atrial fibrillation after PCI: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehz872.031] [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
Funding Acknowledgements
Boehringer Ingelheim International GmbH
On Behalf
The Re-DUAL PCI Investigators
Background
The RE-DUAL PCI study (NCT02164864) compared dabigatran dual antithrombotic therapy (D-DAT) with warfarin triple antithrombotic therapy (W-TAT) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). As previously reported D-DAT reduced bleeding compared with W-TAT and was non-inferior with regard to thromboembolic events.
Aim
The aim of this subgroup analysis of RE-DUAL was to assess the relationship between sex and treatment effects of D-DAT and W-TAT on bleeding and thromboembolic outcomes.
Methods
Patients were randomized to receive W-TAT (warfarin, clopidogrel or ticagrelor, and aspirin) or D-DAT (dabigatran 110 or 150 mg twice daily with clopidogrel or ticagrelor; D110- or D150-DAT). Younger patients (aged < 80 yrs. [< 70 yrs. in Japan]) and US patients irrespective of age received D110-DAT, D150-DAT or W-TAT; older patients (aged ≥ 80 yrs. in non-US countries [≥ 70 yrs. in Japan]) received only D110-DAT or W-TAT. Bleeding and thromboembolic outcomes were assessed according to treatment group and by sex (female vs. male).
Results
A total of 2725 patients were randomized; 2070 patients were male (76.0%) and 655 (24.0%) were female. Overall females were older at time of PCI than males (73.2 ± 7.9 vs. 70.0 ± 8.8 years). The mean CHA2DS2-VASc and modified HAS-BLED scores were higher in women at 4.5 and 2.8, respectively, than in men at 3.3 and 2.7, respectively.
For the primary endpoint of major bleeding events or clinically relevant non-major bleeding events, treatment effects of D110-DAT vs. W-TAT were consistent for female and male patients (females: HR 0.69, 95% CI 0.47-1.01, males HR 0.46, 95%CI 0.37-0.59, interaction p-value 0.084). Similarly, consistent treatment effects were seen for the primary endpoint with D150-DAT vs W-TAT in female and male patients (females HR 0.74, 95% CI 0.48-1.16, males HR 0.71, 95% CI 0.56-0.90, interaction p value 0.83).
No interaction between sex and treatment was observed for D110- or D150-DAT vs W-TAT with regard to the composite efficacy endpoint of death, thromboembolic events or unplanned revascularization (interaction p values 0.73 and 0.72, respectively) (figure).
Conclusion
The treatment effect of dabigatran 110 mg and 150 mg dual therapy vs warfarin triple therapy was consistent across sex groups. This suggests that female and male patients with AF undergoing PCI should be treated equally in terms of the dosage of dabigatran selected for dual therapy strategies.
Abstract P34 Figure. Re-DUAL sex subgroup analysis
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Affiliation(s)
- D Eccleston
- University of Melbourne and GenesisCare, Melbourne, Australia
| | - J M Ten Berg
- St Antonius Hospital, Nieuwegein, Netherlands (The)
| | - P G Steg
- University Paris Diderot , Paris, France
| | - D L Bhatt
- Brigham and Women"s Hospital, Boston, United States of America
| | - S H Hohnloser
- JW Goethe University, Department of Cardiology, Frankfurt am Main, Germany
| | - A De Veer
- St Antonius Hospital, Nieuwegein, Netherlands (The)
| | - M Nordaby
- Boehringer Ingelheim GmbH, Ingelheim, Germany
| | - C Miede
- HMS Analytical Software GmbH , Heidelberg, Germany
| | - T Kimura
- Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan
| | - G Y H Lip
- University of Liverpool, Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - J Oldgren
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - C P Cannon
- Brigham and Women"s Hospital, Boston, United States of America
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ten Berg JM, de Veer A, Oldgren J, Steg PG, Zateyshchikov DA, Jansky P, Seung KB, Hohnloser SH, Lip GY, Nordaby M, Kleine E, Bhatt DL, Cannon CP. Switching of Oral Anticoagulation Therapy After PCI in Patients With Atrial Fibrillation. JACC Cardiovasc Interv 2019; 12:2331-2341. [DOI: 10.1016/j.jcin.2019.08.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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19
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Maeng M, Steg PG, Bhatt DL, Hohnloser SH, Nordaby M, Miede C, Kimura T, Lip GY, Oldgren J, ten Berg JM, Cannon CP. Dabigatran Dual Therapy Versus Warfarin Triple Therapy Post–PCI in Patients With Atrial Fibrillation and Diabetes. JACC Cardiovasc Interv 2019; 12:2346-2355. [DOI: 10.1016/j.jcin.2019.07.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 01/17/2023]
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20
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Lip GYH, Bhatt DL, Hohnloser SH, Kimura T, Miede C, Nordaby M, Oldgren J, Steg PG, Ten Berg JM, Cannon CP. Dabigatran Dual Therapy Versus Warfarin Triple Therapy in Atrial Fibrillation Post-PCI: Time in Therapeutic Range. J Am Coll Cardiol 2019; 74:2431-2433. [PMID: 31699285 DOI: 10.1016/j.jacc.2019.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/12/2019] [Indexed: 11/29/2022]
