Challenges in Conducting Therapeutic Trials in Pregnancy: Emphasizing Recent Lessons Learned

Pregnant people have traditionally been excluded from therapeutic research by restrictions intended for fetal protection. Despite a movement toward inclusion, concerns for the feasibility and safety of including pregnant people in studies continue to limit this research. This article reviews the history of research guidelines in pregnancy and illustrates ongoing challenges, as seen in the development of vaccines and therapies during the coronavirus disease 2019 pandemic and investigation of statins for preeclampsia prevention. It explores new approaches that may be used to improve therapeutic research in pregnancy. A major cultural shift is needed to balance potential maternal and/or fetal risks with potential benefits from participation in research, as well as harm from withholding treatment or providing one that is not evidence-based. Finally, it is important to honor maternal autonomy in decision-making regarding participation in clinical trials.

Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension

BACKGROUND

The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts.

DESIGN

Secondary analysis of data from a prospective randomized clinical trial.

SETTING

Eleven US safety-net and community primary care clinics.

PATIENTS

Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included.

VARIABLE

Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions.

OUTCOMES

Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent).

RESULTS

Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93).

CONCLUSION

Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

Identifying a Heart Rate Recovery Criterion After a 6-Minute Walk Test in COPD

BACKGROUND

Slow heart rate recovery (HRR) after exercise is associated with autonomic dysfunction and increased mortality. What HRR criterion at 1-minute after a 6-minute walk test (6MWT) best defines pulmonary impairment?.

STUDY DESIGN AND METHODS

A total of 5008 phase 2 COPDGene (NCT00608764) participants with smoking history were included. A total of 2127 had COPD and, of these, 385 were followed-up 5-years later. Lung surgery, transplant, bronchiectasis, atrial fibrillation, heart failure and pacemakers were exclusionary. HR was measured from pulse oximetry at end-walk and after 1-min seated recovery. A receiver operator characteristic (ROC) identified optimal HRR cut-off. Generalized linear regression determined HRR association with spirometry, chest CT, symptoms and exacerbations.

RESULTS

HRR after 6MWT (bt/min) was categorized in quintiles: ≤5 (23.0% of participants), 6-10 (20.7%), 11-15 (18.9%), 16-22 (18.5%) and ≥23 (18.9%). Compared to HRR≤5, HRR≥11 was associated with (p<0.001): lower pre-walk HR and 1-min post HR; greater end-walk HR; greater 6MWD; greater FEV1%pred; lower airway wall area and wall thickness. HRR was positively associated with FEV1%pred and negatively associated with airway wall thickness. An optimal HRR ≤10 bt/min yielded an area under the ROC curve of 0.62 (95% CI 0.58-0.66) for identifying FEV1<30%pred. HRR≥11 bt/min was the lowest HRR associated with consistently less impairment in 6MWT, spirometry and CT variables. In COPD, HRR≤10 bt/min was associated with (p<0.001): ≥2 exacerbations in the previous year (OR=1.76[1.33-2.34]); CAT≥10 (OR=1.42[1.18-1.71]); mMRC≥2 (OR=1.42[1.19-1.69]); GOLD 4 (OR=1.98[1.44-2.73]) and GOLD D (OR=1.51[1.18-1.95]). HRR≤10 bt/min was predicted COPD exacerbations at 5-year follow-up (RR=1.83[1.07-3.12], P=0.027).

CONCLUSION

HRR≤10 bt/min after 6MWT in COPD is associated with more severe expiratory flow limitation, airway wall thickening, worse dyspnoea and quality of life, and future exacerbations, suggesting that an abnormal HRR≤10 bt/min after a 6MWT may be used in a comprehensive assessment in COPD for risk of severity, symptoms and future exacerbations.

"Passing Out is a Serious Thing": Patient Expectations for Syncope Evaluation and Management

PURPOSE

Syncope is a complex symptom requiring thoughtful evaluation. The ACC/AHA/HRS published syncope management guidelines in 2017. Effective guideline implementation hinges on overcoming multilevel barriers, including providers' perceptions that patients prefer aggressive diagnostic testing when presenting to the emergency department (ED) with syncope, which conflicts with the 2017 Guideline on Syncope. To better understand this perceived barrier, we explored patient and family caregiver expectations and preferences when presenting to the ED with syncope.

PATIENTS AND METHODS

We conducted semi-structured focus groups (N=12) and in-depth interviews (N=19) with patients presenting to the ED with syncope as well as with their family caregivers. Interviews were recorded, transcribed verbatim, and analyzed by a team of researchers following a directed content analysis. Results were reviewed and shared iteratively with all team members to confirm mutual understanding and agreement.

RESULTS

Syncope patients and caregivers discussed three main desires when presenting to the ED with syncope: 1) clarity regarding their diagnosis,; 2) context surrounding their care plan and diagnostic approach; and 3) to feel seen, heard and cared about by their health care team.

