1
|
Ramos RS, Rocco IS, Viceconte M, Santo JADE, Berwanger O, Santos RHN, Kalil RAK, Jatene FB, Cavalcanti AB, Zilli AC, Pimentel WDS, Hossne Junior NA, Branco JNR, Trimer R, Evora PRB, Gomes WJ, Guizilin S. Association Between Body Mass Index, Obesity, and Clinical Outcomes Following Coronary Artery Bypass Grafting in Brazil: An Analysis of One Year of Follow-up of BYPASS Registry Patients. Braz J Cardiovasc Surg 2024; 39:e20230133. [PMID: 38569010 PMCID: PMC10987126 DOI: 10.21470/1678-9741-2023-0133] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To investigate the association between body mass index (BMI), obesity, clinical outcomes, and mortality following coronary artery bypass grafting (CABG) in Brazil using a large sample with one year of follow-up from the Brazilian Registry of Cardiovascular Surgeries in Adults (or BYPASS) Registry database. METHODS A multicenter cohort-study enrolled 2,589 patients submitted to isolated CABG and divided them into normal weight (BMI 20.0-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obesity (BMI > 30.0 kg/m2) groups. Inpatient postoperative outcomes included the most frequently described complications and events. Collected post-discharge outcomes included rehospitalization and mortality rates within 30 days, six months, and one year of follow-up. RESULTS Sternal wound infections (SWI) rate was higher in obese compared to normal-weight patients (relative risk [RR]=5.89, 95% confidence interval [CI]=2.37-17.82; P=0.001). Rehospitalization rates in six months after discharge were higher in obesity and overweight groups than in normal weight group (χ=6.03, P=0.049); obese patients presented a 2.2-fold increase in the risk for rehospitalization within six months compared to normal-weight patients (RR=2.16, 95% CI=1.17-4.09; P=0.045). Postoperative complications and mortality rates did not differ among groups during time periods. CONCLUSION Obesity increased the risk for SWI, leading to higher rehospitalization rates and need for surgical interventions within six months following CABG. Age, female sex, and diabetes were associated with a higher risk of mortality. The obesity paradox remains controversial since BMI may not be sufficient to assess postoperative risk in light of more complex and dynamic evaluations of body composition and physical fitness.
Collapse
Affiliation(s)
- Rodrigo Santin Ramos
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Isadora Salvador Rocco
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcela Viceconte
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Otavio Berwanger
- Instituto de Pesquisa - IP, Hospital do Coração -
HCor, São Paulo, São Paulo, Brazil
| | | | - Renato Abdala Karam Kalil
- Instituto de Cardiologia do Rio Grande do Sul,
Fundação Universitária de Cardiologia, Porto Alegre, Rio Grande
do Sul, Brazil
| | - Fabio B. Jatene
- Instituto de Pesquisa - IP, Hospital do Coração -
HCor, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Division, Instituto do Coração
- InCor, Hospital das Clínicas da Faculdade de Medicina da Universidade de
São Paulo - HCFMUSP, São Paulo, São Paulo, Brazil
| | | | - Alexandre Cabral Zilli
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Walace de Souza Pimentel
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Nelson Américo Hossne Junior
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - João Nelson Rodrigues Branco
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Renata Trimer
- Department of Physical Therapy, Universidade Federal de São
Carlos, São Carlos, São Paulo, Brazil
| | - Paulo Roberto Barbora Evora
- Department of Surgery and Anatomy, Escola de Medicina de
Riberão Preto, Universidade de São Paulo, Ribeirão Preto,
São Paulo, Brazil
| | - Walter J. Gomes
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Solange Guizilin
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | | |
Collapse
|
2
|
Furtado RHM, Barros E Silva PGM, Fonseca HAR, Serpa-Neto A, Correa TD, Guimarães HP, Pereira AJ, Olivato GB, Zampieri FG, Lisboa T, Junqueira DLM, Lapa MG, Monfardini F, Damiani LP, Echenique LS, Gebara OE, Hoffman Filho CR, Polanczyk CA, Rohde LE, Amazonas R, Machado FR, Avezum A, Azevedo LCP, Veiga VC, Rosa RG, Lopes RD, Cavalcanti AB, Berwanger O. Cardiovascular Safety of Azithromycin in Patients Hospitalized With COVID-19: A Prespecified Pooled Analysis of the COALITION I and COALITION II Randomized Clinical Trials. Am J Cardiol 2024; 214:18-24. [PMID: 38104755 DOI: 10.1016/j.amjcard.2023.11.069] [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: 09/26/2023] [Revised: 11/09/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023]
Abstract
The cardiovascular safety from azithromycin in the treatment of several infectious diseases has been challenged. In this prespecified pooled analysis of 2 multicenter randomized clinical trials, we aimed to assess whether the use of azithromycin might lead to corrected QT (QTc) interval prolongation or clinically relevant ventricular arrhythmias. In the COALITION COVID Brazil I trial, 667 patients admitted with moderate COVID-19 were randomly allocated to hydroxychloroquine, hydroxychloroquine plus azithromycin, or standard of care. In the COALITION COVID Brazil II trial, 447 patients with severe COVID-19 were randomly allocated to hydroxychloroquine alone versus hydroxychloroquine plus azithromycin. The principal end point for the present analysis was the composite of death, resuscitated cardiac arrest, or ventricular arrhythmias. The addition of azithromycin to hydroxychloroquine did not result in any prolongation of the QTc interval (425.8 ± 3.6 ms vs 427.9 ± 3.9 ms, respectively, mean difference -2.1 ms, 95% confidence interval -12.5 to 8.4 ms, p = 0.70). The combination of azithromycin plus hydroxychloroquine compared with hydroxychloroquine alone did not result in increased risk of the primary end point (proportion of patients with events at 15 days 17.2% vs 16.0%, respectively, hazard ratio 1.08, 95% confidence interval 0.78 to 1.49, p = 0.65). In conclusion, in patients hospitalized with COVID-19 already receiving standard-of-care management (including hydroxychloroquine), the addition of azithromycin did not result in the prolongation of the QTc interval or increase in cardiovascular adverse events. Because azithromycin is among the most commonly prescribed antimicrobial agents, our results may inform clinical practice. Clinical Trial Registration: NCT04322123, NCT04321278.
Collapse
Affiliation(s)
- Remo H M Furtado
- Brazilian Clinical Research Institute, São Paulo, Brazil; Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | | | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil; Australian and New Zealand Intensive Care Research Center (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | - Adriano J Pereira
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil
| | | | | | - Thiago Lisboa
- HCor Research Institute, São Paulo, Brazil; Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil
| | | | - Maura G Lapa
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Lucas P Damiani
- Brazilian Clinical Research Institute, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Leandro S Echenique
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Moriah, São Paulo, Brazil
| | | | | | - Carisi A Polanczyk
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil; Hospital de Clínicas (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luis E Rohde
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil; Hospital de Clínicas (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Flávia R Machado
- Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil; Department of Anesthesiology, Pain and Intensive Care Medicine; Universidade Federal de São Paulo, São Paulo, Brazil
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Luciano C P Azevedo
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - Viviane C Veiga
- Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil; BP A Beneficiência Portuguesa de São Paulo, São Paulo, Brazil
| | - Regis G Rosa
- Brazilian Intensive Care Research Network (BRICNET), São Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil; Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | | | - Otavio Berwanger
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Imperial College London, London, United Kingdom; The George Institute for Global Health, London, United Kingdom
| |
Collapse
|
3
|
Polok K, Biccard BM, Chan MTV, Archbold RA, Wang CY, Sigamani A, Urrútia G, Cruz P, Srinathan SK, Szalay D, Harlock J, Tittley JG, Elias F, Jacka MJ, Malaga G, Berwanger O, Studzińska D, Górka J, Montes FR, Chow CK, Ackland GL, Dubois L, Sapsford RJ, Williams C, Cortés OL, Devereaux PJ, Szczeklik W. Mortality and major postoperative complications within 1 year after vascular surgery: a prospective cohort study. Pol Arch Intern Med 2024; 134:16645. [PMID: 38164648 DOI: 10.20452/pamw.16645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Patients undergoing vascular procedures are prone to developing postoperative complications affecting their short‑term mortality. Prospective reports describing the incidence of long‑term complications after vascular surgery are lacking. OBJECTIVES We aimed to describe the incidence of complications 1 year after vascular surgery and to evaluate an association between myocardial injury after noncardiac surgery (MINS) and 1‑year mortality. PATIENTS AND METHODS This is a substudy of a large prospective cohort study Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION). Recruitment took place in 28 centers across 14 countries from August 2007 to November 2013. We enrolled patients aged 45 years or older undergoing vascular surgery, receiving general or regional anesthesia, and hospitalized for at least 1 night postoperatively. Plasma cardiac troponin T concentration was measured before the surgery and on the first, second, and third postoperative day. The patients or their relatives were contacted 1 year after the procedure to assess the incidence of major postoperative complications. RESULTS We enrolled 2641 patients who underwent vascular surgery, 2534 (95.9%) of whom completed 1‑year follow‑up. Their mean (SD) age was 68.2 (9.8) years, and the cohort was predominantly male (77.5%). The most frequent 1‑year complications were myocardial infarction (224/2534, 8.8%), amputation (187/2534, 7.4%), and congestive heart failure (67/2534, 2.6%). The 1‑year mortality rate was 8.8% (223/2534). MINS occurred in 633 patients (24%) and was associated with an increased 1‑year mortality (hazard ratio, 2.82; 95% CI, 2.14-3.72; P <0.001). CONCLUSIONS The incidence of major postoperative complications after vascular surgery is high. The occurrence of MINS is associated with a nearly 3‑fold increase in 1‑year mortality.
Collapse
Affiliation(s)
- Kamil Polok
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Observatory, Cape Town, Western Cape, South Africa
| | - Matthew T V Chan
- Chinese University of Hong Kong, Hong Kong, The People’s Republic of China
| | - R Andrew Archbold
- Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom
| | - Chew Yin Wang
- Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Gerard Urrútia
- Institut d’Investigació Biomèdica, Sant Pau (IIB Sant Pau) – CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Patricia Cruz
- Anesthesia and Reanimation Service, Hospital Gregorio Marañón, Madrid, Spain
| | - Sadeesh K Srinathan
- Department of Surgery, Health Sciences Centre and The University of Manitoba, Winnipeg, Canada
| | - David Szalay
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - John Harlock
- Division of Vascular Surgery, McMaster University, Hamilton, Canada
| | - Jacques G Tittley
- Bearish Family Chair in Vascular Surgery, McMaster University, Hamilton, Canada
| | - Fadi Elias
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Jacka
- Department of Critical Care and Anesthesia, University of Alberta, Edmonton, Canada
| | - German Malaga
- CONEVID – Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Otavio Berwanger
- George Institute for Global Health, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Dorota Studzińska
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek Górka
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Félix R Montes
- Department of Anesthesiology, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gareth L Ackland
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Luc Dubois
- Division of Vascular Surgery, Western University and London Health Sciences Centre, London, Canada
| | | | - Colin Williams
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, Merseyside, United Kingdom
| | - Olga L Cortés
- Research Department, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | | | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland.
| |
Collapse
|
4
|
Santo K, Santos RD, Girotto AN, Nieri J, Monfardini F, Raupp P, Pereira PM, Berwanger O, Machline-Carrion MJ. Statins use for primary prevention of cardiovascular disease: A population-based digitally enabled real-world evidence cross-sectional study in primary care in Brazil. J Clin Lipidol 2024:S1933-2874(24)00025-4. [PMID: 38431498 DOI: 10.1016/j.jacl.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/20/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Statins consist of the main strategy to reduce dyslipidemia-related cardiovascular risk. Nevertheless, there is scarce evidence on the real-world statins use in primary care settings in low-middle-income countries. OBJECTIVE We conducted a cross-sectional retrospective study using anonymized data routinely collected by community health workers in Brazil aimed to evaluate statin use and associated factors in a primary prevention population with cardiovascular risk enhancers. METHODS Study population consisted of adults with hypertension, diabetes and/or dyslipidemia. The primary and secondary outcomes were the proportion of individuals self-reporting statins use on any dose, and high-dose statins/high-intensity lipid lowering therapy (LLT) respectively. RESULTS Of the 2,133,900 adult individuals on the database, 415,766 (19.5%) were included in the study cohort. From this cohort, 89.1% had hypertension, 28.9% diabetes and 5.5% dyslipidemia. The mean age was 61.5 (SD 14.5) years, 63.4% were female and 61.0% were of mixed-race. Only 2.6% and 0.1% of individuals self-reported the use of statins and high-dose statins/high-intensity LLT, respectively. Older age (OR 1.96; 95% CI 1.88,2.05;p < 0.001), living in the South region of Brazil (OR 4.39; 95%CI 3.97,4.85,p < 0.001), heart failure (OR 2.60; 95%CI 2.33,2.89,p < 0.001), chronic kidney disease (OR 1.49; 95%CI 1.35,1.64,p < 0.001) and anti-hypertensive medications use (OR 4.38; 95%CI 4.07,4.71,p < 0.001) were independently associated with statin use. CONCLUSION In a real-world evidence study analyzing data routinely collected in a digitized primary care setting, we observed a very low use of statins in a primary prevention population with cardiovascular risk enhancers in Brazil. Socio-demographic factors and co-morbidities were associated to higher statins use rates.
Collapse
Affiliation(s)
- Karla Santo
- Hospital Israelita Albert Einstein, 755 Comendador Elias Jafet Street, room 408/409, Floor L4, Morumbi, São Paulo, SP, Postal Code 05653-000, Brazil (Santo, Santos, Nieri, Monfardini and Berwanger).
| | - Raul D Santos
- Hospital Israelita Albert Einstein, 755 Comendador Elias Jafet Street, room 408/409, Floor L4, Morumbi, São Paulo, SP, Postal Code 05653-000, Brazil (Santo, Santos, Nieri, Monfardini and Berwanger); Heart Institute (InCor), University of Sao Paulo Medical School, 44 Dr Enéas Carvalho de Aguiar Avenue, Cerqueira César, São Paulo, SP, Postal Code 05403-900, Brazil (Santos)
| | - Alysson Nathan Girotto
- epHealth Primary Care Solutions, 3339 Dr. Antônio Luiz Moura Gonzaga Road, Room 107 Block A, Rio Tavares, Florianópolis, SC, Postal Code 88048-300, Brazil (Girotto and Pereira)
| | - Josue Nieri
- Hospital Israelita Albert Einstein, 755 Comendador Elias Jafet Street, room 408/409, Floor L4, Morumbi, São Paulo, SP, Postal Code 05653-000, Brazil (Santo, Santos, Nieri, Monfardini and Berwanger)
| | - Frederico Monfardini
- Hospital Israelita Albert Einstein, 755 Comendador Elias Jafet Street, room 408/409, Floor L4, Morumbi, São Paulo, SP, Postal Code 05653-000, Brazil (Santo, Santos, Nieri, Monfardini and Berwanger)
| | - Priscila Raupp
- Novartis Biociências Brazil, 90 Professor Vicente Rao Avenue, Cidade Monções, São Paulo, SP, Postal Code 04706-900, Brazil (Raupp)
| | - Pedro Marton Pereira
- epHealth Primary Care Solutions, 3339 Dr. Antônio Luiz Moura Gonzaga Road, Room 107 Block A, Rio Tavares, Florianópolis, SC, Postal Code 88048-300, Brazil (Girotto and Pereira); epHealth UK, C/O Taylor Vinters, Floor 33 Tower 42, 25 Old Broad Street, London, EC2N 1HQ, United Kingdom (Pereira); Instituto epHealth, 2302 Consolação Street, CJ 21, Room 104, Consolação, Sao Paulo, SP, Postal Code 01302-001, Brazil (Pereira)
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein, 755 Comendador Elias Jafet Street, room 408/409, Floor L4, Morumbi, São Paulo, SP, Postal Code 05653-000, Brazil (Santo, Santos, Nieri, Monfardini and Berwanger); The George Institute for Global Health, 4 Wood Ln, London, NW9 7PA, United Kingdom (Berwanger); Imperial College London, 80 Wood Ln, London, W12 7TA, United Kingdom (Berwanger)
| | - M Julia Machline-Carrion
- epHealth UK, C/O Taylor Vinters, Floor 33 Tower 42, 25 Old Broad Street, London, EC2N 1HQ, United Kingdom (Pereira); Instituto epHealth, 2302 Consolação Street, CJ 21, Room 104, Consolação, Sao Paulo, SP, Postal Code 01302-001, Brazil (Pereira)
| |
Collapse
|
5
|
Schiavon CA, Cavalcanti AB, Oliveira JD, Machado RHV, Santucci EV, Santos RN, Oliveira JS, Damiani LP, Junqueira D, Halpern H, Monteiro FDLJ, Noujaim PM, Cohen RV, de Sousa MG, Bortolotto LA, Berwanger O, Drager LF. Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years. J Am Coll Cardiol 2024; 83:637-648. [PMID: 38325988 DOI: 10.1016/j.jacc.2023.11.032] [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: 08/24/2023] [Revised: 10/23/2023] [Accepted: 11/08/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality. OBJECTIVES The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission. METHODS We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle. RESULTS A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%). CONCLUSIONS Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).