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21
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Hohnloser SH, Steg PG, Oldgren J, Nickenig G, Kiss RG, Ongen Z, Navarro Estrada JL, Oude Ophuis T, Lip GY, Nordaby M, Kleine E, ten Berg JM, Bhatt DL, Cannon CP. Renal Function and Outcomes With Dabigatran Dual Antithrombotic Therapy in Atrial Fibrillation Patients After PCI. JACC Cardiovasc Interv 2019; 12:1553-1561. [DOI: 10.1016/j.jcin.2019.05.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/17/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
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22
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Cardoso R, Willems S, Gerstenfeld EP, Verma A, Schilling R, Hohnloser SH, Okumura K, Nordaby M, Brouwer MA, Calkins H. Uninterrupted anticoagulation with non-vitamin K antagonist oral anticoagulants in atrial fibrillation catheter ablation: Lessons learned from randomized trials. Clin Cardiol 2018; 42:198-205. [PMID: 30460702 DOI: 10.1002/clc.23120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 01/30/2023] Open
Abstract
Catheter ablation has been established as a rhythm control strategy in selected patients with atrial fibrillation (AF) who have failed or wish to avoid anti-arrhythmic drugs. Uninterrupted oral anticoagulation with vitamin K antagonists (VKAs) peri-ablation is associated with a lower risk of thromboembolic and bleeding complications as compared to interrupted oral anticoagulation and bridging heparin. However, a substantial portion of patients with AF are treated with non-vitamin K antagonist oral anticoagulants (NOACs). Herein, we perform an in-depth review and comparison of three recent randomized trials of uninterrupted oral anticoagulation with NOACs vs VKAs in patients undergoing AF catheter ablation. Furthermore, we report pooled results of these randomized trials. The pooled incidence of major bleeding was significantly lower with NOACs as compared to VKAs (2% vs 4.9%, respectively; odds ratio [OR] 0.40; 95% confidence intervals [CI] 0.16-0.99). Similarly, cardiac tamponade was also reduced in the NOAC group (0.4% vs 1.5%; OR 0.27; 95% CI 0.07-0.97). Thromboembolic complications were not significantly different between groups. Overall, these findings support the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement's class I recommendation for uninterrupted NOAC use in patients undergoing AF catheter ablation.
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Affiliation(s)
- Rhanderson Cardoso
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephan Willems
- Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg, Germany
| | - Edward P Gerstenfeld
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Atul Verma
- Division of Cardiology, University of Toronto, Toronto, Canada
| | - Richard Schilling
- Division of Cardiology, Barts Heart Centre, Saint Bartholomew's Hospital, London, UK
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Matias Nordaby
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Mauri L, Steg PS, Bhatt DL, Hohnloser SH, Nordaby M, Miede C, Kimura T, Lip GYH, Oldgren J, Ten Berg JM, Cannon C. P3180The effect of PCI complexity on the efficacy and safety of dabigatran dual therapy vs warfarin triple therapy in atrial fibrillation: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Mauri
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
| | - P S Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - D L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
| | | | - M Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - C Miede
- HMS Analytical Software GmbH, Weimar (Lahn), Germany
| | | | - G Y H Lip
- University of Birmingham, Birmingham, United Kingdom
| | | | - J M Ten Berg
- St. Antonius Ziekenhuis, Department of Cardiology, Nieuwegein, Netherlands
| | - C Cannon
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
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Ten Berg JM, Steg PG, Bhatt DL, Hohnloser SH, De Veer ANNE, Nordaby M, Miede C, Kimura T, Lip GYH, Oldgren J, Cannon CP. P2243The effect of age on the efficacy and safety of dabigatran dual therapy in atrial fibrillation after PCI: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J M Ten Berg
- St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - P G Steg
- FACT, an F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM U_1148 and Hôpital Bichat Assist, Paris, France
| | - D L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
| | - S H Hohnloser
- Johann Wolfgang Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
| | | | - M Nordaby
- Boehringer Ingelheim GmbH, Ingelheim, Germany
| | - C Miede
- HMS Analytical Software GmbH, Weimar (Lahn), Germany
| | - T Kimura
- Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan
| | - G Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - J Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - C P Cannon