CONCLUSION

Clinicians have cited patient preferences for aggressive diagnostic testing as a barrier to adhering to the 2017 Guideline on Syncope, which recommends against routine administration of imaging testing (eg, echocardiograms). Our results suggest that while participants preferred diagnostic testing as a means to achieve clarity and even a feeling of being cared for, other strategies, such as a patient-engaged approach to communication and shared decision-making, may address the spectrum of patient expectations when presenting to the ED with syncope while adhering to guideline recommendations.

Insights from Monitoring Aspirin Adherence: A Medication Adherence Cascade Tool

BACKGROUND

Adherence to recommended medications is a key issue in the care of patients with cardiovascular disease (CVD) and barriers to adherence are well established during the medication adherence cascade, the processes of prescribing, obtaining, taking, and maintaining medication use. Aspirin avoids many of the barriers in the medication adherence cascade as it does not require a prescription (prescribing) and is inexpensive, easily accessible (obtaining), prescribed once-daily (taking) as an over-the-counter medication and is generally perceived by patients as safe (maintaining). The purpose of this paper is to report aspirin adherence and propose the Medication Adherence Cascade Tool to assist clinicians to consider all aspects of medication adherence.

METHODS

Adherence to aspirin was monitored with an electronic pillbox. Frequency analysis, independent T-tests, and ANOVA were completed on 151 patients with underlying heart failure who were prescribed aspirin within a larger parent study. Chi-square tests were completed to assess differences in baseline demographic characteristics.

FINDINGS

Mean aspirin adherence was 82.2% overall, with 11.9% of sample with adherence 50%, 18.5% with adherence 50-80%, and 69.5% with adherence ≥80%. Greater adherence was observed in self-identified White as compared to Black patients (84.47% vs 73.53%; p = 0.014), and patients ≥70 years of age compared to <70 years (87.00% vs 77.49%; p = 0.009).

INTERPRETATION

Aspirin adherence was suboptimal despite the fact that it addresses most of the barriers on the medication adherence cascade (ie, relatively easy access, low cost, and low risk). A Medication Adherence Cascade Tool (MACT) is proposed as a clinical guide to facilitate patient-provider co-production of strategies to address medication adherence. The tool can assist patients and providers to co-produce adherence to achieve optimal medication benefits.

GWAS of QRS duration identifies new loci specific to Hispanic/Latino populations

Background

The electrocardiographically quantified QRS duration measures ventricular depolarization and conduction. QRS prolongation has been associated with poor heart failure prognosis and cardiovascular mortality, including sudden death. While previous genome-wide association studies (GWAS) have identified 32 QRS SNPs across 26 loci among European, African, and Asian-descent populations, the genetics of QRS among Hispanics/Latinos has not been previously explored.

Methods

We performed a GWAS of QRS duration among Hispanic/Latino ancestry populations (n = 15,124) from four studies using 1000 Genomes imputed genotype data (adjusted for age, sex, global ancestry, clinical and study-specific covariates). Study-specific results were combined using fixed-effects, inverse variance-weighted meta-analysis.

Results

We identified six loci associated with QRS (P<5x10^-8), including two novel loci: MYOCD, a nuclear protein expressed in the heart, and SYT1, an integral membrane protein. The top SNP in the MYOCD locus, intronic SNP rs16946539, was found in Hispanics/Latinos with a minor allele frequency (MAF) of 0.04, but is monomorphic in European and African descent populations. The most significant QRS duration association was with intronic SNP rs3922344 (P = 1.19x10^-24) in SCN5A/SCN10A. Three other previously identified loci, CDKN1A, VTI1A, and HAND1, also exceeded the GWAS significance threshold among Hispanics/Latinos. A total of 27 of 32 previously identified QRS duration SNPs were shown to generalize in Hispanics/Latinos.

Conclusions

Our QRS duration GWAS, the first in Hispanic/Latino populations, identified two new loci, underscoring the utility of extending large scale genomic studies to currently under-examined populations.

Rare variants in fox-1 homolog A (RBFOX1) are associated with lower blood pressure

Many large genome-wide association studies (GWAS) have identified common blood pressure (BP) variants. However, most of the identified BP variants do not overlap with the linkage evidence observed from family studies. We thus hypothesize that multiple rare variants contribute to the observed linkage evidence. We performed linkage analysis using 517 individuals in 130 European families from the Cleveland Family Study (CFS) who have been genotyped on the Illumina OmniExpress Exome array. The largest linkage peak was observed on chromosome 16p13 (MLOD = 2.81) for systolic blood pressure (SBP). Follow-up conditional linkage and association analyses in the linkage region identified multiple rare, coding variants in RBFOX1 associated with reduced SBP. In a 17-member CFS family, carriers of the missense variant rs149974858 are normotensive despite being obese (average BMI = 60 kg/m2). Gene-based association test of rare variants using SKAT-O showed significant association with SBP (p-value = 0.00403) and DBP (p-value = 0.0258) in the CFS participants and the association was replicated in large independent replication studies (N = 57,234, p-value = 0.013 for SBP, 0.0023 for PP). RBFOX1 is expressed in brain tissues, the atrial appendage and left ventricle in the heart, and in skeletal muscle tissues, organs/tissues which are potentially related to blood pressure. Our study showed that associations of rare variants could be efficiently detected using family information.