Collapse
Affiliation(s)
- Carlos A Schiavon
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil; Hospital BP, A Beneficencia Portuguesa de São Paulo, São Paulo, Brazil.
| | | | - Juliana D Oliveira
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil; Hospital BP, A Beneficencia Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Renato N Santos
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil
| | | | - Lucas P Damiani
- Research Institute, Heart Hospital (hcor), São Paulo, Brazil
| | | | - Helio Halpern
- Surgical Center, Heart Hospital (hcor), São Paulo, Brazil
| | | | | | | | - Marcio G de Sousa
- Dante Pazzanese Institute of Cardiology, Department of Hypertension, São Paulo, Brazil
| | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Otavio Berwanger
- Imperial College London, George Institute for Global Health UK, London, United Kingdom
| | - Luciano F Drager
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanes, São Paulo, Brazil
| |
Collapse
|
6
|
Roshanov PS, Chan MTV, Borges FK, Conen D, Wang CY, Xavier D, Berwanger O, Marcucci M, Sessler DI, Szczeklik W, Spence J, Alonso-Coello P, Fernández C, Pearse RM, Malaga G, Garg AX, Srinathan SK, Jacka MJ, Tandon V, McGillion M, Popova E, Sigamani A, Abraham V, Biccard BM, Villar JC, Chow CK, Polanczyk CA, Tiboni M, Whitlock R, Ackland GL, Panju M, Lamy A, Sapsford R, Williams C, Wu WKK, Cortés OL, MacNeil SD, Patel A, Belley-Côté EP, Ofori S, McIntyre WF, Leong DP, Heels-Ansdell D, Gregus K, Devereaux PJ. One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study. Anesthesiology 2024; 140:8-24. [PMID: 37713506 DOI: 10.1097/aln.0000000000004763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND In previous analyses, myocardial injury after noncardiac surgery, major bleeding, and sepsis were independently associated with most deaths in the 30 days after noncardiac surgery, but most of these deaths occurred during the index hospitalization for surgery. The authors set out to describe outcomes after discharge from hospital up to 1 yr after inpatient noncardiac surgery and associations between predischarge complications and postdischarge death up to 1 yr after surgery. METHODS This study was an analysis of patients discharged after inpatient noncardiac surgery in a large international prospective cohort study across 28 centers from 2007 to 2013 of patients aged 45 yr or older followed to 1 yr after surgery. The study estimated (1) the cumulative postdischarge incidence of death and other outcomes up to a year after surgery and (2) the adjusted time-varying associations between postdischarge death and predischarge complications including myocardial injury after noncardiac surgery, major bleeding, sepsis, infection without sepsis, stroke, congestive heart failure, clinically important atrial fibrillation or flutter, amputation, venous thromboembolism, and acute kidney injury managed with dialysis. RESULTS Among 38,898 patients discharged after surgery, the cumulative 1-yr incidence was 5.8% (95% CI, 5.5 to 6.0%) for all-cause death and 24.7% (95% CI, 24.2 to 25.1%) for all-cause hospital readmission. Predischarge complications were associated with 33.7% (95% CI, 27.2 to 40.2%) of deaths up to 30 days after discharge and 15.0% (95% CI, 12.0 to 17.9%) up to 1 yr. Most of the association with death was due to myocardial injury after noncardiac surgery (15.6% [95% CI, 9.3 to 21.9%] of deaths within 30 days, 6.4% [95% CI, 4.1 to 8.7%] within 1 yr), major bleeding (15.0% [95% CI, 8.3 to 21.7%] within 30 days, 4.7% [95% CI, 2.2 to 7.2%] within 1 yr), and sepsis (5.4% [95% CI, 2.2 to 8.6%] within 30 days, 2.1% [95% CI, 1.0 to 3.1%] within 1 yr). CONCLUSIONS One in 18 patients 45 yr old or older discharged after inpatient noncardiac surgery died within 1 yr, and one quarter were readmitted to the hospital. The risk of death associated with predischarge perioperative complications persists for weeks to months after discharge. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Pavel S Roshanov
- Department of Medicine, Western University, London, Canada; Population Health Research Institute, Hamilton, Canada
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong, Hong Kong
| | - Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - David Conen
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - C Y Wang
- Honorary Professor; Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Denis Xavier
- St. John's Medical College Hospital, Bangalore, India
| | - Otavio Berwanger
- George Institute for Global Health, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Maura Marcucci
- Clinical Epidemiology and Research Centre (CERC), Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milan, Italy; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jessica Spence
- Anesthesia and Critical Care, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Hospital Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red (CIBER) de Epidemiología y Salud Pública, Madrid, Spain
| | - Carmen Fernández
- Department of Anesthesiology and Intensive Care Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rupert M Pearse
- Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - German Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Amit X Garg
- Department of Medicine, University of Western Ontario, London, Canada
| | | | - Michael J Jacka
- Department of Critical Care and Anesthesia, University of Alberta, Edmonton, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Michael McGillion
- School of Nursing, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Ekaterine Popova
- IIB Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Alben Sigamani
- Numen Health, Bangalore, India; Narayana Hrudayalaya Health City Bangalore, Bangalore, India
| | - Valsa Abraham
- Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, South Africa
| | | | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Carísi A Polanczyk
- Graduate Program in Epidemiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Institute for Health Technology Assessment, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard Whitlock
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Gareth L Ackland
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, Canada
| | - André Lamy
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Robert Sapsford
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Colin Williams
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - William Ka Kei Wu
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, New Territories, Hong Kong
| | - Olga L Cortés
- Research Department and Nursing Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá DC, Colombia
| | - S Danielle MacNeil
- Schulich School of Medicine and Dentistry, Western University, London, Canada; Otolaryngology-Head & Neck Surgery, London Health Sciences Centre, London, Canada
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Sandra Ofori
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - William F McIntyre
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Darryl P Leong
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | | | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| |
Collapse
|
7
|
Tavares CDAM, de Azevedo LCP, Rea-Neto Á, Campos NS, Amendola CP, Bergo RR, Kozesinski-Nakatani AC, David-João PG, Westphal GA, Guimarães Júnior MRR, Lobo SMA, Tavares MS, Dracoulakis MDA, de Souza GM, de Almeida GMB, Gebara OCE, Tomba PO, Albuquerque CSN, Silva MCR, Pereira AJ, Damiani LP, Corrêa TD, Serpa-Neto A, Berwanger O, Zampieri FG. Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study. Crit Care Sci 2023; 35:256-265. [PMID: 38133155 PMCID: PMC10734800 DOI: 10.5935/2965-2774.20230129-en] [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: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. METHODS DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. CONCLUSION DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. CLINICALTRIALS.GOV REGISTRY NCT05558098.
Collapse
Affiliation(s)
| | | | - Álvaro Rea-Neto
- Centro de Estudos e de Pesquisas em Terapia Intensiva - Curitiba
(PR), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
| | | | | |
Collapse
|
8
|
Yu J, Sweeting AN, Gianacas C, Houston L, Lee V, Fletcher RA, Perkovic V, Li Q, Neuen BL, Berwanger O, Heerspink HJL, de Zeeuw D, Arnott C. The effects of canagliflozin in type 2 diabetes in subgroups defined by population-specific body mass index: Insights from the CANVAS Program and CREDENCE trial. Diabetes Obes Metab 2023; 25:3724-3735. [PMID: 37671609 DOI: 10.1111/dom.15267] [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: 06/03/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/07/2023]
Abstract
AIM To assess the effects of canagliflozin on clinical outcomes and intermediate markers across population-specific body mass index (BMI) categories in the CANVAS Program and CREDENCE trial. METHODS Individual participant data were pooled and analysed in subgroups according to population-specific BMI. The main outcomes of interest were: major adverse cardiovascular events (MACE, a composite of nonfatal myocardial infarction, nonfatal stroke or cardiovascular death); composite renal outcome; and changes in systolic blood pressure (SBP), body weight, albuminuria and estimated glomerular filtration rate (eGFR) slope. Cox proportional hazards models and mixed-effect models were used. RESULTS A total of 14 520 participants were included, of whom 9378 (65%) had obesity. Overall, canagliflozin reduced the risk of MACE (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.75 to 0.93) with no heterogeneity of treatment effect across BMI subgroups (Pheterogeneity = 0.76). Similarly, canagliflozin reduced composite renal outcomes (HR 0.75, 95% CI 0.66 to 0.84) with no heterogeneity across subgroups observed (Pheterogeneity = 0.72). The effects of canagliflozin on body weight and SBP differed across BMI subgroups (Pheterogeneity <0.01 and 0.04, respectively) but were consistent for albuminuria (Pheterogeneity = 0.60). Chronic eGFR slope with canagliflozin treatment was consistent across subgroups (Pheterogeneity >0.95). CONCLUSIONS The cardiovascular and renal benefits of canagliflozin and its safety profile were consistent across population-specific BMI subgroups for adults in the CANVAS Program and CREDENCE trial.
Collapse
Affiliation(s)
- Jie Yu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Arianne N Sweeting
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The Charles Perkins Centre, University of Sydney, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chris Gianacas
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Lauren Houston
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Vivian Lee
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Otavio Berwanger
- The George Institute for Global Health UK Office, Imperial College London, London, UK
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
9
|
Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [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] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
10
|
Oliveira JD, Schiavon CA, Oliveira JS, Santos RN, Damiani LP, Ikeoka D, Santucci EV, Machado RHV, Bortolotto LA, Berwanger O, Cavalcanti AB, Drager LF. Shorter History of Hypertension as a Predictor of Hypertension Remission after 3-years of Bariatric Surgery: Data from the GATEWAY Trial. Obes Surg 2023; 33:2485-2492. [PMID: 37392354 DOI: 10.1007/s11695-023-06711-2] [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] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Previous evidence explored predictors of hypertension (HTN) remission after bariatric but data are limited to observational studies and lack of ambulatory blood pressure monitoring (ABPM). This study was aimed to evaluate the rate of HTN remission after bariatric surgery using ABPM and to define predictors of mid-term HTN remission. METHODS We included patients enrolled in the surgical arm of the GATEWAY randomized trial. HTN remission was defined as controlled blood pressure (< 130 × 80 mmHg) evaluated by 24-h ABPM while no need of anti-hypertensive medications after 36 months. A multivariable logistic regression model was used to assess the predictors of HTN remission after 36 months. RESULTS 46 patients submitted Roux-en-Y gastric bypass (RYGB). HTN remission occurred in 39% (n = 14 out of 36 patients with complete data at 36 months). Patients with HTN remission had shorter HTN history than no remission group (5.9 ± 5.5 vs. 12.5 ± 8.1 years; p = 0.01). The baseline insulin levels were lower in patients who presented HTN remission, although not statistically significant (OR: 0.90; CI 95%: 0.80-0.99; p = 0.07). In the multivariate analysis, the HTN history (years) was the only independent predictor of HTN remission (OR: 0.85; 95% CI: 0.70-0.97; p = 0.04). Therefore, for each additional year of HTN history, the chance of HTN remission decreases by approximately 15% after RYGB. CONCLUSION After 3 years of RYGB, HTN remission defined by ABPM was common and independently associated with a shorter HTN history. These data underscore the need of early effective approach of obesity aiming greater impact in its comorbidities.
Collapse
Affiliation(s)
- Juliana D Oliveira
- Unidade de Hipertensão, Disciplina de Nefrologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Dr Eneas de Carvalho Aguiar, 255, São Paulo, CEP 05403-900, Brazil
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Carlos A Schiavon
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Julia S Oliveira
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Renato N Santos
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | | | - Dimas Ikeoka
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | - Eliana V Santucci
- Research Institute - Heart Hospital (HCor) - São Paulo, São Paulo, Brazil
| | | | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Dr Eneas de Carvalho Aguiar, 255, São Paulo, CEP 05403-900, Brazil.
- Unidade de Hipertensão, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- Cardiology Center, Hospital Sírio Libanês, São Paulo, Brazil.
| |
Collapse
|
11
|
Hess CN, Hsia J, Carroll IA, Nehler MR, Ruf W, Morrow DA, Nicolau JC, Berwanger O, Szarek M, Capell WH, Johri S, Pursley MS, Gupta R, Meehan PS, Franchi F, Effron MB, Marshall D, Graybill CA, Graybill SP, Keuer T, Bristow MR, Bonaca MP. Novel Tissue Factor Inhibition for Thromboprophylaxis in COVID-19: Primary Results of the ASPEN-COVID-19 Trial. Arterioscler Thromb Vasc Biol 2023. [PMID: 37381988 PMCID: PMC10364965 DOI: 10.1161/atvbaha.122.318748] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Thrombo-inflammation is central to COVID-19-associated coagulopathy. TF (tissue factor), a driver disordered coagulation and inflammation in viral infections, may be a therapeutic target in COVID-19. The safety and efficacy of the novel TF inhibitor rNAPc2 (recombinant nematode anticoagulation protein c2) in COVID-19 are unknown. METHODS ASPEN-COVID-19 was an international, randomized, open-label, active comparator clinical trial with blinded end point adjudication. Hospitalized patients with COVID-19 and elevated D-dimer levels were randomized 1:1:2 to lower or higher dose rNAPc2 on days 1, 3, and 5 followed by heparin on day 8 or to heparin per local standard of care. In comparisons of the pooled rNAPc2 versus heparin groups, the primary safety end point was major or nonmajor clinically relevant International Society of Thrombosis and Haemostasis bleeding through day 8. The primary efficacy end point was proportional change in D-dimer concentration from baseline to day 8, or discharge if before day 8. Patients were followed for 30 days. RESULTS Among 160 randomized patients, median age was 54 years, 43.1% were female, and 38.8% had severe baseline COVID-19. There were no significant differences between rNAPc2 and heparin in bleeding or other safety events. Overall, median change in D-dimer was -16.8% (interquartile range, -45.7 to 36.8; P=0.41) with rNAPc2 treatment and -11.2% (-36.0 to 34.4; P=0.91) with heparin (Pintergroup=0.47). In prespecified analyses, in severely ill patients, D-dimer levels tended to increase more within the heparin (median, 29.0% [-14.9 to 145.2]; P=0.02) than the rNAPc2 group (median, 25.9% [-49.1 to 136.4]; P=0.14; Pintergroup=0.96); in mildly ill patients, D-dimer levels were reduced within each group with a numerically greater reduction with rNAPc2 versus heparin (rNAPc2 median, -32.7% [-44.7 to 4.3]; P=0.007 and heparin median, -16.8% [-36.0 to 0.5]; P=0.008, Pintergroup=0.34). CONCLUSIONS rNAPc2 treatment in hospitalized patients with COVID-19 was well tolerated without excess bleeding or serious adverse events but did not significantly reduce D-dimer more than heparin at day 8. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04655586.
Collapse
Affiliation(s)
- Connie N Hess
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| | - Judith Hsia
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| | - Ian A Carroll
- ARCA biopharma, Westminster, CO (I.A.C., D.M., C.A.G., S.P.G., T.K., M.R.B.)
| | - Mark R Nehler
- Department of Surgery, University of Colorado, Aurora. (M.R.N., R.G.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| | - Wolfram Ruf
- Johannes Gutenberg University Medical Center, Mainz, Germany (W.R.)
- Scripps Research, La Jolla, CA (W.R.)
| | - David A Morrow
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M.)
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, Brazil (J.C.N.)
| | | | - Michael Szarek
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
- The State University of New York Downstate Health Sciences University, Brooklyn (M.S.)
| | - Warren H Capell
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| | | | | | - Ryan Gupta
- Department of Surgery, University of Colorado, Aurora. (M.R.N., R.G.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| | | | | | | | - Debra Marshall
- ARCA biopharma, Westminster, CO (I.A.C., D.M., C.A.G., S.P.G., T.K., M.R.B.)
| | | | - Sophie P Graybill
- ARCA biopharma, Westminster, CO (I.A.C., D.M., C.A.G., S.P.G., T.K., M.R.B.)
| | - Thomas Keuer
- ARCA biopharma, Westminster, CO (I.A.C., D.M., C.A.G., S.P.G., T.K., M.R.B.)
| | - Michael R Bristow
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- ARCA biopharma, Westminster, CO (I.A.C., D.M., C.A.G., S.P.G., T.K., M.R.B.)
| | - Marc P Bonaca
- Department of Medicine, University of Colorado, Aurora. (C.N.H., J.H., M.S., W.H.C., M.R.B., M.P.B.)