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
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De Caterina R, Lopez Sendon JL, Mehta S, Opolski G, Oldgren J, Steg PG, Hohnloser S, Lip GYH, Kimura T, Nordaby M, Kleine E, Ten Berg JM, Bhatt DL, Cannon C. P2298High body mass index and outcomes of dual antithrombotic therapy with dabigatran and a P2Y12 inhibitor in patients with atrial fibrillation undergoing PCI: Results from RE-DUAL PCI. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - S Mehta
- McMaster University, Hamilton, Canada
| | - G Opolski
- Medical University of Warsaw, Warsaw, Poland
| | | | - P G Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - S Hohnloser
- JW Goethe University, Frankfurt am Main, Germany
| | - G Y H Lip
- Birmingham City Hospital, Birmingham, United Kingdom
| | | | - M Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - E Kleine
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - D L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
| | - C Cannon
- Baim Institute for Clinical Research, Boston, United States of America
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26
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Maeng M, Steg PG, Bhatt DL, Hohnloser SH, Nordaby M, Miede C, Kimura T, Lip GYH, Oldgren J, Ten Berg JM, Cannon CP. P5333Dual antithrombotic therapy with dabigatran vs triple therapy with warfarin after PCI in patients with atrial fibrillation and diabetes mellitus (a RE-DUAL PCI subgroup analysis). Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Maeng
- Aarhus University Hospital, Aarhus, Denmark
| | - P G Steg
- Hospital Bichat-Claude Bernard, Paris, France
| | - D L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
| | | | - M Nordaby
- Boehringer Ingelheim GmbH, Ingelheim, Germany
| | - C Miede
- HMS Analytical Software GmbH, Weimar (Lahn), Germany
| | | | - G Y H Lip
- University of Birmingham, Birmingham, United Kingdom
| | | | - J M Ten Berg
- St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - C P Cannon
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, United States of America
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Berg JT, de Veer A, Oldgren J, Steg P, Zateyshchikov DA, Janský P, Seung KB, Hohnloser S, Lip G, Nordaby M, Kleine E, Bhatt D, Cannon C. IS IT SAFE TO SWITCH OAC IN PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION? RESULTS FROM A RE-DUAL PCI SUBANALYSIS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Hohnloser S, Steg P, Oldgren J, Nickenig G, Kiss RG, Ongen Z, Estrada JN, Ophuis TO, Lip G, Nordaby M, Kleine E, Berg JT, Bhatt D, Cannon C. DOES RENAL FUNCTION INFLUENCE THE BENEFIT OF DUAL ANTITHROMBOTIC THERAPY WITH DABIGATRAN IN PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION? RESULTS FROM RE-DUAL PCI. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30855-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Yoshida Y, Watarai M, Fujii K, Shimizu W, Satomi K, Inden Y, Murakami Y, Murakami M, Iwasa A, Kimura M, Yamada N, Nakagawa T, Nordaby M, Okumura K. Comparison of uninterrupted anticoagulation with dabigatran etexilate or warfarin in the periprocedural period for atrial fibrillation catheter ablation: Results of the Japanese subgroup of the RE-CIRCUIT trial. J Arrhythm 2018; 34:148-157. [PMID: 29657590 PMCID: PMC5891433 DOI: 10.1002/joa3.12024] [Citation(s) in RCA: 4] [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: 09/13/2017] [Accepted: 11/20/2017] [Indexed: 01/10/2023] Open
Abstract
Background There are limited data on uninterrupted anticoagulation with direct oral anticoagulants during catheter ablation for atrial fibrillation (AF), particularly in Japan. We planned a subgroup analysis of the RE-CIRCUIT study, comparing the use of uninterrupted dabigatran therapy with warfarin therapy during catheter ablation among the Japanese subgroup and with that in the total population. Methods The RE-CIRCUIT study utilized a prospective, randomized, open-label, blinded endpoint design, and the primary endpoint was the incidence of major bleeding events (MBEs). Patients were randomized to uninterrupted dabigatran 150 mg twice daily or warfarin. In this study, we analyzed the results in Japanese patients. Results Of 704 enrolled patients in the study, 112 Japanese patients were randomized to dabigatran (n = 65) or warfarin (n = 47). MBEs were experienced by two patients: one in the dabigatran group (1.6%, cardiac tamponade) and one in the warfarin group (2.2%, groin hematoma) (risk difference vs warfarin -0.6%; 95% CI -5.8, 4.7). Within the Japanese subgroup, there were no thromboembolic events in both groups. Conclusion While not designed to show statistical difference between two treatment groups, our results from the Japanese subgroup supported those from the overall population. Furthermore, this study provided clinical information regarding MBE, especially cardiac tamponade, in Japanese patients.
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Affiliation(s)
- Yukihiko Yoshida
- Department of Cardiology Japanese Red Cross Nagoya Daini Hospital Nagoya Aichi Japan
| | - Masato Watarai
- Department of Cardiology Aichi Prefectural Welfare Federation of Agricultural Co-operative Associations Anjo-kosei Hospital Anjo Aichi Japan
| | - Kenshi Fujii
- Cardiovascular Division Sakurabashi Watanabe Hospital Osaka Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Hospital Bunkyo-ku Tokyo Japan
| | - Kazuhiro Satomi
- Department of Cardiology Tokyo Medical University Shinjyuku-ku Tokyo Japan
| | - Yasuya Inden
- Department of Cardiology Nagoya University Hospital Nagoya Aichi Japan
| | - Yoshimasa Murakami
- Division of Cardiology Nagoya City East Medical Center Nagoya Aichi Japan
| | - Masato Murakami
- Department of Cardiology Shonan Kamakura General Hospital Kamakura Kanagawa Japan
| | - Atsushi Iwasa
- Department of Cardiology New Tokyo Hospital Matsudo Chiba Japan
| | - Masaomi Kimura
- Department of Cardiology and Nephrology Hirosaki University Hospital Hirosaki Aomori Japan
| | - Nobuko Yamada
- Nippon Boehringer Ingelheim Co., Ltd. Shinagawa-ku Tokyo Japan
| | | | - Matias Nordaby
- Boehringer Ingelheim Pharma GmbH & Co. K GIngelheim am Rhein Germany
| | - Ken Okumura
- Division of Cardiology Saiseikai Kumamoto Hospital Kumamoto Japan
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Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, Maeng M, Merkely B, Zeymer U, Gropper S, Nordaby M, Kleine E, Harper R, Manassie J, Januzzi JL, Ten Berg JM, Steg PG, Hohnloser SH. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med 2017; 377:1513-1524. [PMID: 28844193 DOI: 10.1056/nejmoa1708454] [Citation(s) in RCA: 892] [Impact Index Per Article: 127.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Triple antithrombotic therapy with warfarin plus two antiplatelet agents is the standard of care after percutaneous coronary intervention (PCI) for patients with atrial fibrillation, but this therapy is associated with a high risk of bleeding. METHODS In this multicenter trial, we randomly assigned 2725 patients with atrial fibrillation who had undergone PCI to triple therapy with warfarin plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and aspirin (for 1 to 3 months) (triple-therapy group) or dual therapy with dabigatran (110 mg or 150 mg twice daily) plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and no aspirin (110-mg and 150-mg dual-therapy groups). Outside the United States, elderly patients (≥80 years of age; ≥70 years of age in Japan) were randomly assigned to the 110-mg dual-therapy group or the triple-therapy group. The primary end point was a major or clinically relevant nonmajor bleeding event during follow-up (mean follow-up, 14 months). The trial also tested for the noninferiority of dual therapy with dabigatran (both doses combined) to triple therapy with warfarin with respect to the incidence of a composite efficacy end point of thromboembolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularization. RESULTS The incidence of the primary end point was 15.4% in the 110-mg dual-therapy group as compared with 26.9% in the triple-therapy group (hazard ratio, 0.52; 95% confidence interval [CI], 0.42 to 0.63; P<0.001 for noninferiority; P<0.001 for superiority) and 20.2% in the 150-mg dual-therapy group as compared with 25.7% in the corresponding triple-therapy group, which did not include elderly patients outside the United States (hazard ratio, 0.72; 95% CI, 0.58 to 0.88; P<0.001 for noninferiority). The incidence of the composite efficacy end point was 13.7% in the two dual-therapy groups combined as compared with 13.4% in the triple-therapy group (hazard ratio, 1.04; 95% CI, 0.84 to 1.29; P=0.005 for noninferiority). The rate of serious adverse events did not differ significantly among the groups. CONCLUSIONS Among patients with atrial fibrillation who had undergone PCI, the risk of bleeding was lower among those who received dual therapy with dabigatran and a P2Y12 inhibitor than among those who received triple therapy with warfarin, a P2Y12 inhibitor, and aspirin. Dual therapy was noninferior to triple therapy with respect to the risk of thromboembolic events. (Funded by Boehringer Ingelheim; RE-DUAL PCI ClinicalTrials.gov number, NCT02164864 .).