- CPC Clinical Research, Aurora, CO (C.N.H., J.H., M.R.N., M.S., W.H.C., R.G., M.P.B.)
| |
Collapse
|
12
|
Guimarães PO, Franken M, Tavares CAM, Silveira FS, Antunes MO, Bergo RR, Joaquim RM, Hirai JCS, Andrade PB, Pitta FG, Mariani J, Nascimento BR, de Paula JET, Silveira MS, Costa TAO, Dall'Orto FTC, Serpa RG, Sampaio FBA, Ohe LN, Mangione FM, Furtado RHM, Sarmento-Leite R, Monfardini F, Assis SRL, Nicolau JC, Sposito AC, Lopes RD, Onuma Y, Valgimigli M, Angiolillo DJ, Serruys PWJC, Berwanger O, Bacal F, Lemos PA. P2Y12 inhibitor monotherapy versus dual antiplatelet therapy in patients with acute coronary syndromes undergoing coronary stenting: rationale and design of the NEOMINDSET Trial. EUROINTERVENTION 2023:EIJ-D-23-00125. [PMID: 37306039 DOI: 10.4244/eij-d-23-00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Dual antiplatelet therapy (DAPT) is currently the standard of care after percutaneous coronary intervention (PCI). Recent studies suggest that reducing DAPT to 1-3 months followed by an aspirin-free single antiplatelet therapy (SAPT) strategy with a potent P2Y12 inhibitor is safe and associated with less bleeding. However, to date, no randomised trial has tested the impact of initiating SAPT immediately after PCI, particularly in patients with acute coronary syndromes (ACS). NEOMINDSET is a multicentre, randomised, open-label trial with a blinded outcome assessment designed to compare SAPT versus DAPT in 3,400 ACS patients undergoing PCI with the latest-generation drug-eluting stents (DES). After successful PCI and up to 4 days following hospital admission, patients are randomised to receive SAPT with a potent P2Y12 inhibitor (ticagrelor or prasugrel) or DAPT (aspirin plus a potent P2Y12 inhibitor) for 12 months. Aspirin is discontinued immediately after randomisation in the SAPT group. The choice between ticagrelor and prasugrel is at the investigator's discretion. The primary hypothesis is that SAPT will be non-inferior to DAPT with respect to the composite endpoint of all-cause mortality, stroke, myocardial infarction or urgent target vessel revascularisation, but superior to DAPT on rates of bleeding defined by Bleeding Academic Research Consortium 2, 3 or 5 criteria. NEOMINDSET is the first study that is specifically designed to test SAPT versus DAPT immediately following PCI with DES in ACS patients. This trial will provide important insights on the efficacy and safety of withdrawing aspirin in the early phase of ACS. (ClinicalTrials.gov: NCT04360720).
Collapse
Affiliation(s)
| | | | - Caio A M Tavares
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | | | - Murillo O Antunes
- Hospital Universitário São Francisco de Assis na Providência de Deus, Bragança Paulista, Brazil
| | | | | | | | - Pedro B Andrade
- Irmandade da Santa Casa de Misericórdia de Marilia, Marilia, Brazil
| | - Fabio G Pitta
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - José Mariani
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Tiberio A O Costa
- Hospital Universitário São Francisco de Assis na Providência de Deus, Bragança Paulista, Brazil
| | | | - Renato G Serpa
- Hospital Santa Casa de Misericórdia de Vitória, Vitória, Brazil
| | | | - Louis N Ohe
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Remo H M Furtado
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Rogerio Sarmento-Leite
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | | | | | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Andrei C Sposito
- Department of Internal Medicine, School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | | | - Fernando Bacal
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
13
|
Zimerman A, da Silveira AD, Borges MS, Engster PH, Schaan TU, de Souza GC, de Souza IP, Ritt LEF, Stein R, Berwanger O, Vaduganathan M, Rohde LE. Functional assessment based on cardiopulmonary exercise testing in mild heart failure: A multicentre study. ESC Heart Fail 2023; 10:1689-1697. [PMID: 36808902 PMCID: PMC10192241 DOI: 10.1002/ehf2.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/25/2022] [Accepted: 01/09/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS In this multicentre study, we compared cardio-pulmonary exercise test (CPET) parameters between heart failure (HF) patients classified as New York Heart Association (NYHA) class I and II to assess NYHA performance and prognostic role in mild HF. METHODS AND RESULTS We included consecutive HF patients in NYHA class I or II who underwent CPET in three Brazilian centres. We analysed the overlap between kernel density estimations for the per cent-predicted peak oxygen consumption (VO2 ), minute ventilation/carbon dioxide production (VE/VCO2 ) slope, and oxygen uptake efficiency slope (OUES) by NYHA class. Area under the receiver-operating characteristic curve (AUC) was used to assess the capacity of per cent-predicted peak VO2 to discriminate between NYHA class I and II. For prognostication, time to all-cause death was used to produce Kaplan-Meier estimates. Of 688 patients included in this study, 42% were classified as NYHA I and 58% as NYHA II, 55% were men, and mean age was 56 years. Median global per cent-predicted peak VO2 was 66.8% (IQR 56-80), VE/VCO2 slope was 36.9 (31.6-43.3), and mean OUES was 1.51 (±0.59). Kernel density overlap between NYHA class I and II was 86% for per cent-predicted peak VO2 , 89% for VE/VCO2 slope, and 84% for OUES. Receiving-operating curve analysis showed a significant, albeit limited performance of per cent-predicted peak VO2 alone to discriminate between NYHA class I vs. II (AUC 0.55, 95% CI 0.51-0.59, P = 0.005). Model accuracy for probability of being classified as NYHA class I (vs. NYHA class II) across the spectrum of the per cent-predicted peak VO2 was limited, with an absolute probability increment of 13% when per cent-predicted peak VO2 increased from 50% to 100%. Overall mortality in NYHA class I and II was not significantly different (P = 0.41), whereas NYHA class III patients displayed a distinctively higher death rate (P < 0.001). CONCLUSIONS Patients with chronic HF classified as NYHA I overlapped substantially with those classified as NYHA II in objective physiological measures and prognosis. NYHA classification may represent a poor discriminator of cardiopulmonary capacity in patients with mild HF.
Collapse
Affiliation(s)
- André Zimerman
- Post‐Graduate Program in Cardiology and Cardiovascular Sciences, Medical SchoolUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Anderson D. da Silveira
- Post‐Graduate Program in Cardiology and Cardiovascular Sciences, Medical SchoolUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Marina S. Borges
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Pedro H.B. Engster
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Thomas U. Schaan
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Gabriel C. de Souza
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | | | | | - Ricardo Stein
- Post‐Graduate Program in Cardiology and Cardiovascular Sciences, Medical SchoolUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert EinsteinSão PauloBrazil
| | | | - Luis Eduardo Rohde
- Post‐Graduate Program in Cardiology and Cardiovascular Sciences, Medical SchoolUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Cardiovascular DivisionHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| |
Collapse
|
14
|
Lucchetta R, Matuoka JY, de Oliveira HA, Oliveira G, Cavalcanti AB, Azevedo L, Berwanger O, Lopes RD, Rosa RG, Veiga VC, Avezum Á. Hydroxychloroquine for Non-Hospitalized COVID-19 Patients: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Arq Bras Cardiol 2023; 120:e20220380. [PMID: 37042856 PMCID: PMC10263429 DOI: 10.36660/abc.20220380] [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] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Previous systematic reviews have identified no benefit of hydroxychloroquine and chloroquine in non-hospitalized COVID-19 patients. After publication of these reviews, the results of COPE, the largest randomized trial conducted to date, became available. OBJECTIVES To conduct a systematic review and meta-analyses of randomized clinical trials (RCTs) to synthesize the evidence on the efficacy and safety of hydroxychloroquine and chloroquine for non-hospitalized COVID-19 patients compared to placebo or standard of care. METHODS Searches were conducted in PubMed, Embase, The Cochrane Library, and ClinicalTrials.gov complemented by manual search. Pairwise meta-analyses, risk of bias, and evidence certainty assessments were conducted, including optimal information size analysis (OIS). A level of significance of 0.05 was adopted in the meta-analysis. PROSPERO: CRD42021265427. RESULTS Eight RCTs with 3,219 participants were included. COVID-19 hospitalization and any adverse events rates were not significantly different between hydroxychloroquine (5.6% and 35.1%) and control (7.4% and 20.4%) (risk ratio, RR, 0.77, 95% confidence interval, CI, 0.57-1.04, I2: 0%; RR 1.78, 95%-CI 0.90; 3.52, I2: 93%, respectively). The OIS (7,880) was not reached for COVID-19 hospitalization, independently of the simulation for anticipated event rate and RR reduction estimate. CONCLUSION Evidence of very low certainty showed lack of benefit with hydroxychloroquine in preventing COVID-19 hospitalizations. Despite being the systematic review with the largest number of participants included, the OIS, considering pre-vaccination response to infection, has not yet been reached.
Collapse
Affiliation(s)
- Rosa Lucchetta
- Hospital Alemão Oswaldo CruzSão PauloSPBrasilHospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Jessica Y. Matuoka
- Hospital Alemão Oswaldo CruzSão PauloSPBrasilHospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | | | - Gustavo Oliveira
- Hospital Alemão Oswaldo CruzSão PauloSPBrasilHospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | - Luciano Azevedo
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP – Brasil
| | - Otavio Berwanger
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Renato Delascio Lopes
- Duke University HospitalDurhamNorth CarolinaEUADuke University Hospital, Durham, North Carolina – EUA
| | - Regis Goulart Rosa
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
| | - Viviane Cordeiro Veiga
- Beneficência Portuguesa de São PauloSão PauloSPBrasilBeneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Álvaro Avezum
- Hospital Alemão Oswaldo CruzSão PauloSPBrasilHospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| |
Collapse
|
15
|
Alves MAM, Feitosa ADM, Mota-Gomes MA, Paiva AMG, Barroso WS, Miranda RD, Barbosa ECD, Brandão AA, Diniz PGS, Berwanger O, Lima-Filho JL, Sposito AC, Coca A, Nadruz W. Accuracy of screening strategies for masked hypertension: a large-scale nationwide study based on home blood pressure monitoring. Hypertens Res 2023; 46:742-750. [PMID: 36380200 DOI: 10.1038/s41440-022-01103-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022]
Abstract
This study compared the ability of guideline-proposed office blood pressure (OBP) screening thresholds [European Society of Hypertension (ESH) guidelines: 130/85 mmHg for individuals with an OBP < 140/90 mmHg; American College of Cardiology/American Heart Association (ACC/AHA) guidelines: 120/75 mmHg for individuals with an OBP < 130/80 mmHg] and novel screening scores to identify normotensive individuals at high risk of having masked hypertension (MH) in an office setting. We cross-sectionally evaluated untreated participants with an OBP < 140/90 mmHg (n = 22,266) and an OBP < 130/80 mmHg (n = 10,005) who underwent home blood pressure monitoring (HBPM) (derivation cohort) from 686 Brazilian sites. MH was defined according to criteria suggested by the ESH (OBP < 140/90 mmHg; HBPM ≥ 135/85 mmHg), Brazilian Society of Cardiology (BSC) (OBP < 140/90 mmHg; HBPM ≥ 130/80 mmHg) and ACC/AHA (OBP < 130/80 mmHg; HBPM ≥ 130/80 mmHg). Scores were generated from multivariable logistic regression coefficients between MH and clinical variables (OBP, age, sex, and BMI). Considering the ESH, BSC, and ACC/AHA criteria, 17.2%, 38.5%, and 21.2% of the participants had MH, respectively. Guideline-proposed OBP screening thresholds yielded area under curve (AUC) values of 0.640 (for ESH criteria), 0.641 (for BSC criteria), and 0.619 (for ACC/AHA criteria) for predicting MH, while scores presented as continuous variables or quartiles yielded AUC values of 0.700 and 0.688 (for ESH criteria), 0.720 and 0.709 (for BSC criteria), and 0.671 and 0.661 (for ACC/AHA criteria), respectively. Further analyses performed with alternative untreated participants (validation cohort; n = 2807 with an OBP < 140/90 mmHg; n = 1269 with an OBP < 130/80 mmHg) yielded similar AUC values. In conclusion, the accuracy of guideline-proposed OBP screening thresholds in identifying individuals at high risk of having MH in an office setting is limited and is inferior to that yielded by scores derived from simple clinical variables.
Collapse
Affiliation(s)
- Marco A M Alves
- Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, PE, Brazil
| | - Audes D M Feitosa
- Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, PE, Brazil.,Pronto Socorro Cardiológico de Pernambuco (PROCAPE), University of Pernambuco, Recife, PE, Brazil.,UNICAP Clinical Research Institute, Recife, PE, Brazil
| | | | | | - Weimar S Barroso
- Hypertension League, Cardiovascular Section, Federal University of Goiás, Goiânia, GO, Brazil
| | - Roberto D Miranda
- Cardiovascular Section, Geriatrics Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.,Hospital Israelita Albert Eistein, São Paulo, SP, Brazil
| | - Eduardo C D Barbosa
- Department of Hypertension and Cardiometabolism, São Francisco Hospital - Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Andréa A Brandão
- School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Paulo G S Diniz
- Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, PE, Brazil
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - José L Lima-Filho
- Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, PE, Brazil
| | - Andrei C Sposito
- Department of Internal Medicine, School of Medical Sciences, State University of Campinas, SP Paulo, Brazil
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Wilson Nadruz
- Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, PE, Brazil. .,Department of Internal Medicine, School of Medical Sciences, State University of Campinas, SP Paulo, Brazil.
| |
Collapse
|
16
|
Berwanger O. Rivaroxaban for Patients With Acute Coronary Syndromes-Where Do We Stand? JAMA Netw Open 2023; 6:e2255724. [PMID: 36763365 DOI: 10.1001/jamanetworkopen.2022.55724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Affiliation(s)
- Otavio Berwanger
- George Institute for Global Health UK, Imperial College London, London, United Kingdom
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
17
|
Rosa RG, Cavalcanti AB, Azevedo LCP, Veiga VC, de Souza D, Dos Santos RDRM, Schardosim RFDC, Rech GS, Trott G, Schneider D, Robinson CC, Haubert TA, Pallaoro VEL, Brognoli LG, de Souza AP, Costa LS, Barroso BM, Pelliccioli MP, Gonzaga J, Studier NDS, Dagnino APA, Neto JDM, da Silva SS, Gimenes BDP, Dos Santos VB, Estivalete GPM, Pellegrino CDM, Polanczyk CA, Kawano-Dourado L, Tomazini BM, Lisboa TC, Teixeira C, Zampieri FG, Zavascki AP, Gersh BJ, Avezum Á, Machado FR, Berwanger O, Lopes RD, Falavigna M. Association between acute disease severity and one-year quality of life among post-hospitalisation COVID-19 patients: Coalition VII prospective cohort study. Intensive Care Med 2023; 49:166-177. [PMID: 36594987 PMCID: PMC9808680 DOI: 10.1007/s00134-022-06953-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/05/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE To assess the association between acute disease severity and 1-year quality of life in patients discharged after hospitalisation due to coronavirus disease 2019 (COVID-19). METHODS We conducted a prospective cohort study nested in 5 randomised clinical trials between March 2020 and March 2022 at 84 sites in Brazil. Adult post-hospitalisation COVID-19 patients were followed for 1 year. The primary outcome was the utility score of EuroQol five-dimension three-level (EQ-5D-3L). Secondary outcomes included all-cause mortality, major cardiovascular events, and new disabilities in instrumental activities of daily living. Adjusted generalised estimating equations were used to assess the association between outcomes and acute disease severity according to the highest level on a modified ordinal scale during hospital stay (2: no oxygen therapy; 3: oxygen by mask or nasal prongs; 4: high-flow nasal cannula oxygen therapy or non-invasive ventilation; 5: mechanical ventilation). RESULTS 1508 COVID-19 survivors were enrolled. Primary outcome data were available for 1156 participants. At 1 year, compared with severity score 2, severity score 5 was associated with lower EQ-5D-3L utility scores (0.7 vs 0.84; adjusted difference, - 0.1 [95% CI - 0.15 to - 0.06]); and worse results for all-cause mortality (7.9% vs 1.2%; adjusted difference, 7.1% [95% CI 2.5%-11.8%]), major cardiovascular events (5.6% vs 2.3%; adjusted difference, 2.6% [95% CI 0.6%-4.6%]), and new disabilities (40.4% vs 23.5%; adjusted difference, 15.5% [95% CI 8.5%-22.5]). Severity scores 3 and 4 did not differ consistently from score 2. CONCLUSIONS COVID-19 patients who needed mechanical ventilation during hospitalisation have lower 1-year quality of life than COVID-19 patients who did not need mechanical ventilation during hospitalisation.
Collapse
Affiliation(s)
- Regis Goulart Rosa
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil. .,Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil. .,Research Unit, INOVA Medical, Porto Alegre, RS, Brazil.
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Hcor Research Institute, Hospital Do Coração, São Paulo, SP, Brazil
| | - Luciano César Pontes Azevedo
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,BP-A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Denise de Souza
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | | | | | - Gabriela Soares Rech
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Geraldine Trott
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Daniel Schneider
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Caroline Cabral Robinson
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Tainá Aparecida Haubert
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | | | - Liége Gregoletto Brognoli
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Ana Paula de Souza
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Lauren Sezerá Costa
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Bruna Machado Barroso
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | | | - Janine Gonzaga
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Nicole Dos Santos Studier
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | | | - Juliana de Mesquita Neto
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Sabrina Souza da Silva
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | - Bruna Dos Passos Gimenes
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil
| | | | | | | | - Carisi Anne Polanczyk
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil.,Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,National Institute for Health Technology Assessment, IATS/CNPq, Porto Alegre, RS, Brazil
| | | | - Bruno Martins Tomazini
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Hcor Research Institute, Hospital Do Coração, São Paulo, SP, Brazil.,Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Thiago Costa Lisboa
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,PPG Ciências Pneumológicas UFRGS, Porto Alegre, RS, Brazil.,Intensive Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Cassiano Teixeira
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Intensive Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,UFCSPA Medical School, Porto Alegre, RS, Brazil
| | - Fernando Godinho Zampieri
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Hcor Research Institute, Hospital Do Coração, São Paulo, SP, Brazil.,Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Alexandre Prehn Zavascki
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil.,Infectious Diseases and Infection Control Service, Hospital Moinhos de Vento, Porto Alegre, RS, Brazil.,Internal Medicine Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil.,Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - Maicon Falavigna
- Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10º Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil.,Research Unit, INOVA Medical, Porto Alegre, RS, Brazil.,National Institute for Health Technology Assessment, IATS/CNPq, Porto Alegre, RS, Brazil
| |
Collapse
|
18
|
Mehran R, Steg PG, Pfeffer MA, Jering K, Claggett B, Lewis EF, Granger C, Køber L, Maggioni A, Mann DL, McMurray JJV, Rouleau JL, Solomon SD, Ducrocq G, Berwanger O, De Pasquale CG, Landmesser U, Petrie M, Leng DSK, van der Meer P, Lefkowitz M, Zhou Y, Braunwald E. The Effects of Angiotensin Receptor-Neprilysin Inhibition on Major Coronary Events in Patients With Acute Myocardial Infarction: Insights From the PARADISE-MI Trial. Circulation 2022; 146:1749-1757. [PMID: 36321459 DOI: 10.1161/circulationaha.122.060841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients who survive an acute myocardial infarction (AMI), angiotensin-converting enzyme inhibitors decrease the risk of subsequent major cardiovascular events. Whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan reduce major coronary events more effectively than angiotensin-converting enzyme inhibitors in high-risk patients with recent AMI remains unknown. We aimed to compare the effects of sacubitril/valsartan on coronary outcomes in patients with AMI. METHODS We conducted a prespecified analysis of the PARADISE-MI trial (Prospective ARNI vs ACE Inhibitors Trial to Determine Superiority in Reducing Heart Failure Events After MI), which compared sacubitril/valsartan (97/103 mg twice daily) with ramipril (5 mg twice daily) for reducing heart failure events after myocardial infarction in 5661 patients with AMI complicated by left ventricular systolic dysfunction, pulmonary congestion, or both. In the present analysis, the prespecified composite coronary outcome was the first occurrence of death from coronary heart disease, nonfatal myocardial infarction, hospitalization for angina, or postrandomization coronary revascularization. RESULTS Patients were randomly assigned at a median of 4.4 [3.0-5.8] days after index AMI (ST-segment-elevation myocardial infarction 76%, non-ST-segment-elevation myocardial infarction 24%), by which time 89% of patients had undergone coronary reperfusion. Compared with ramipril, sacubitril/valsartan decreased the risk of coronary outcomes (hazard ratio, 0.86 [95% CI, 0.74-0.99], P=0.04) over a median follow-up of 22 months. Rates of the components of the composite outcomes were lower in patients on sacubitril/valsartan but were not individually significantly different. CONCLUSIONS In survivors of an AMI with left ventricular systolic dysfunction and pulmonary congestion, sacubitril/valsartan-compared with ramipril-reduced the risk of a prespecified major coronary composite outcome. Dedicated studies are necessary to confirm this finding and elucidate its mechanism. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02924727.
Collapse
Affiliation(s)
- Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, France (P.G.S.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA (E.F.L.)
| | | | - Lars Køber
- Professor of Cardiology, Department of Clinical Medicine, University of Copenhagen, Denmark (L.K.)
| | - Aldo Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy (A.M.)
| | - Douglas L Mann
- Washington University Medical Center, St Louis, MO (D.L.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat Assistance Publique Hôpitaux de Paris. France (G.D.)
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo-SP, Brazil (O.B.)
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia (C.G.D.P.)
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany (U.L.)
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (P.v.d.M.)
| | - Martin Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| |
Collapse
|
19
|
Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Luz Diaz M, Diaz R, Yusufali A, Kumar Sharma S, Tarhuni WM, Hassany M, Avezum A, Harper W, Wasserman S, Almas A, Drapkina O, Felix C, Lopes RD, Berwanger O, Lopez-Jaramillo P, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and the combination of rivaroxaban and aspirin in patients hospitalised with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1169-1177. [PMID: 36228641 PMCID: PMC9635892 DOI: 10.1016/s2213-2600(22)00298-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND COVID-19 disease is accompanied by a dysregulated immune response and hypercoagulability. The Anti-Coronavirus Therapies (ACT) inpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with the combination of rivaroxaban and aspirin for prevention of disease progression in patients hospitalised with COVID-19. METHODS The ACT inpatient, open-label, 2 × 2 factorial, randomised, controlled trial was done at 62 clinical centres in 11 countries. Patients aged at least 18 years with symptomatic, laboratory confirmed COVID-19 who were within 72 h of hospitalisation or worsening clinically if already hospitalised were randomly assigned (1:1) to receive colchicine 1·2 mg followed by 0·6 mg 2 h later and then 0·6 mg twice daily for 28 days versus usual care; and in a second (1:1) randomisation, to the combination of rivaroxaban 2·5 mg twice daily plus aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome, assessed at 45 days in the intention-to-treat population, for the colchicine randomisation was the composite of the need for high-flow oxygen, mechanical ventilation, or death; and for the rivaroxaban plus aspirin randomisation was the composite of major thrombosis (myocardial infarction, stroke, acute limb ischaemia, or pulmonary embolism), the need for high-flow oxygen, mechanical ventilation, or death. The trial is registered at www. CLINICALTRIALS gov, NCT04324463 and is ongoing. FINDINGS Between Oct 2, 2020, and Feb 10, 2022, at 62 sites in 11 countries, 2749 patients were randomly assigned to colchicine or control and the combination of rivaroxaban and aspirin or to the control. 2611 patients were included in the analysis of colchicine (n=1304) versus control (n=1307); 2119 patients were included in the analysis of rivaroxaban and aspirin (n=1063) versus control (n=1056). Follow-up was more than 98% complete. Overall, 368 (28·2%) of 1304 patients allocated to colchicine and 356 (27·2%) of 1307 allocated to control had a primary outcome (hazard ratio [HR] 1·04, 95% CI 0·90-1·21, p=0·58); and 281 (26·4%) of 1063 patients allocated to the combination of rivaroxaban and aspirin and 300 (28·4%) of 1056 allocated to control had a primary outcome (HR 0·92, 95% CI 0·78-1·09, p=0·32). Results were consistent in subgroups defined by vaccination status, disease severity at baseline, and timing of randomisation in relation to onset of symptoms. There was no increase in the number of patients who had at least one serious adverse event for colchicine versus control groups (87 [6·7%] of 1304 vs 90 [6·9%] of 1307) or with rivaroxaban and aspirin versus control groups (85 [8·0%] vs 91 [8·6%]). Among patients assigned to colchicine, 8 (0·61%) had adverse events that led to discontinuation of study drug, mostly gastrointestinal in nature. 17 (1·6%) patients assigned to the combination of rivaroxaban and aspirin had bleeding compared with seven (0·66%) of those allocated to control (p=0·042); the number of serious bleeding events was two (0·19%) versus six (0·57%), respectively (p=0·18). No patients assigned to rivaroxaban and aspirin had serious adverse events that led to discontinuation of study drug. INTERPRETATION Among patients hospitalised with COVID-19, neither colchicine nor the combination of rivaroxaban and aspirin prevent disease progression or death. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada,Correspondence to: Prof John W Eikelboom, Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Maria Luz Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - William Harper
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Aysha Almas
- Section of Internal Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Oxana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | | | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
20
|
Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Tarhuni WM, Hassany M, Kontsevaya A, Harper W, Sharma SK, Lopez-Jaramillo P, Dans AL, Palileo-Villanueva LM, Avezum A, Pais P, Xavier D, Felix C, Yusufali A, Lopes RD, Berwanger O, Ali Z, Wasserman S, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and aspirin in community patients with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1160-1168. [PMID: 36228639 PMCID: PMC9635862 DOI: 10.1016/s2213-2600(22)00299-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The large number of patients worldwide infected with the SARS-CoV-2 virus has overwhelmed health-care systems globally. The Anti-Coronavirus Therapies (ACT) outpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin for prevention of disease progression in community patients with COVID-19. METHODS The ACT outpatient, open-label, 2 × 2 factorial, randomised, controlled trial, was done at 48 clinical sites in 11 countries. Patients in the community aged 30 years and older with symptomatic, laboratory confirmed COVID-19 who were within 7 days of diagnosis and at high risk of disease progression were randomly assigned (1:1) to receive colchicine 0·6 mg twice daily for 3 days and then 0·6 mg once daily for 25 days versus usual care, and in a second (1:1) randomisation to receive aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome was assessed at 45 days in the intention-to-treat population; for the colchicine randomisation it was hospitalisation or death, and for the aspirin randomisation it was major thrombosis, hospitalisation, or death. The ACT outpatient trial is registered at ClinicalTrials.gov, NCT04324463 and is ongoing. FINDINGS Between Aug 27, 2020, and Feb 10, 2022, 3917 patients were randomly assigned to colchicine or control and to aspirin or control; after excluding 36 patients due to administrative reasons 3881 individuals were included in the analysis (n=1939 colchicine vs n=1942 control; n=1945 aspirin vs 1936 control). Follow-up was more than 99% complete. Overall event rates were 5 (0·1%) of 3881 for major thrombosis, 123 (3·2%) of 3881 for hospitalisation, and 23 (0·6%) of 3881 for death; 66 (3·4%) of 1939 patients allocated to colchicine and 65 (3·3%) of 1942 patients allocated to control experienced hospitalisation or death (hazard ratio [HR] 1·02, 95% CI 0·72-1·43, p=0·93); and 59 (3·0%) of 1945 of patients allocated to aspirin and 73 (3·8%) of 1936 patients allocated to control experienced major thrombosis, hospitalisation, or death (HR 0·80, 95% CI 0·57-1·13, p=0·21). Results for the primary outcome were consistent in all prespecified subgroups, including according to baseline vaccination status, timing of randomisation in relation to onset of symptoms (post-hoc analysis), and timing of enrolment according to the phase of the pandemic (post-hoc analysis). There were more serious adverse events with colchicine than with control (34 patients [1·8%] of 1939 vs 27 [1·4%] of 1942) but none in either group that led to discontinuation of study interventions. There was no increase in serious adverse events with aspirin versus control (31 [1·6%] vs 31 [1·6%]) and none that led to discontinuation of study interventions. INTERPRETATION The results provide no support for the use of colchicine or aspirin to prevent disease progression or death in outpatients with COVID-19. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, and Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Anna Kontsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Antonio L Dans
- UP College of Medicine, University of the Philippines Manila, Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Prem Pais
- St John's Research Institute, Bangalore, India
| | - Denis Xavier
- St John's Medical College, St John's Research Institute, Bangalore, India
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | - Zeeshan Ali
- Jinnah Sindh Medical University and Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
21
|
Cantor WJ, Tan M, Berwanger O, Lavi S, White HD, Nicolau JC, Dehghani P, Tajer CD, Lopes RD, Moia DDF, Nicholls SJ, Parkhomenko A, Averkov O, Brass N, Lutchmedial S, Malaga G, Damiani LP, Piegas LS, Granger CB, Goodman SG. Morphine and clinical outcomes in patients with ST segment elevation myocardial infarction treated with fibrinolytic and antiplatelet therapy: Insights from the TREAT trial. Am Heart J 2022; 251:1-12. [PMID: 35533724 DOI: 10.1016/j.ahj.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/31/2021] [Revised: 02/22/2022] [Accepted: 05/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Morphine is commonly used to relieve pain, anxiety and dyspnea in STEMI but it lowers blood pressure and delays the activity of oral antiplatelet agents. The impact of morphine on clinical outcomes remains unknown. This analysis was performed to determine if morphine use was associated with increased risk of adverse clinical events among STEMI patients treated with fibrinolytic therapy and clopidogrel or ticagrelor. METHODS In the Ticagrelor in Patients with ST Elevation Myocardial Infarction Treated with Pharmacological Thrombolysis (TREAT) study, 3799 STEMI patients treated with fibrinolysis were randomized to receive clopidogrel or ticagrelor. Morphine use was left to the discretion of the treating physicians. In this pre-specified analysis, we evaluated clinical outcomes based on the use and timing of morphine administration. Outcomes were stratified by randomized treatment group. Multivariable analysis was performed using Inverse Probability Treatment Weighting (IPTW) weighting. RESULTS Morphine was used in 53% of patients. After adjustment using IPTW weighting, morphine use was associated with higher hazard of reinfarction at 7 days (HR 4.9, P = .0006) and 30 days (HR 1.7, P = .04), and lower hazard of major bleeding (HR 0.37, P = .006). There was no significant difference in mortality at any time point. CONCLUSIONS Among patients with STEMI treated with fibrinolytic therapy, morphine use was associated with a higher risk of early reinfarction and a lower risk of major bleeding but no difference in mortality. CLINICAL TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02298088.
Collapse
Affiliation(s)
- Warren J Cantor
- Department of Medicine, Southlake Regional Health Centre, University of Toronto, 581 Davis Drive, Newmarket, Toronto, Ontario L3Y 2P6, Canada.
| | - Mary Tan
- Department of Medicine, Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Shahar Lavi
- Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Harvey D White
- Department of Medicine, Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Payam Dehghani
- Department of Medicine, Prairie Vascular Research Network and Saskatchewan Health Authority, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Carlos D Tajer
- Department of Medicine, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Renato D Lopes
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, United States; Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Diogo D F Moia
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | - Stephen J Nicholls
- Department of Medicine, Monash Cardiovascular Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Parkhomenko
- Department of Medicine, Emergency Cardiology Department, Institute of Cardiology, Kiev, Ukraine
| | - Oleg Averkov
- Department of Medicine, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Neil Brass
- Department of Medicine, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Sohrab Lutchmedial
- Department of Medicine, New Brunswick Heart Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Germán Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lucas P Damiani
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Shaun G Goodman
- Department of Medicine, Canadian Heart Research Centre (CHRC) and Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Berwanger O, Pfeffer M, Claggett B, Jering KS, Maggioni AP, Steg PG, Mehran R, Lewis EF, Zhou Y, van der Meer P, De Pasquale C, Merkely B, Filippatos G, McMurray JJ, Granger CB, Solomon SD, Braunwald E. SACUBITRIL/VALSARTAN VERSUS RAMIPRIL FOR PATIENTS WITH ACUTE MYOCARDIAL INFARCTION:
WIN‐RATIO
ANALYSIS OF THE
PARADISE‐MI
TRIAL. Eur J Heart Fail 2022; 24:1918-1927. [DOI: 10.1002/ejhf.2663] [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] [Received: 08/09/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein Sao Paulo SP Brazil
| | - Marc Pfeffer
- Cardiovascular Division Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | - Brian Claggett
- Cardiovascular Division Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | - Karola S. Jering
- Cardiovascular Division Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | | | - Philippe Gabriel Steg
- Université Paris‐Cité, Institut Universitaire de France, AP‐HP (Assistance Publique‐Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U‐1148 Paris France
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Eldrin F. Lewis
- Division of Cardiovascular Medicine Stanford University School of Medicine, Stanford University Palo Alto CA
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation East Hanover NJ USA
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen University of Groningen The Netherlands
| | - Carmine De Pasquale
- Flinders Medical Centre, Southern Adelaide Local Health Network South Australia
| | - Béla Merkely
- Heart and Vascular Center Semmelweis University Budapest Hungary
| | - Gerasimos Filippatos
- Department of Cardiology, Athens University Hospital Attikon National and Kapodistrian University of Athens Greece
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre University of Glasgow Glasgow Scotland
| | | | - Scott D. Solomon
- Cardiovascular Division Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | - Eugene Braunwald
- Cardiovascular Division Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| |
Collapse
|
23
|
Berwanger O, Santo K. Cardiovascular Care in Brazil: Current Status, Challenges, and Opportunities. Circulation 2022; 146:435-437. [PMID: 35939540 DOI: 10.1161/circulationaha.122.059320] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Karla Santo
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| |
Collapse
|
24
|
Avezum Á, Oliveira GBF, Oliveira H, Lucchetta RC, Pereira VFA, Dabarian AL, D O Vieira R, Silva DV, Kormann APM, Tognon AP, De Gasperi R, Hernandes ME, Feitosa ADM, Piscopo A, Souza AS, Miguel CH, Nogueira VO, Minelli C, Magalhães CC, Morejon KML, Bicudo LS, Souza GEC, Gomes MAM, Fo JJFR, Schwarzbold AV, Zilli A, Amazonas RB, Moreira FR, Alves LBO, Assis SRL, Neves PDMM, Matuoka JY, Boszczowski I, Catarino DGM, Veiga VC, Azevedo LCP, Rosa RG, Lopes RD, Cavalcanti AB, Berwanger O. Hydroxychloroquine versus placebo in the treatment of non-hospitalised patients with COVID-19 (COPE - Coalition V): A double-blind, multicentre, randomised, controlled trial. Lancet Reg Health Am 2022; 11:100243. [PMID: 35378952 PMCID: PMC8968238 DOI: 10.1016/j.lana.2022.100243] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Previous Randomised controlled trials (RCT) evaluating chloroquine and hydroxychloroquine in non-hospitalised COVID-19 patients have found no significant difference in hospitalisation rates. However, low statistical power precluded definitive answers. Methods We conducted a multicenter, double-blind, RCT in 56 Brazilian sites. Adults with suspected or confirmed COVID-19 presenting with mild or moderate symptoms with ≤ 07 days prior to enrollment and at least one risk factor for clinical deterioration were randomised (1:1) to receive hydroxychloroquine 400 mg twice a day (BID) in the first day, 400 mg once daily (OD) thereafter for a total of seven days, or matching placebo. The primary outcome was hospitalisation due to COVID-19 at 30 days, which was assessed by an adjudication committee masked to treatment allocation and following the intention-to-treat (ITT) principle. An additional analysis was performed only in participants with SARS-CoV-2 infection confirmed by molecular or serology testing (modified ITT [mITT] analysis). This trial was registered at ClinicalTrials.gov, NCT04466540. Findings From May 12, 2020 to July 07, 2021, 1372 patients were randomly allocated to hydroxychloroquine or placebo. There was no significant difference in the risk of hospitalisation between hydroxychloroquine and placebo groups (44/689 [6·4%] and 57/683 [8·3%], RR 0·77 [95% CI 0·52–1·12], respectively, p=0·16), and similar results were found in the mITT analysis with 43/478 [9·0%] and 55/471 [11·7%] events, RR 0·77 [95% CI 0·53–1·12)], respectively, p=0·17. To further complement our data, we conducted a meta-analysis which suggested no significant benefit of hydroxychloroquine in reducing hospitalisation among patients with positive testing (69/1222 [5·6%], and 88/1186 [7·4%]; RR 0·77 [95% CI 0·57–1·04]). Interpretation In outpatients with mild or moderate forms of COVID-19, the use of hydroxychloroquine did not reduce the risk of hospitalisation compared to the placebo control. Our findings do not support the routine use of hydroxychloroquine for treatment of COVID-19 in the outpatient setting. Funding COALITION COVID-19 Brazil and EMS.