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Affiliation(s)
- Christopher P Cannon
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Deepak L Bhatt
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Jonas Oldgren
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Gregory Y H Lip
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Stephen G Ellis
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Takeshi Kimura
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Michael Maeng
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Bela Merkely
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Uwe Zeymer
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Savion Gropper
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Matias Nordaby
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Eva Kleine
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Ruth Harper
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Jenny Manassie
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - James L Januzzi
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Jurrien M Ten Berg
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - P Gabriel Steg
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
| | - Stefan H Hohnloser
- From the Baim Institute for Clinical Research (C.P.C., J.L.J.), Brigham and Women's Hospital, Heart and Vascular Center, and Harvard Medical School (C.P.C., D.L.B.), and the Cardiology Division, Massachusetts General Hospital, and Harvard Medical School (J.L.J.) - all in Boston; Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (J.O.); the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham (G.Y.H.L.), Boehringer Ingelheim, Bracknell (R.H., J.M.), and Imperial College, London, London (P.G.S.) - all in the United Kingdom; Cleveland Clinic, Cleveland (S.G.E.); Kyoto University, Department of Cardiovascular Medicine, Kyoto, Japan (T.K.); Aarhus University Hospital, Skejby, Denmark (M.M.); University Heart and Vascular Center, Budapest, Hungary (B.M.); Klinikum der Stadt Ludwigshafen am Rhein, Medizinische Klinik B, Ludwigshafen (U.Z.), Boehringer Ingelheim, Ingelheim (S.G., M.N., E.K.), and Johann Wolfgang Goethe University, Department of Medicine, Division of Cardiology, Frankfurt am Main (S.H.H.) - all in Germany; St. Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.M.B.); and the French Alliance for Cardiovascular Trials, F-CRIN Network, DHU FIRE, Université Paris Diderot, INSERM Unité 1148, and Hôpital Bichat Assistance Publique, Paris (P.G.S.)
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Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - Matias Nordaby
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
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Calkins H, Willems S, Gerstenfeld EP, Verma A, Schilling R, Hohnloser SH, Okumura K, Serota H, Nordaby M, Guiver K, Biss B, Brouwer MA, Grimaldi M. Uninterrupted Dabigatran versus Warfarin for Ablation in Atrial Fibrillation. N Engl J Med 2017; 376:1627-1636. [PMID: 28317415 DOI: 10.1056/nejmoa1701005] [Citation(s) in RCA: 291] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Catheter ablation of atrial fibrillation is typically performed with uninterrupted anticoagulation with warfarin or interrupted non-vitamin K antagonist oral anticoagulant therapy. Uninterrupted anticoagulation with a non-vitamin K antagonist oral anticoagulant, such as dabigatran, may be safer; however, controlled data are lacking. We investigated the safety of uninterrupted dabigatran versus warfarin in patients undergoing ablation of atrial fibrillation. METHODS In this randomized, open-label, multicenter, controlled trial with blinded adjudicated end-point assessments, we randomly assigned patients scheduled for catheter ablation of paroxysmal or persistent atrial fibrillation to receive either dabigatran (150 mg twice daily) or warfarin (target international normalized ratio, 2.0 to 3.0). Ablation was performed after 4 to 8 weeks of uninterrupted anticoagulation, which was continued during and for 8 weeks after ablation. The primary end point was the incidence of major bleeding events during and up to 8 weeks after ablation; secondary end points included thromboembolic and other bleeding events. RESULTS The trial enrolled 704 patients across 104 sites; 635 patients underwent ablation. Baseline characteristics were balanced between treatment groups. The incidence of major bleeding events during and up to 8 weeks after ablation was lower with dabigatran than with warfarin (5 patients [1.6%] vs. 22 patients [6.9%]; absolute risk difference, -5.3 percentage points; 95% confidence interval, -8.4 to -2.2; P<0.001). Dabigatran was associated with fewer periprocedural pericardial tamponades and groin hematomas than warfarin. The two treatment groups had a similar incidence of minor bleeding events. One thromboembolic event occurred in the warfarin group. CONCLUSIONS In patients undergoing ablation for atrial fibrillation, anticoagulation with uninterrupted dabigatran was associated with fewer bleeding complications than uninterrupted warfarin. (Funded by Boehringer Ingelheim; RE-CIRCUIT ClinicalTrials.gov number, NCT02348723 .).