Collapse
Affiliation(s)
- Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Gustavo B F Oliveira
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Haliton Oliveira
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Rosa C Lucchetta
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | | | | | | | | | | | | | | | | | - Audes D M Feitosa
- Pronto Socorro Cardiológico Universitário - Prof. Luiz Tavares (PROCAPE), Recife, PE, Brazil
| | | | | | - Carlos H Miguel
- Estratégia Saúde da Família Dr. João Paccola Primo. Prefeitura Municipal, Lençois Paulista, SP, Brazil
| | - Vinicius O Nogueira
- Centro de Pesquisa em Medicina Tropical de Rondônia. Porto Velho, RO, Brazil
| | | | | | | | - Letícia S Bicudo
- Irmandade de Misericórdia do Hospital da Santa Casa de Monte Alto, SP, Brazil
| | | | - Marco A M Gomes
- Centro de Pesquisas Clínicas Dr. Marco Mota, Maceió, AL, Brazil
| | | | | | | | | | - Frederico R Moreira
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Lucas B O Alves
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Silvia R L Assis
- Academic Research Organization - Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Precil D M M Neves
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Jessica Y Matuoka
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Icaro Boszczowski
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Daniela G M Catarino
- International Research Center, Hospital Alemão Oswaldo Cruz, Rua Treze de Maio, 1815; Bloco A, 1o SS, São Paulo, SP 01327-001, Brazil
| | - Viviane C Veiga
- Intensive Care Unit, BP - A Beneficência Portuguesa de São Paulo, SP, Brazil
| | - Luciano C P Azevedo
- Research and Education Institute, Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Regis G Rosa
- Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Brazilian Clinical Research Institute, São Paulo, SP, Brazil
| | | | - Otavio Berwanger
- Academic Research Organization - Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | |
Collapse
|
25
|
Berwanger O, Machline-Carrion MJ. Digital Health-Enabled Clinical Trials in Stroke: Ready for Prime Time? Stroke 2022; 53:2967-2975. [PMID: 35770670 DOI: 10.1161/strokeaha.122.037378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As stroke continues to represent a major global health care problem, advancing our knowledge of new effective and safe stroke interventions represents a public health priority. The identification of these therapies requires the conduct of high-quality and well-powered randomized clinical trials. Despite its potential to inform clinical practice, traditional randomized clinical trial models have their drawbacks, including elevated costs, long completion times, failure to recruit the target sample sizes, lack of diversity, and complex operational procedures. Therefore, improving the participants' experience and trials' overall efficiency constitutes an important unmet need. Innovative models such as virtual and decentralized patient-centric trials have been proposed as a valuable strategy in this pursuit. In this narrative review, we discuss the limitations of traditional randomized clinical trial models and present the concept, advantages, and challenges of decentralized digitally enabled approaches to the conduct of stroke clinical trials.
Collapse
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo, Brazil (O.B.)
| | - M Julia Machline-Carrion
- Department of Medical Affairs, epHealth Primary Care Solutions, Florianópolis, Santa Catarina, Brazil (M.J.M.-C.)
| |
Collapse
|
26
|
Bahit MC, Vora AN, Li Z, Wojdyla DM, Thomas L, Goodman SG, Aronson R, Jordan JD, Kolls BJ, Dombrowski KE, Vinereanu D, Halvorsen S, Berwanger O, Windecker S, Mehran R, Granger CB, Alexander JH, Lopes RD. Apixaban or Warfarin and Aspirin or Placebo After Acute Coronary Syndrome or Percutaneous Coronary Intervention in Patients With Atrial Fibrillation and Prior Stroke: A Post Hoc Analysis From the AUGUSTUS Trial. JAMA Cardiol 2022; 7:682-689. [PMID: 35612866 DOI: 10.1001/jamacardio.2022.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Data are limited regarding the risk of cerebrovascular ischemic events and major bleeding in patients with atrial fibrillation (AF) and recent acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI). Objective Determine the efficacy and safety of apixaban or vitamin K antagonists (VKA) and aspirin or placebo according to prior stroke, transient ischemic attack (TIA), or thromboembolism (TE). Design, Setting, and Participants In this prospective, multicenter, 2-by-2 factorial, randomized clinical trial, post hoc parallel analyses were performed to compare randomized treatment regimens according to presence or absence of prior stroke/TIA/TE using Cox proportional hazards models. Patients with AF, recent ACS or PCI, and planned use of P2Y12 inhibitors for 6 months or longer were included; 33 patients with missing data about prior stroke/TIA/TE were excluded. Interventions Apixaban (5 mg or 2.5 mg twice daily) or VKA and aspirin or placebo. Main Outcomes and Measures Major or clinically relevant nonmajor (CRNM) bleeding. Results Of 4581 patients included, 633 (13.8%) had prior stroke/TIA/TE. Patients with vs without prior stroke/TIA/TE were older; had higher CHA2DS2-VASC and HAS-BLED scores; and more frequently had prior bleeding, heart failure, diabetes, and prior oral anticoagulant use. Apixaban was associated with lower rates of major or CRNM bleeding and death or hospitalization than VKA in patients with (hazard ratio [HR], 0.69; 95% CI, 0.46-1.03) and without (HR, 0.68; 95% CI, 0.57-0.82) prior stroke/TIA/TE. Patients without prior stroke/TIA/TE receiving aspirin vs placebo had higher rates of bleeding; this difference appeared less substantial among patients with prior stroke/TIA/TE (P = .01 for interaction). Aspirin was associated with numerically lower rates of death or ischemic events than placebo in patients with (HR, 0.71; 95% CI, 0.42-1.20) and without (HR, 0.93; 95% CI, 0.72-1.21) prior stroke/TIA/TE (not statistically significant). Conclusions and Relevance The safety and efficacy of apixaban compared with VKA was consistent with the AUGUSTUS findings, irrespective of prior stroke/TIA/TE. Aspirin increased major or CRNM bleeding, particularly in patients without prior stroke/TIA/TE. Although aspirin may have some benefit in patients with prior stroke, our findings support the use of apixaban and a P2Y12 inhibitor without aspirin for the majority of patients with AF and ACS and/or PCI, regardless of prior stroke/TIA/TE status. Trial Registration ClinicalTrials.gov Identifier: NCT02415400.
Collapse
Affiliation(s)
- M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | - Amit N Vora
- UPMC Heart and Vascular Institute, Harrisburg, Pennsylvania.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Terrence Donnelly Heart Center, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - J Dedrick Jordan
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Brad J Kolls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Keith E Dombrowski
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa
| | - Dragos Vinereanu
- Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital, Bucharest, Romania
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | | | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Cardiovascular Research Foundation, New York, New York
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
27
|
Heerspink HJ, Furtado RH, Berwanger O, Koch GG, Martinez F, Mukhtar O, Verma S, Gasparyan SB, Tang F, Windsor SL, de Souza-Dantas VC, del Sueldo M, Frankel R, Javaheri A, Maldonado RA, Morse C, Mota-Gomes M, Shemin D, Silva OL, Tognon AP, Twahirwa M, Buenconsejo J, Esterline R, Oscarsson J, Ambery P, Langkilde AM, Kosiborod MN. Dapagliflozin and Kidney Outcomes in Hospitalized Patients with COVID-19 Infection: An Analysis of the DARE-19 Randomized Controlled Trial. Clin J Am Soc Nephrol 2022; 17:643-654. [PMID: 35483733 PMCID: PMC9269587 DOI: 10.2215/cjn.14231021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/21/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients who were hospitalized with coronavirus disease 2019 (COVID-19) infection are at high risk of AKI and KRT, especially in the presence of CKD. The Dapagliflozin in Respiratory Failure in Patients with COVID-19 (DARE-19) trial showed that in patients hospitalized with COVID-19, treatment with dapagliflozin versus placebo resulted in numerically fewer participants who experienced organ failure or death, although these differences were not statistically significant. We performed a secondary analysis of the DARE-19 trial to determine the efficacy and safety of dapagliflozin on kidney outcomes in the overall population and in prespecified subgroups of participants defined by baseline eGFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The DARE-19 trial randomized 1250 patients who were hospitalized (231 [18%] had eGFR <60 ml/min per 1.73 m2) with COVID-19 and cardiometabolic risk factors to dapagliflozin or placebo. Dual primary outcomes (time to new or worsened organ dysfunction or death, and a hierarchical composite end point of recovery [change in clinical status by day 30]), and the key secondary kidney outcome (composite of AKI, KRT, or death), and safety were assessed in participants with baseline eGFR <60 and ≥60 ml/min per 1.73 m2. RESULTS The effect of dapagliflozin versus placebo on the primary prevention outcome (hazard ratio, 0.80; 95% confidence interval, 0.58 to 1.10), primary recovery outcome (win ratio, 1.09; 95% confidence interval, 0.97 to 1.22), and the composite kidney outcome (hazard ratio, 0.74; 95% confidence interval, 0.50 to 1.07) were consistent across eGFR subgroups (P for interaction: 0.98, 0.67, and 0.44, respectively). The effects of dapagliflozin on AKI were also similar in participants with eGFR <60 ml/min per 1.73 m2 (hazard ratio, 0.71; 95% confidence interval, 0.29 to 1.77) and ≥60 ml/min per 1.73 m2 (hazard ratio, 0.69; 95% confidence interval, 0.37 to 1.29). Dapagliflozin was well tolerated in participants with eGFR <60 and ≥60 ml/min per 1.73 m2. CONCLUSIONS The effects of dapagliflozin on primary and secondary outcomes in hospitalized participants with COVID-19 were consistent in those with eGFR below/above 60 ml/min per 1.73 m2. Dapagliflozin was well tolerated and did not increase the risk of AKI in participants with eGFR below or above 60 ml/min per 1.73 m2.
Collapse
Affiliation(s)
- Hiddo J.L. Heerspink
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,The George Institute for Global Health, Newtown, NSW, Australia
| | - Remo H.M. Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil,Instituto do Coracao do Hospital das Clinicas da FMUSP, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Gary G. Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Omar Mukhtar
- Department of Medicine, Experimental Medicine and Immunotherapeutics Division, University of Cambridge, Cambridge, United Kingdom
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada,Department of Surgery and Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Samvel B. Gasparyan
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Vicente Cés de Souza-Dantas
- Intensive Care Unit, University Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mildren del Sueldo
- Department of Cardiology, Clinica de Especialidades, Villa Maria, Argentina
| | - Robert Frankel
- Cardiology, Maimonides Medical Center, New York, New York
| | - Ali Javaheri
- Washington University School of Medicine, St Louis, Missouri
| | - Rafael A. Maldonado
- Nephrology and Transplantation Service, Clínica Privada Vélez Sarsfield, Postgraduate School of Nephrology, National University of Córdoba, Córdoba, Argentina
| | - Caryn Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Marco Mota-Gomes
- Centro Universitário Cesmac/Hospital do Coração de Alagoas, Maceió, Brazil
| | - Douglas Shemin
- Division of Kidney Diseases and Hypertension, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Osvaldo Lourenço Silva
- Centro Integrado de Pesquisas, Hospital de Base-São José do Rio Preto, São José do Rio Preto, Brazil
| | | | - Marcel Twahirwa
- Diabetes and Endocrinology Institute, Doctors Hospital at Renaissance, Edinburg, Texas
| | - Joan Buenconsejo
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Russell Esterline
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Jan Oscarsson
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikhail N. Kosiborod
- The George Institute for Global Health, Newtown, NSW, Australia,Saint Luke's Mid America Heart Institute, Kansas City, Missouri,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| |
Collapse
|
28
|
Hess CN, Nehler MR, Hsia JA, Ruf W, Morrow DA, Nicolau J, Berwanger O, Szarek M, Capell W, Johri S, Pursley M, Gupta R, Marshall D, Graybill C, Carroll I, Keuer T, Bristow M, Bonaca MP. Abstract 113: Novel Tissue Factor Inhibition For Thromboprophylaxis In COVID-19: Primary Results Of The ASPEN-COVID-19 Phase 2b Randomized Trial. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.113] [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] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background:
Tissue factor contributes to thrombo-inflammation in viral infection and may be a target in COVID-19. Recombinant nematode anticoagulant protein c2 (rNAPc2), a tissue factor inhibitor with anticoagulant, anti-inflammatory, and antiviral properties, has not been studied in COVID-19.
Methods:
In Phase 2b of ASPEN-COVID-19 (NCT04655586), an open-label blinded endpoint study, COVID-19 inpatients with elevated D-dimer are randomized 1:1:2 to higher or lower dose rNAPc2 given subcutaneously up to 5 days or local standard of care heparin. Primary efficacy and safety endpoints are D-dimer change (to Day 8 or discharge if earlier) and ISTH major bleeding. Recovery time is an exploratory outcome.
Results:
160 patients were randomized at 24 sites in 3 countries. The average age was 56 years, 43% were female, 19% were Hispanic, and 21% were black. Baseline comorbidities included hypertension (51%), diabetes (35%), and smoking (35%); 11% were critically ill. On average, randomization occurred 10 days after COVID-19 symptom onset, and qualifying D-dimers were elevated 3.7-fold above the upper limit of normal. Median recovery time was 6 days (aggregate distribution shown in Figure). Enrollment has completed, database lock is anticipated Q1 2022, and final results will be ready for presentation at Vascular Discovery.
Conclusion:
ASPEN tests the hypothesis that compared to heparin, rNAPc2 reduces D-dimer in COVID-19. Results may help to provide a novel therapy for thromboprophylaxis in virus-related coagulopathies.
Collapse
Affiliation(s)
| | | | | | | | | | - Jose Nicolau
- InCor, Univ of São Paulo Med Sch, Sao Paolo, Brazil
| | | | | | | | - Shilpa Johri
- Pulmonary Associates of Richmond, Inc, Richmond, VA
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Scanavini-Filho MA, Berwanger O, Matthias W, Aguiar MO, Chiang HP, Azevedo L, Baracioli LM, Lima FG, Furtado RHM, Dalcoquio TF, Menezes FR, Ferrari AG, de Luca F, Giugliano RP, Goodman S, Nicolau JC. Effects of Ticagrelor and Clopidogrel on Coronary Microcirculation in Patients with Acute Myocardial Infarction. Adv Ther 2022; 39:1832-1843. [PMID: 35218519 PMCID: PMC8989815 DOI: 10.1007/s12325-022-02061-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/25/2022] [Indexed: 11/27/2022]
Abstract
Introduction Clopidogrel has been demonstrated to be effective in improving coronary microcirculation (CM) among patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolytics. Ticagrelor is a more potent adenosine diphosphate (ADP) receptor blocker proven to be superior to clopidogrel among patients with acute coronary syndromes. The present study aimed to compare the effects of ticagrelor and clopidogrel on CM in patients with STEMI treated with fibrinolytics. Methods The present study prospectively included 48 patients participating in the TREAT trial, which randomly assigned patients with STEMI undergoing fibrinolysis to ticagrelor versus clopidogrel. The primary endpoint of this study was the evaluation of the CM using the global myocardial perfusion score index (global MPSI) obtained by myocardial contrast echocardiography (MCE). Platelet aggregation to ADP was evaluated by Multiplate® and expressed as area under the curve (AUC). Results The global MPSI demonstrated no differences between the groups [mean 1.4 (1.2–1.5) in the ticagrelor group and 1.2 (1.2–1.5) in the clopidogrel group (p = 0.41)]. Platelet aggregability was lower in the ticagrelor group (18.1 ± 9.7 AUC), compared to the clopidogrel group (26.1 ± 12.5 AUC, p = 0.01). Conclusion We found no improvement in coronary microcirculation with ticagrelor compared to clopidogrel among patients with STEMI treated with fibrinolytics, despite the fact that platelet aggregation to ADP was lower with ticagrelor. Clinical Trials Registration NCT03104062. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02061-0.
Collapse
Affiliation(s)
- Marco Antonio Scanavini-Filho
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein, 627 Albert Einstein Ave, São Paulo, SP 05652-900 Brazil
| | - Wilson Matthias
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Miguel O. Aguiar
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Hsu P. Chiang
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Luciene Azevedo
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Luciano M. Baracioli
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Felipe G. Lima
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Remo H. M. Furtado
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Talia F. Dalcoquio
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Fernando R. Menezes
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Aline G. Ferrari
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Fabio de Luca
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Robert P. Giugliano
- Brigham and Women’s Hospital, Harvard Medical School, 350 Longwood Ave, Boston, MA 02215 USA
| | - Shaun Goodman
- St. Michael’s Hospital, University of Toronto, 36 Queen St E, Toronto, ON M5B 1W8 Canada
| | - José C. Nicolau
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
- Rua Mato Grosso 306, CJ 713, São Paulo, SP 01239-040 Brazil
| |
Collapse
|
30
|
Eikelboom J, Rangarajan S, Jolly SS, Belley-Cote EP, Whitlock R, Beresh H, Lewis G, Xu L, Chan N, Bangdiwala S, Diaz R, Orlandini A, Hassany M, Tarhuni WM, Yusufali AM, Sharma SK, Konstsevaya A, Jaramillo PL, Avezum A, Dans AL, Wasserman S, Camilo F, Kazmi K, Pais P, Xavier D, Lopes RD, Berwanger O, Nkeshimana M, Harper W, Loeb M, Choudhri S, Farkouh ME, Bosch J, Anand SS, Yusuf S. The Anti-Coronavirus Therapy (ACT) trials: design, baseline characteristics, and challenges. CJC Open 2022; 4:568-576. [PMID: 35252829 PMCID: PMC8887957 DOI: 10.1016/j.cjco.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 12/14/2022] Open
Abstract
Background Effective treatments for COVID-19 are urgently needed, but conducting randomized trials during the pandemic has been challenging. Methods The Anti-Coronavirus Therapy (ACT) trials are parallel factorial international trials that aimed to enroll 3500 outpatients and 2500 inpatients with symptomatic COVID-19. The outpatient trial is evaluating colchicine vs usual care, and aspirin vs usual care. The primary outcome for the colchicine randomization is hospitalization or death, and for the aspirin randomization, it is major thrombosis, hospitalization, or death. The inpatient trial is evaluating colchicine vs usual care, and the combination of rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily vs usual care. The primary outcome for the colchicine randomization is need for high-flow oxygen, need for mechanical ventilation, or death, and for the rivaroxaban plus aspirin randomization, it is major thrombotic events, need for high-flow oxygen, need for mechanical ventilation, or death. Results At the completion of enrollment on February 10, 2022, the outpatient trial had enrolled 3917 patients, and the inpatient trial had enrolled 2611 patients. Challenges encountered included lack of preliminary data about the interventions under evaluation, uncertainties related to the expected event rates, delays in regulatory and ethics approvals, and in obtaining study interventions, as well as the changing pattern of the COVID-19 pandemic. Conclusions The ACT trials will determine the efficacy of anti-inflammatory therapy with colchicine, and antithrombotic therapy with aspirin given alone or in combination with rivaroxaban, across the spectrum of mild, moderate, and severe COVID-19. Lessons learned from the conduct of these trials will inform planning of future trials.
Collapse
Affiliation(s)
- John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Heather Beresh
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Gayle Lewis
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Noel Chan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Shrikant Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Rafael Diaz
- ECLA (Estudios Clínicos Latino America) ICR (Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Andres Orlandini
- ECLA (Estudios Clínicos Latino America) ICR (Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Wadea M Tarhuni
- Dept of Medicine, University of Saskatchewan, Saskatoon , Canada.,Dept of Medicine, Western University, Clinical Skills Building London, Canada.,Windsor Cardiac Centre, Windsor, Canada
| | - A M Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, UAE
| | | | - Anna Konstsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russian Federation
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Felix Camilo
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Khawar Kazmi
- National Institute of Cardiovascular Diseases, Rafique Shaheed Road, Karachi, Pakistan
| | - Prem Pais
- St. John's Research Institute, Bangalore, India
| | - Denis Xavier
- St. John's Medical College, St. John's Research Institute, Bangalore, India
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, North Carolina, USA
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Global Cardiovascular Coalition, Alameda Campinas, São Paulo, Brazil
| | - Menelas Nkeshimana
- Centre Hospitalier Universitaire de Kigali, Rwanda.,University of Rwanda, Dept. Of Internal Medicine, Kigali, Rwanda
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University. Hamilton, Canada
| | - Shurjeel Choudhri
- Bayer Inc., Medical & Scientific Affairs, Pharmaceuticals, Mississauga, Canada
| | | | - Jackie Bosch
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| |
Collapse
|
31
|
Oliveira HAD, Ferri CP, Boszczowski I, Oliveira GBF, Cavalcanti AB, Rosa RG, Lopes RD, Azevedo LCP, Veiga VC, Berwanger O, Avezum Á. Justificativa e Desenho do Ensaio Clínico Randomizado COVID-19 Outpatient Prevention Evaluation (COPE - Coalition V): Hidroxicloroquina vs. Placebo em Pacientes Não Hospitalizados. Arq Bras Cardiol 2022; 118:378-387. [PMID: 35262569 PMCID: PMC8856682 DOI: 10.36660/abc.20210832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/24/2021] [Indexed: 01/31/2023] Open
Abstract
Fundamento Apesar da necessidade de opções terapêuticas específicas para a doença do coronavírus 2019 (covid-19), ainda não há evidências da eficácia de tratamentos específicos no contexto ambulatorial. Há poucos estudos randomizados que avaliam a hidroxicloroquina (HCQ) em pacientes não hospitalizados. Esses estudos não indicaram benefício com o uso da HCQ; no entanto, avaliaram desfechos primários diferentes e apresentaram vieses importantes na avaliação dos desfechos. Objetivo Investigar se a HCQ possui o potencial de prevenir hospitalizações por covid-19 quando comparada ao placebo correspondente. Métodos O estudo COVID-19 Outpatient Prevention Evaluation (COPE) é um ensaio clínico randomizado, pragmático, duplo-cego, multicêntrico e controlado por placebo que avalia o uso da HCQ (800 mg no dia 1 e 400 mg do dia 2 ao dia 7) ou placebo correspondente na prevenção de hospitalizações por covid-19 em casos precoces confirmados ou suspeitos de pacientes não hospitalizados. Os critérios de inclusão são adultos (≥ 18 anos) que procuraram atendimento médico com sintomas leves de covid-19, com randomização ≤ 7 dias após o início dos sintomas, sem indicação de hospitalização na triagem do estudo e com pelo menos um fator de risco para complicações (> 65 anos, hipertensão, diabetes melito, asma, doença pulmonar obstrutiva crônica ou outras doenças pulmonares crônicas, tabagismo, imunossupressão ou obesidade). Todos os testes de hipótese serão bilaterais. Um valor de p < 0,05 será considerado estatisticamente significativo em todas as análises. Clinicaltrials.gov: NCT04466540. Resultados Os desfechos clínicos serão avaliados centralmente por um comitê de eventos clínicos independente cegado para a alocação dos grupos de tratamento. O desfecho primário de eficácia será avaliado de acordo com o princípio da intenção de tratar. Conclusão Este estudo apresenta o potencial de responder de forma confiável a questão científica do uso da HCQ em pacientes ambulatoriais com covid-19. Do nosso conhecimento, este é o maior estudo avaliando o uso de HCQ em indivíduos com covid-19 não hospitalizados.
Collapse
|
32
|
Kosiborod MN, Esterline R, Oscarsson J, Gasparyan SB, Furtado RHM, Verma S, Berwanger O. Dapagliflozin in patients with COVID-19: mind the kidneys - Authors' reply. Lancet Diabetes Endocrinol 2022; 10:98-99. [PMID: 34921753 PMCID: PMC8673873 DOI: 10.1016/s2213-8587(21)00326-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Mikhail N Kosiborod
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA; Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
| | - Russell Esterline
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gaithersburg, USA
| | - Jan Oscarsson
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Samvel B Gasparyan
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Instituto do Coracao do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada; Department of Surgery and Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| |
Collapse
|
33
|
Pfeffer MA, Claggett B, Lewis EF, Granger CB, Køber L, Maggioni AP, Mann DL, McMurray JJ, Rouleau JL, Solomon SD, Steg PG, Berwanger O, Cikes M, De Pasquale CG, Fernandez A, Filippatos G, Jering K, Landmesser U, Menon V, Merkely B, Petrie MC, Petrov I, Schou M, Senni M, Kheng Leng DS, van der Meer P, Lefkowitz M, Zhou Y, Wang Y, Braunwald E. Impact of Sacubitril/Valsartan Versus Ramipril on Total Heart Failure Events in the PARADISE-MI Trial. Circulation 2022; 145:87-89. [PMID: 34797725 PMCID: PMC8716414 DOI: 10.1161/circulationaha.121.057429] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School Boston, MA, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School Boston, MA, USA
| | - Eldrin F. Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Lars Køber
- Rigshospitalet, Blegdamsvej, University of Copenhagen, Denmark
| | | | | | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | | | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School Boston, MA, USA
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, Paris, France
| | - Otavio Berwanger
- Otavio Berwanger, Academic Research Organization (ARO) – Hospital Israelita Albert Einstein, São Paulo-SP, Brazil
| | - Maja Cikes
- Maja Cikes, Department of Cardiovascular Diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Croatia
| | - Carmine G. De Pasquale
- Carmine G. De Pasquale, Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Alberto Fernandez
- Alberto Fernandez, Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina
| | - Gerasimos Filippatos
- Gerasimos Filippatos M.D., Director of the HF Unit at the Attikon University Hospital, Athens, Greece
| | - Karola Jering
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School Boston, MA, USA
| | - Ulf Landmesser
- Ulf Landmesser, Department of Cardiology, Charité University Medicine Berlin, German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin Institute of Health (BIH), Berlin, Germany
| | - Venugopal Menon
- Venugopal Menon, M.D., Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Béla Merkely
- Béla Merkely, Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Mark C. Petrie
- Mark C. Petrie, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ivo Petrov
- Ivo Petrov, Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria
| | - Morten Schou
- Morten Schou, Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Michele Senni
- Michele Senni, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Peter van der Meer
- Peter van der Meer, Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | | | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Yi Wang
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School Boston, MA, USA
| |
Collapse
|
34
|
McCaw ZR, Claggett BL, Tian L, Solomon SD, Berwanger O, Pfeffer MA, Wei LJ. Practical Recommendations on Quantifying and Interpreting Treatment Effects in the Presence of Terminal Competing Risks: A Review. JAMA Cardiol 2021; 7:450-456. [PMID: 34851356 DOI: 10.1001/jamacardio.2021.4932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/11/2022]
Abstract
Importance In a comparative trial, the time to a clinical event is often a key end point. However, the occurrence of a terminal event, such as death or premature study discontinuation, may preclude observation of this outcome. Although various methods for handling competing risks are available, no specific recommendations have been made for scenarios encountered in practice, especially when the terminal event profiles of the study arms are dissimilar. Moreover, appropriate methods for a desirable outcome, such as live hospital discharge, have seldom been discussed. Observations Several of the most commonly used methods are reviewed. The first regards the terminal event as censoring and applies standard survival analysis to the event of interest. The between-group difference is usually summarized by the cause-specific hazard ratio. This summary measure is inappropriate when the new therapy markedly prolongs time to the terminal event. Moreover, the corresponding Kaplan-Meier curve for the end point of interest is uninterpretable. The second method is to use the cumulative incidence curve, which is the probability of experiencing the event of interest by each time point, acknowledging that patients who have died will never experience the event. However, the resulting pseudo hazard ratio is difficult to interpret. With a proper alternative summary measure, this approach works well for a desirable outcome but may not for an undesirable outcome. The third method focuses on the event-free survival time by combining information from occurrences of the terminal event and the event of interest simultaneously. This clinically interpretable method naturally accounts for differences in terminal event rates when comparing treatments with respect to the time to an undesirable outcome. Conclusions and Relevance This article enhances our understanding of each method's advantages and shortcomings and assists practitioners in choosing appropriate methods for handling competing risk problems in practice.
Collapse
Affiliation(s)
| | - Brian Lee Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Otavio Berwanger
- Academic Research Organization-Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee-Jen Wei
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
35
|
Pfeffer MA, Claggett B, Lewis EF, Granger CB, Køber L, Maggioni AP, Mann DL, McMurray JJV, Rouleau JL, Solomon SD, Steg PG, Berwanger O, Cikes M, De Pasquale CG, East C, Fernandez A, Jering K, Landmesser U, Mehran R, Merkely B, Vaghaiwalla Mody F, Petrie MC, Petrov I, Schou M, Senni M, Sim D, van der Meer P, Lefkowitz M, Zhou Y, Gong J, Braunwald E. Angiotensin Receptor-Neprilysin Inhibition in Acute Myocardial Infarction. N Engl J Med 2021; 385:1845-1855. [PMID: 34758252 DOI: 10.1056/nejmoa2104508] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with symptomatic heart failure, sacubitril-valsartan has been found to reduce the risk of hospitalization and death from cardiovascular causes more effectively than an angiotensin-converting-enzyme inhibitor. Trials comparing the effects of these drugs in patients with acute myocardial infarction have been lacking. METHODS We randomly assigned patients with myocardial infarction complicated by a reduced left ventricular ejection fraction, pulmonary congestion, or both to receive either sacubitril-valsartan (97 mg of sacubitril and 103 mg of valsartan twice daily) or ramipril (5 mg twice daily) in addition to recommended therapy. The primary outcome was death from cardiovascular causes or incident heart failure (outpatient symptomatic heart failure or heart failure leading to hospitalization), whichever occurred first. RESULTS A total of 5661 patients underwent randomization; 2830 were assigned to receive sacubitril-valsartan and 2831 to receive ramipril. Over a median of 22 months, a primary-outcome event occurred in 338 patients (11.9%) in the sacubitril-valsartan group and in 373 patients (13.2%) in the ramipril group (hazard ratio, 0.90; 95% confidence interval [CI], 0.78 to 1.04; P = 0.17). Death from cardiovascular causes or hospitalization for heart failure occurred in 308 patients (10.9%) in the sacubitril-valsartan group and in 335 patients (11.8%) in the ramipril group (hazard ratio, 0.91; 95% CI, 0.78 to 1.07); death from cardiovascular causes in 168 (5.9%) and 191 (6.7%), respectively (hazard ratio, 0.87; 95% CI, 0.71 to 1.08); and death from any cause in 213 (7.5%) and 242 (8.5%), respectively (hazard ratio, 0.88; 95% CI, 0.73 to 1.05). Treatment was discontinued because of an adverse event in 357 patients (12.6%) in the sacubitril-valsartan group and 379 patients (13.4%) in the ramipril group. CONCLUSIONS Sacubitril-valsartan was not associated with a significantly lower incidence of death from cardiovascular causes or incident heart failure than ramipril among patients with acute myocardial infarction. (Funded by Novartis; PARADISE-MI ClinicalTrials.gov number, NCT02924727.).