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Affiliation(s)
- Hugh Calkins
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Stephan Willems
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Edward P Gerstenfeld
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Atul Verma
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Richard Schilling
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Stefan H Hohnloser
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Ken Okumura
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Harvey Serota
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Matias Nordaby
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Kelly Guiver
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Branislav Biss
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Marc A Brouwer
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
| | - Massimo Grimaldi
- From Johns Hopkins Medical Institutions, Baltimore (H.C.); Department of Cardiology-Electrophysiology, University Heart Center Hamburg, Hamburg (S.W.), Department of Cardiology, J.W. Goethe University, Frankfurt (S.H.H.), and Boehringer Ingelheim Pharma, Ingelheim am Rhein (M.N.) - all in Germany; Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco (E.P.G.); University of Toronto, Toronto (A.V.); Barts Heart Centre, Saint Bartholomew's Hospital, London (R.S.), and Biometrics and Data Sciences Department, Boehringer Ingelheim, Bracknell (K.G.) - both in the United Kingdom; Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan (K.O.); St. Louis Heart and Vascular, St. Louis (H.S.); Department of Clinical Operations, Boehringer Ingelheim Regional Center Vienna, Vienna (B.B.); Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B.); and Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, Italy (M.G.)
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Tinahones FJ, Gallwitz B, Nordaby M, Götz S, Maldonado-Lutomirsky M, Woerle HJ, Broedl UC. Linagliptin as add-on to empagliflozin and metformin in patients with type 2 diabetes: Two 24-week randomized, double-blind, double-dummy, parallel-group trials. Diabetes Obes Metab 2017; 19:266-274. [PMID: 27762093 DOI: 10.1111/dom.12814] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 08/19/2016] [Revised: 10/13/2016] [Accepted: 10/13/2016] [Indexed: 01/03/2023]
Abstract
AIM To evaluate the efficacy and safety of linagliptin vs placebo as add-on to empagliflozin and metformin in patients with type 2 diabetes. MATERIALS AND METHODS Patients with inadequate glycaemic control despite stable-dose metformin received open-label empagliflozin 10 mg (study 1) or 25 mg (study 2) as add-on therapy for 16 weeks. Subsequently, those with HbA1c ≥7.0 and ≤10.5% (>53 and ≤91 mmol/mol) (N = 482) were randomized to 24 weeks' double-blind, double-dummy treatment with linagliptin 5 mg or placebo in study 1, or to linagliptin 5 mg or placebo in study 2; all patients continued treatment with metformin and empagliflozin 10 mg (study 1) or metformin and empagliflozin 25 mg (study 2). The primary endpoint was change from baseline (defined as the last value before first intake of randomized, double-blind treatment) in HbA1c at week 24. RESULTS At week 24, HbA1c (mean baseline 7.82-8.04 [62-64 mmol/mol]) was significantly reduced with linagliptin vs placebo; adjusted mean (SE) differences in change from baseline in HbA1c with linagliptin vs placebo were -.32% (.10) (-3.59 [1.08] mmol/mol) ( P = .001) for patients on empagliflozin 10 mg and metformin, and -0.47% (0.10) (-5.15 [1.04] mmol/mol) ( P < 0.001) for patients on empagliflozin 25 mg and metformin. Adverse events were reported in more patients receiving placebo than in those receiving linagliptin: 55.5% vs 48.4% in study 1 and 58.9% vs 52.7% in study 2. CONCLUSIONS Linagliptin as add-on to empagliflozin and metformin for 24 weeks improved glycaemic control vs placebo, and was well tolerated.
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Affiliation(s)
- Francisco J Tinahones
- Department of Diabetes, Endocrinology and Nutrition, Instituto de Investigación Biomédica de Málaga (IBIMA) Hospital Universitario Virgen de la Victoria, Universidad Málaga, Málaga, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Málaga, Spain
| | - Baptist Gallwitz
- Department of Medicine IV (Endocrinology, Diabetes, Angiology, Nephrology & Clinical Chemistry), Eberhard Karls University, Tübingen, Germany
| | - Matias Nordaby
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Sophia Götz
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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