Collapse
Affiliation(s)
- Marc A Pfeffer
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Brian Claggett
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Eldrin F Lewis
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Christopher B Granger
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Lars Køber
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Aldo P Maggioni
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Douglas L Mann
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - John J V McMurray
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Jean-Lucien Rouleau
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Scott D Solomon
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Philippe G Steg
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Otavio Berwanger
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Maja Cikes
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Carmine G De Pasquale
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Cara East
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Alberto Fernandez
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Karola Jering
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Ulf Landmesser
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Roxana Mehran
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Béla Merkely
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Freny Vaghaiwalla Mody
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Mark C Petrie
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Ivo Petrov
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Morten Schou
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Michele Senni
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - David Sim
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Peter van der Meer
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Martin Lefkowitz
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Yinong Zhou
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Jianjian Gong
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| | - Eugene Braunwald
- From the Cardiovascular Division (M.A.P., B.C., S.D.S., K.J., E.B.) and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division (E.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto (E.F.L.), and the Heart Failure and Preventive Cardiology Programs, Department of Veterans Affairs Greater Los Angeles, University of California, Los Angeles, Los Angeles (F.V.M.) - both in California; Duke University Medical Center, Durham, NC (C.B.G.); Rigshospitalet, Blegdamsvej, University of Copenhagen (L.K.), and the Department of Cardiology, Herlev-Gentofte University Hospital (M. Schou) - both in Copenhagen; National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M. Senni) - both in Italy; Washington University School of Medicine, St. Louis (D.L.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Montreal Heart Institute, University of Montreal, Montreal (J.-L.R.); Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris (P.G.S.); Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo (O.B.); the Department of Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia (M.C.); the Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia (C.G.D.P.); Baylor Soltero CV Research Center, Baylor Scott and White Heart and Vascular Hospital, Dallas (C.E.); Cardiology Service, Sanatorio Modelo Quilmes, Quilmes, Argentina (A.F.); the Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin (U.L.); Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.); National Heart Center Singapore, Singapore (D.S.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); and Novartis, East Hanover, NJ (M.L., Y.Z., J.G.)
| |
Collapse
|
36
|
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo-SP, Brazil
| |
Collapse
|
37
|
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, Sao Paulo-SP, Brazil.
| |
Collapse
|
38
|
Lopes RD, de Barros E Silva PGM, Furtado RHM, Alexander JH, Berwanger O. Age-adjusted D-dimer cutoffs to guide anticoagulation in COVID-19 - Authors' reply. Lancet 2021; 398:1304. [PMID: 34627488 PMCID: PMC8497020 DOI: 10.1016/s0140-6736(21)01909-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/09/2021] [Indexed: 12/03/2022]
Affiliation(s)
- Renato D Lopes
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC 27701, USA.
| | | | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - John H Alexander
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC 27701, USA
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| |
Collapse
|
39
|
Kosiborod MN, Esterline R, Furtado RHM, Oscarsson J, Gasparyan SB, Koch GG, Martinez F, Mukhtar O, Verma S, Chopra V, Buenconsejo J, Langkilde AM, Ambery P, Tang F, Gosch K, Windsor SL, Akin EE, Soares RVP, Moia DDF, Aboudara M, Hoffmann Filho CR, Feitosa ADM, Fonseca A, Garla V, Gordon RA, Javaheri A, Jaeger CP, Leaes PE, Nassif M, Pursley M, Silveira FS, Barroso WKS, Lazcano Soto JR, Nigro Maia L, Berwanger O. Dapagliflozin in patients with cardiometabolic risk factors hospitalised with COVID-19 (DARE-19): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Diabetes Endocrinol 2021; 9:586-594. [PMID: 34302745 PMCID: PMC8294807 DOI: 10.1016/s2213-8587(21)00180-7] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND COVID-19 can lead to multiorgan failure. Dapagliflozin, a SGLT2 inhibitor, has significant protective benefits for the heart and kidney. We aimed to see whether this agent might provide organ protection in patients with COVID-19 by affecting processes dysregulated during acute illness. METHODS DARE-19 was a randomised, double-blind, placebo-controlled trial of patients hospitalised with COVID-19 and with at least one cardiometabolic risk factor (ie, hypertension, type 2 diabetes, atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease). Patients critically ill at screening were excluded. Patients were randomly assigned 1:1 to dapagliflozin (10 mg daily orally) or matched placebo for 30 days. Dual primary outcomes were assessed in the intention-to-treat population: the outcome of prevention (time to new or worsened organ dysfunction or death), and the hierarchial composite outcome of recovery (change in clinical status by day 30). Safety outcomes, in patients who received at least one study medication dose, included serious adverse events, adverse events leading to discontinuation, and adverse events of interest. This study is registered with ClinicalTrials.gov, NCT04350593. FINDINGS Between April 22, 2020 and Jan 1, 2021, 1250 patients were randomly assigned with 625 in each group. The primary composite outcome of prevention showed organ dysfunction or death occurred in 70 patients (11·2%) in the dapagliflozin group, and 86 (13·8%) in the placebo group (hazard ratio [HR] 0·80, 95% CI 0·58-1·10; p=0·17). For the primary outcome of recovery, 547 patients (87·5%) in the dapagliflozin group and 532 (85·1%) in the placebo group showed clinical status improvement, although this was not statistically significant (win ratio 1·09, 95% CI 0·97-1·22; p=0·14). There were 41 deaths (6·6%) in the dapagliflozin group, and 54 (8·6%) in the placebo group (HR 0·77, 95% CI 0·52-1·16). Serious adverse events were reported in 65 (10·6%) of 613 patients treated with dapagliflozin and in 82 (13·3%) of 616 patients given the placebo. INTERPRETATION In patients with cardiometabolic risk factors who were hospitalised with COVID-19, treatment with dapagliflozin did not result in a statistically significant risk reduction in organ dysfunction or death, or improvement in clinical recovery, but was well tolerated. FUNDING AstraZeneca.
Collapse
Affiliation(s)
- Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
| | - Russell Esterline
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Remo H M Furtado
- Academic Research Organization-Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Instituto do Coracao do Hospital das Clinicas da FMUSP, Sao Paulo, Brazil
| | - Jan Oscarsson
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Samvel B Gasparyan
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Gary G Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Omar Mukhtar
- Experimental Medicine and Immunotherapeutics Division, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada; Department of Surgery and Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | | | - Joan Buenconsejo
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Anna Maria Langkilde
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Late-stage Development, CVRM, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | - Ronaldo V P Soares
- Academic Research Organization-Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Diogo D F Moia
- Academic Research Organization-Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Matthew Aboudara
- Division of Pulmonary and Critical Care, Saint Luke's Health System, Kansas City, MO, USA
| | | | | | | | - Vishnu Garla
- Department of Endocrinology, Diabetes and Metabolism, Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA; Mississippi Center for Clinical and Translational Research, Jackson, MI, USA
| | | | - Ali Javaheri
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Paulo E Leaes
- Irmandade Da Santa Casa de Misericórdia de Porto Alegre, Brazil
| | - Michael Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | - Weimar Kunz Sebba Barroso
- Liga de Hipertensão Arterial -Universidade Federal de Goiás, Brazil; HCAMP-Secretaria Estadual de Saúde, Goiás, Brazil
| | | | - Lilia Nigro Maia
- Centro Integrado de Pesquisas, Hospital de Base, São José do Rio Preto, Brazil
| | - Otavio Berwanger
- Academic Research Organization-Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| |
Collapse
|
40
|
Lopes RD, de Barros E Silva PGM, Furtado RHM, Macedo AVS, Ramacciotti E, Damini LP, Bronhara B, Cavalcanti AB, Rosa RG, Azevedo LCP, Veiga VC, Machado FR, Ritt LE, Martins PDA, Alexander JH, Avezum A, Berwanger O. Randomized clinical trial to evaluate a routine full anticoagulation Strategy in Patients with Coronavirus Infection (SARS-CoV2) admitted to hospital: Rationale and design of the ACTION (AntiCoagulaTlon cOroNavirus)-Coalition IV trial. Am Heart J 2021; 238:1-11. [PMID: 33891907 PMCID: PMC8057688 DOI: 10.1016/j.ahj.2021.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Observational studies have suggested a higher risk of thrombotic events in patients with coronavirus disease 2019 (COVID-19). Moreover, elevated D-dimer levels have been identified as an important prognostic marker in COVID-19 directly associated with disease severity and progression. Prophylactic anticoagulation for hospitalized COVID-19 patients might not be enough to prevent thrombotic events; therefore, therapeutic anticoagulation regimens deserve clinical investigation. DESIGN ACTION is an academic-led, pragmatic, multicenter, open-label, randomized, phase IV clinical trial that aims to enroll around 600 patients at 40 sites participating in the Coalition COVID-19 Brazil initiative. Eligible patients with a confirmed diagnosis of COVID-19 with symptoms up to 14 days and elevated D-dimer levels will be randomized to a strategy of full-dose anticoagulation for 30 days with rivaroxaban 20 mg once daily (or full-dose heparin if oral administration is not feasible) vs standard of care with any approved venous thromboembolism prophylaxis regimen during hospitalization. A confirmation of COVID-19 was mandatory for study entry, based on specific tests used in clinical practice (RT-PCR, antigen test, IgM test) collected before randomization, regardless of in the outpatient setting or not. Randomization will be stratified by clinical stability at presentation. The primary outcome is a hierarchical analysis of mortality, length of hospital stay, or duration of oxygen therapy at the end of 30 days. Secondary outcomes include the World Health Organization's 8-point ordinal scale at 30 days and the following efficacy outcomes: incidence of venous thromboembolism , acute myocardial infarction, stroke, systemic embolism, major adverse limb events, duration of oxygen therapy, disease progression, and biomarkers. The primary safety outcomes are major or clinically relevant non-major bleeding according to the International Society on Thrombosis and Haemostasis criteria. SUMMARY The ACTION trial will evaluate whether in-hospital therapeutic anticoagulation with rivaroxaban for stable patients, or enoxaparin for unstable patients, followed by rivaroxaban through 30 days compared with standard prophylactic anticoagulation improves clinical outcomes in hospitalized patients with COVID-19 and elevated D-dimer levels.
Collapse
Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Brazilian Clinical Research Institute, São Paulo, Brazil.
| | - Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCOR Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazill
| | | | | | - Lucas Petri Damini
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCOR Research Institute, São Paulo, Brazil
| | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCOR Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
| | - Regis G Rosa
- Hospital Moinhos de Vento, Porto Alegre, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - Luciano C P Azevedo
- Hospital Moinhos de Vento, Porto Alegre, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - Viviane C Veiga
- Hospital Moinhos de Vento, Porto Alegre, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Flávia R Machado
- Hospital Moinhos de Vento, Porto Alegre, Brazil; Federal University of São Paulo (UNIFES), Paulista School of Medicine (EPM), São Paulo, Brazil
| | - Luiz Eduardo Ritt
- Hospital Cardio-Pulmonar, Salvador, Brazil; Escola Bahiana de Medicina, Salvador, Brazil
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
41
|
Guimarães PO, Quirk D, Furtado RH, Maia LN, Saraiva JF, Antunes MO, Kalil Filho R, Junior VM, Soeiro AM, Tognon AP, Veiga VC, Martins PA, Moia DDF, Sampaio BS, Assis SRL, Soares RVP, Piano LPA, Castilho K, Momesso RGRAP, Monfardini F, Guimarães HP, Ponce de Leon D, Dulcine M, Pinheiro MRT, Gunay LM, Deuring JJ, Rizzo LV, Koncz T, Berwanger O. Tofacitinib in Patients Hospitalized with Covid-19 Pneumonia. N Engl J Med 2021; 385:406-415. [PMID: 34133856 PMCID: PMC8220898 DOI: 10.1056/nejmoa2101643] [Citation(s) in RCA: 305] [Impact Index Per Article: 101.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy and safety of tofacitinib, a Janus kinase inhibitor, in patients who are hospitalized with coronavirus disease 2019 (Covid-19) pneumonia are unclear. METHODS We randomly assigned, in a 1:1 ratio, hospitalized adults with Covid-19 pneumonia to receive either tofacitinib at a dose of 10 mg or placebo twice daily for up to 14 days or until hospital discharge. The primary outcome was the occurrence of death or respiratory failure through day 28 as assessed with the use of an eight-level ordinal scale (with scores ranging from 1 to 8 and higher scores indicating a worse condition). All-cause mortality and safety were also assessed. RESULTS A total of 289 patients underwent randomization at 15 sites in Brazil. Overall, 89.3% of the patients received glucocorticoids during hospitalization. The cumulative incidence of death or respiratory failure through day 28 was 18.1% in the tofacitinib group and 29.0% in the placebo group (risk ratio, 0.63; 95% confidence interval [CI], 0.41 to 0.97; P = 0.04). Death from any cause through day 28 occurred in 2.8% of the patients in the tofacitinib group and in 5.5% of those in the placebo group (hazard ratio, 0.49; 95% CI, 0.15 to 1.63). The proportional odds of having a worse score on the eight-level ordinal scale with tofacitinib, as compared with placebo, was 0.60 (95% CI, 0.36 to 1.00) at day 14 and 0.54 (95% CI, 0.27 to 1.06) at day 28. Serious adverse events occurred in 20 patients (14.1%) in the tofacitinib group and in 17 (12.0%) in the placebo group. CONCLUSIONS Among patients hospitalized with Covid-19 pneumonia, tofacitinib led to a lower risk of death or respiratory failure through day 28 than placebo. (Funded by Pfizer; STOP-COVID ClinicalTrials.gov number, NCT04469114.).
Collapse
Affiliation(s)
- Patrícia O Guimarães
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Daniel Quirk
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Remo H Furtado
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Lilia N Maia
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - José F Saraiva
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Murillo O Antunes
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Roberto Kalil Filho
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Vagner M Junior
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Alexandre M Soeiro
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Alexandre P Tognon
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Viviane C Veiga
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Priscilla A Martins
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Diogo D F Moia
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Bruna S Sampaio
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Silvia R L Assis
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Ronaldo V P Soares
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Luciana P A Piano
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Kleber Castilho
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Roberta G R A P Momesso
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Frederico Monfardini
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Helio P Guimarães
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Dario Ponce de Leon
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Majori Dulcine
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Marcia R T Pinheiro
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Levent M Gunay
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - J Jasper Deuring
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Luiz V Rizzo
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Tamas Koncz
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| | - Otavio Berwanger
- From the Hospital Israelita Albert Einstein (P.O.G., R.H.F., D.D.F.M., B.S.S., S.R.L.A., R.V.P.S., L.P.A.P., K.C., R.G.R.A.P.M., F.M., H.P.G., L.V.R., O.B.), the Heart Institute, InCor, University of São Paulo Medical School (R.H.F., R.K.F., V.M.J.), BP Mirante-A Beneficência Portuguesa de São Paulo (A.M.S.), BP-A Beneficência Portuguesa de São Paulo (V.C.V.), and Pfizer (M.D., M.R.T.P.), São Paulo, Centro Integrado de Pesquisa, Hospital de Base, São José do Rio Preto Medical School, São José do Rio Preto (L.N.M.), Pontifícia Universidade Católica de Campinas, Campinas (J.F.S.), Hospital Universitário São Francisco de Assis na Providência de Deus and Irmandade do Senhor Bom Jesus dos Passos da Santa Casa de Misericórida de Bragança Paulista, Bragança Paulista (M.O.A.), Hospital São Vicente de Paulo, Passo Fundo (A.P.T.), and Hospital Estadual Jayme dos Santos Neves, Vila Velha (P.A.M.) - all in Brazil; Pfizer, Collegeville, PA (D.Q.); Pfizer, Lima, Peru (D.P.L.); Pfizer, Istanbul, Turkey (L.M.G.); Pfizer, Rotterdam, the Netherlands (J.J.D.); and Pfizer, New York (T.K.)
| |
Collapse
|
42
|
Lemos PA, Guimarães PO, Franken M, Berwanger O. Antithrombotic therapy in the elderly: The more we know, the more we can offer. Int J Cardiol 2021; 339:58-59. [PMID: 34242688 DOI: 10.1016/j.ijcard.2021.06.054] [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] [Received: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Instituto do Coração (InCor), São Paulo Medical School, São Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
43
|
Lopes RD, de Barros E Silva PGM, Furtado RHM, Macedo AVS, Bronhara B, Damiani LP, Barbosa LM, de Aveiro Morata J, Ramacciotti E, de Aquino Martins P, de Oliveira AL, Nunes VS, Ritt LEF, Rocha AT, Tramujas L, Santos SV, Diaz DRA, Viana LS, Melro LMG, de Alcântara Chaud MS, Figueiredo EL, Neuenschwander FC, Dracoulakis MDA, Lima RGSD, de Souza Dantas VC, Fernandes ACS, Gebara OCE, Hernandes ME, Queiroz DAR, Veiga VC, Canesin MF, de Faria LM, Feitosa-Filho GS, Gazzana MB, Liporace IL, de Oliveira Twardowsky A, Maia LN, Machado FR, de Matos Soeiro A, Conceição-Souza GE, Armaganijan L, Guimarães PO, Rosa RG, Azevedo LCP, Alexander JH, Avezum A, Cavalcanti AB, Berwanger O. Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet 2021; 397:2253-2263. [PMID: 34097856 PMCID: PMC8177770 DOI: 10.1016/s0140-6736(21)01203-4] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population. METHODS We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days. This study is registered with ClinicalTrials.gov (NCT04394377) and is completed. FINDINGS From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group. INTERPRETATION In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation. FUNDING Coalition COVID-19 Brazil, Bayer SA.
Collapse
Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil.
| | - Pedro Gabriel Melo de Barros E Silva
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil; Hospital Samaritano Paulista, São Paulo, Brazil
| | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
| | | | - Bruna Bronhara
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Lucas Petri Damiani
- Brazilian Clinical Research Institute, São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | | | | | - Eduardo Ramacciotti
- Brazilian Clinical Research Institute, São Paulo, Brazil; Science Valley Research Institute, São Paulo, Brazil; Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | | | - Ana Thereza Rocha
- Hospital Cárdio Pulmonar, Salvador, Brazil; Escola Bahiana de Medicina, Salvador, Brazil; Universidade Federal da Bahia, Salvador, Brazil
| | | | | | | | - Lorena Souza Viana
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Viviane C Veiga
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | - Gilson Soares Feitosa-Filho
- Escola Bahiana de Medicina, Salvador, Brazil; Santa Casa de Misericórdia da Bahia-Hospital Santa Izabel, Salvador, Brazil; Centro Universitário Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | - Lilia Nigro Maia
- Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Regis G Rosa
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network, São Paulo, Brazil; Hospital Sírio Libanês Research and Education Institute, São Paulo, Brazil
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
44
|
Rosa RG, Robinson CC, Veiga VC, Cavalcanti AB, Azevedo LCPD, Machado FR, Berwanger O, Avezum Á, Lopes RD, Lisboa TC, Teixeira C, Zampieri FG, Tomazini BM, Kawano-Dourado L, Schneider D, Souza DD, Santos RDRMD, Silva SSD, Trott G, Gimenes BDP, Souza APD, Barroso BM, Costa LS, Brognoli LG, Pelliccioli MP, Studier NDS, Schardosim RFDC, Haubert TA, Pallaoro VEL, Oliveira DMD, Velho PI, Medeiros GS, Gazzana MB, Zavascki AP, Pitrez PM, Oliveira RPD, Polanczyk CA, Nasi LA, Hammes LS, Falavigna M. Quality of life and long-term outcomes after hospitalization for COVID-19: Protocol for a prospective cohort study (Coalition VII). Rev Bras Ter Intensiva 2021; 33:31-37. [PMID: 33886851 PMCID: PMC8075344 DOI: 10.5935/0103-507x.20210003] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/02/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The long-term effects caused by COVID-19 are unknown. The present study aims to assess factors associated with health-related quality of life and long-term outcomes among survivors of hospitalization for COVID-19 in Brazil. METHODS This is a multicenter prospective cohort study nested in five randomized clinical trials designed to assess the effects of specific COVID-19 treatments in over 50 centers in Brazil. Adult survivors of hospitalization due to proven or suspected SARS-CoV-2 infection will be followed-up for a period of 1 year by means of structured telephone interviews. The primary outcome is the 1-year utility score of health-related quality of life assessed by the EuroQol-5D3L. Secondary outcomes include all-cause mortality, major cardiovascular events, rehospitalizations, return to work or study, physical functional status assessed by the Lawton-Brody Instrumental Activities of Daily Living, dyspnea assessed by the modified Medical Research Council dyspnea scale, need for long-term ventilatory support, symptoms of anxiety and depression assessed by the Hospital Anxiety and Depression Scale, symptoms of posttraumatic stress disorder assessed by the Impact of Event Scale-Revised, and self-rated health assessed by the EuroQol-5D3L Visual Analog Scale. Generalized estimated equations will be performed to test the association between five sets of variables (1- demographic characteristics, 2- premorbid state of health, 3- characteristics of acute illness, 4- specific COVID-19 treatments received, and 5- time-updated postdischarge variables) and outcomes. ETHICS AND DISSEMINATION The study protocol was approved by the Research Ethics Committee of all participant institutions. The results will be disseminated through conferences and peer-reviewed journals.
Collapse
Affiliation(s)
- Regis Goulart Rosa
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Educação e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Otavio Berwanger
- Organização de Pesquisa Acadêmica, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Álvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Renato Delascio Lopes
- Brazilian Clinical Research Institute - São Paulo (SP), Brasil.,Instituto Duke de Pesquisa Clínica, Duke University Medical Center - Durham, NC, Estados Unidos
| | - Thiago Costa Lisboa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Cassiano Teixeira
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Fernando Godinho Zampieri
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Kosiborod M, Berwanger O, Koch GG, Martinez F, Mukhtar O, Verma S, Chopra V, Javaheri A, Ambery P, Gasparyan SB, Buenconsejo J, Sjöström CD, Langkilde AM, Oscarsson J, Esterline R. Effects of dapagliflozin on prevention of major clinical events and recovery in patients with respiratory failure because of COVID-19: Design and rationale for the DARE-19 study. Diabetes Obes Metab 2021; 23:886-896. [PMID: 33319454 PMCID: PMC8049025 DOI: 10.1111/dom.14296] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
AIMS Coronavirus disease 2019 (COVID-19) is caused by a novel severe acute respiratory syndrome coronavirus 2. It can lead to multiorgan failure, including respiratory and cardiovascular decompensation, and kidney injury, with significant associated morbidity and mortality, particularly in patients with underlying metabolic, cardiovascular, respiratory or kidney disease. Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, has shown significant cardio- and renoprotective benefits in patients with type 2 diabetes (with and without atherosclerotic cardiovascular disease), heart failure and chronic kidney disease, and may provide similar organ protection in high-risk patients with COVID-19. MATERIALS AND METHODS DARE-19 (NCT04350593) is an investigator-initiated, collaborative, international, multicentre, randomized, double-blind, placebo-controlled study testing the dual hypotheses that dapagliflozin can reduce the incidence of cardiovascular, kidney and/or respiratory complications or all-cause mortality, or improve clinical recovery, in adult patients hospitalized with COVID-19 but not critically ill on admission. Eligible patients will have ≥1 cardiometabolic risk factor for COVID-19 complications. Patients will be randomized 1:1 to dapagliflozin 10 mg or placebo. Primary efficacy endpoints are time to development of new or worsened organ dysfunction during index hospitalization, or all-cause mortality, and the hierarchical composite endpoint of change in clinical status through day 30 of treatment. Safety of dapagliflozin in individuals with COVID-19 will be assessed. CONCLUSIONS DARE-19 will evaluate whether dapagliflozin can prevent COVID-19-related complications and all-cause mortality, or improve clinical recovery, and assess the safety profile of dapagliflozin in this patient population. Currently, DARE-19 is the first large randomized controlled trial investigating use of sodium-glucose cotransporter 2 inhibitors in patients with COVID-19.
Collapse
Affiliation(s)
- Mikhail Kosiborod
- Saint Luke's Mid America Heart InstituteUniversity of MissouriKansas CityMissouriUSA
- The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Otavio Berwanger
- Academic Research Organization ‐ Hospital Israelita Albert EinsteinSão PauloBrazil
| | - Gary G. Koch
- The University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Omar Mukhtar
- Experimental Medicine & Immunotherapeutics Division, Department of MedicineUniversity of CambridgeCambridgeUK
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical ScienceLi Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoOntarioCanada
| | | | - Ali Javaheri
- Washington University School of MedicineSt LouisMissouriUSA
| | - Philip Ambery
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Samvel B. Gasparyan
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Joan Buenconsejo
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGaithersburgMarylandUSA
| | - C. David Sjöström
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | | | - Jan Oscarsson
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Russell Esterline
- Late‐Stage Development, CVRM, BioPharmaceuticals R&DAstraZenecaGaithersburgMarylandUSA
| |
Collapse
|
46
|
Furlan SF, Drager LF, Santos RN, Damiani LP, Bersch-Ferreira AC, Miranda TA, Machado RHV, Santucci EV, Bortolotto LA, Lorenzi-Filho G, Berwanger O, Cavalcanti AB, Schiavon CA. Three-year effects of bariatric surgery on obstructive sleep apnea in patients with obesity grade 1 and 2: a sub-analysis of the GATEWAY trial. Int J Obes (Lond) 2021; 45:914-917. [PMID: 33589771 DOI: 10.1038/s41366-021-00752-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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] [Received: 05/10/2020] [Revised: 12/21/2020] [Accepted: 01/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Most of the evidence on bariatric surgery on obstructive sleep apnea (OSA) is based on observational studies and/or short-term follow-up in patients with obesity grade 3. SUBJECTS/METHODS This randomized study compared the effects of roux-en-Y gastric bypass (RYGB) or usual care (UC) on OSA severity in patients with obesity grade 1-2. Mild, moderate, and severe OSA was defined by the apnea-hypopnoea index (AHI): 5-14.9; 15-29.9, and ≥30 events/h, respectively. OSA remission was defined by converting any form of OSA into normal AHI (<5 events/h). RESULTS After 3-year of follow-up, the body-mass index increased in the UC while decreased in the RYGB group: +1.7 (-1.9; 2.7) versus -10.6 (-12.7; -9.2) kg/m2, respectively. The AHI increased by 5 (-4.2; 12.7) in the UC group while reduced in the RYGB group to -13.2 (-22.7; -7) events/h. UC significantly increase the frequency of moderate OSA (from 15.4 to 46.2%). In contrast, RYGB had a huge impact on reaching no OSA status (from 4.2 to 70.8%) in parallel to a decrease of moderate (from 41.7 to 8.3%) and severe OSA (from 20.8 to 0%). CONCLUSIONS RYGB is an attractive strategy for mid-term OSA remission or decrease moderate-to-severe forms of OSA in patients with obesity grade 1-2.
Collapse
Affiliation(s)
- Sofia F Furlan
- Program in Cardiology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.,Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil. .,Renal Division, University of São Paulo Medical School, São Paulo, Brazil.
| | | | - Lucas P Damiani
- Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | | | | | | | | | - Luiz A Bortolotto
- Hypertension Unit, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
47
|
Affiliation(s)
- Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, 05652-900 Sao Paulo, Brazil.
| |
Collapse
|
48
|
Veiga VC, Prats JAGG, Farias DLC, Rosa RG, Dourado LK, Zampieri FG, Machado FR, Lopes RD, Berwanger O, Azevedo LCP, Avezum Á, Lisboa TC, Rojas SSO, Coelho JC, Leite RT, Carvalho JC, Andrade LEC, Sandes AF, Pintão MCT, Castro CG, Santos SV, de Almeida TML, Costa AN, Gebara OCE, de Freitas FGR, Pacheco ES, Machado DJB, Martin J, Conceição FG, Siqueira SRR, Damiani LP, Ishihara LM, Schneider D, de Souza D, Cavalcanti AB, Scheinberg P. Effect of tocilizumab on clinical outcomes at 15 days in patients with severe or critical coronavirus disease 2019: randomised controlled trial. BMJ 2021; 372:n84. [PMID: 33472855 PMCID: PMC7815251 DOI: 10.1136/bmj.n84] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether tocilizumab improves clinical outcomes for patients with severe or critical coronavirus disease 2019 (covid-19). DESIGN Randomised, open label trial. SETTING Nine hospitals in Brazil, 8 May to 17 July 2020. PARTICIPANTS Adults with confirmed covid-19 who were receiving supplemental oxygen or mechanical ventilation and had abnormal levels of at least two serum biomarkers (C reactive protein, D dimer, lactate dehydrogenase, or ferritin). The data monitoring committee recommended stopping the trial early, after 129 patients had been enrolled, because of an increased number of deaths at 15 days in the tocilizumab group. INTERVENTIONS Tocilizumab (single intravenous infusion of 8 mg/kg) plus standard care (n=65) versus standard care alone (n=64). MAIN OUTCOME MEASURE The primary outcome, clinical status measured at 15 days using a seven level ordinal scale, was analysed as a composite of death or mechanical ventilation because the assumption of odds proportionality was not met. RESULTS A total of 129 patients were enrolled (mean age 57 (SD 14) years; 68% men) and all completed follow-up. All patients in the tocilizumab group and two in the standard care group received tocilizumab. 18 of 65 (28%) patients in the tocilizumab group and 13 of 64 (20%) in the standard care group were receiving mechanical ventilation or died at day 15 (odds ratio 1.54, 95% confidence interval 0.66 to 3.66; P=0.32). Death at 15 days occurred in 11 (17%) patients in the tocilizumab group compared with 2 (3%) in the standard care group (odds ratio 6.42, 95% confidence interval 1.59 to 43.2). Adverse events were reported in 29 of 67 (43%) patients who received tocilizumab and 21 of 62 (34%) who did not receive tocilizumab. CONCLUSIONS In patients with severe or critical covid-19, tocilizumab plus standard care was not superior to standard care alone in improving clinical outcomes at 15 days, and it might increase mortality. TRIAL REGISTRATION ClinicalTrials.gov NCT04403685.
Collapse
Affiliation(s)
- Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
| | - João A G G Prats
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Danielle L C Farias
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Regis G Rosa
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | - Fernando G Zampieri
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
| | - Flávia R Machado
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- Anesthesiology, Pain and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- Hospital Sírio-Libanês, São Paulo, Brazil
| | - Álvaro Avezum
- International Research Center-Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Thiago C Lisboa
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
| | - Salomón S O Rojas
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Juliana C Coelho
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Rodrigo T Leite
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Júlio C Carvalho
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| | - Luis E C Andrade
- Fleury Medicine and Health Laboratories, Grupo Fleury, São Paulo, Brazil
| | - Alex F Sandes
- Fleury Medicine and Health Laboratories, Grupo Fleury, São Paulo, Brazil
| | - Maria C T Pintão
- Fleury Medicine and Health Laboratories, Grupo Fleury, São Paulo, Brazil
| | - Claudio G Castro
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Thiago M L de Almeida
- Anesthesiology, Pain and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Lucas P Damiani
- HCor Research Institute, São Paulo, Brazil
- Estátikos Consultoria Estatística, São Paulo, Brazil
| | | | | | | | - Alexandre B Cavalcanti
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
| | - Phillip Scheinberg
- BP-A Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 769-Bela Vista, São Paulo-SP, 01323-001, Brazil
| |
Collapse
|
49
|
Hijazi Z, Alexander JH, Li Z, Wojdyla DM, Mehran R, Granger CB, Parkhomenko A, Bahit MC, Windecker S, Aronson R, Berwanger O, Halvorsen S, de Waha-Thiele S, Sinnaeve P, Darius H, Storey RF, Lopes RD. Apixaban or Vitamin K Antagonists and Aspirin or Placebo According to Kidney Function in Patients With Atrial Fibrillation After Acute Coronary Syndrome or Percutaneous Coronary Intervention: Insights From the AUGUSTUS Trial. Circulation 2021; 143:1215-1223. [PMID: 33461308 DOI: 10.1161/circulationaha.120.051020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the AUGUSTUS trial (An Open-Label, 2×2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists, and aspirin caused more bleeding than placebo in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention treated with a P2Y12 inhibitor. We evaluated the risk-benefit balance of antithrombotic therapy according to kidney function. METHODS In 4456 patients, the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula was used to calculate baseline estimated glomerular filtration rate (eGFR). The effect of apixaban versus vitamin K antagonists and aspirin versus placebo was assessed across kidney function categories by using Cox models. The primary outcome was International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding. Secondary outcomes included death or hospitalization and ischemic events (death, stroke, myocardial infarction, stent thrombosis [definite or probable], or urgent revascularization). Creatinine clearance <30 mL/min was an exclusion criterion in the AUGUSTUS trial. RESULTS Overall, 30%, 52%, and 19% had an eGFR of >80, >50 to 80, and 30 to 50 mL·min-1·1.73 m-2, respectively. At the 6-month follow-up, a total of 543 primary outcomes of bleeding, 1125 death or hospitalizations, and 282 ischemic events occurred. Compared with vitamin K antagonists, patients assigned apixaban had lower rates for all 3 outcomes across most eGFR categories without significant interaction. The absolute risk reduction with apixaban was most pronounced in those with an eGFR of 30 to 50 mL·min-1·1.73 m-2 for bleeding events with rates of 13.1% versus 21.3% (hazard ratio, 0.59; 95% CI, 0.41-0.84). Patients assigned aspirin had a higher risk of bleeding in all eGFR categories with an even greater increase among those with eGFR >80 mL·min-1·1.73 m-2: 16.6% versus 5.6% (hazard ratio, 3.22; 95% CI, 2.19-4.74; P for interaction=0.007). The risk of death or hospitalization and ischemic events were comparable to aspirin and placebo across eGFR categories with hazard ratios ranging from 0.97 (95% CI, 0.76-1.23) to 1.28 (95% CI, 1.02-1.59) and from 0.75 (95% CI, 0.48-1.17) to 1.34 (95% CI, 0.81-2.22), respectively. CONCLUSIONS The safety and efficacy of apixaban was consistent irrespective of kidney function, compared with warfarin, and in accordance with the overall trial results. The risk of bleeding with aspirin was consistently higher across all kidney function categories. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02415400.
Collapse
Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (Z.H.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Roxana Mehran
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and Cardiovascular Research Foundation, New York, NY (R.M.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | | | - M Cecilia Bahit
- Instituto de Neurología Cognitiva (INECO) Neurociencias Oroño, Fundación INECO, Rosario, Argentina (M.C.B.)
| | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W.)
| | | | | | | | - Suzanne de Waha-Thiele
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany (S.dW.-T.).,German Center for Cardiovascular Research (DZHK), Lübeck (S.dW.-T.)
| | - Peter Sinnaeve
- University Hospitals Leuven, University of Leuven, Belgium (P.S.)
| | - Harald Darius
- Vivantes Neukoelln Medical Center, Berlin, Germany (H.D.)
| | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| |
Collapse
|
50
|
Silva PGMDBE, Berwanger O, Precoma DB, Cavalcante MA, Vilela-Martin JF, Figueiredo EL, Lopes RD, Bodanese LC, Guimarães JI, Andrade JPD, Paola AAVD, Malachias MVB, Mattos LAPE, Bacal F, Dutra OP. Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT). Arq Bras Cardiol 2021; 116:108-116. [PMID: 33331461 PMCID: PMC8159499 DOI: 10.36660/abc.20190885] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/17/2020] [Accepted: 05/14/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. OBJECTIVES To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. METHODS This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. RESULTS From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. CONCLUSIONS In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).
Collapse
Affiliation(s)
| | | | - Dalton Bertolim Precoma
- Pontificia Universidade Católica do Paraná - Escola de Medicina, Curitiba, PR - Brasil
- Sociedade Hospitalar Angelina Caron - Cardiologia, Campina Grande do Sul, PR - Brasil
| | - Margaret Assad Cavalcante
- Universidade do Oeste Paulista (Unoeste), Presidente Prudente, SP - Brasil
- Hospital Regional de Presidente Prudente, Presidente Prudente, SP - Brasil
| | - José Fernando Vilela-Martin
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
- Departamento de Hipertensão Arterial da Sociedade Brasileira de Cardiologia, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Marcus Vinicius Bolivar Malachias
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Instituto de Hipertensão Arterial - Diretoria Clínica, Belo Horizonte, MG - Brasil
| | | | - Fernando Bacal
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas Instituto do Coração, São Paulo, SP - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| |
Collapse
|